Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE): Trial of Fentanyl versus Fentanyl

Objectives This article observes the mean daily dose of fentanyl required for adequate sedation in critically ill, mechanically ventilated children randomized to receive dexmedetomidine or placebo.Methods We conducted Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE), a multicenter, double-blind, randomized, placebo-controlled, dose-escalating trial. We enrolled children aged 35 weeks postmenstrual to 17 years (inclusive) admitted across 13 pediatric multidisciplinary and cardiac intensive care units. Adequate sedation was based on a State Behavioral Score and Richmond Agitation-Sedation Scale of -1 or lower. Only the first two dexmedetomidine dosing cohorts opened for enrollment, due to early trial closure during the coronavirus 2019 pandemic. Thirty children were randomized over 13 months and included in the analyses.Results Demographic and baseline characteristics were not different between dexmedetomidine and placebo cohorts. Similarly, mean daily fentanyl use was not different, using an unadjusted mixed regression model that considered treatment, time, and a treatment-by-time interaction. Adverse events and safety events of special interest were not different between cohorts.Conclusion The DOSE trial revealed that dexmedetomidine added to fentanyl does not impact safety and may not spare fentanyl use in critically ill children, although the trial did not meet its recruitment goals, due to early closure during the coronavirus 2019 pandemic. More rigorous inpatient pediatric trials like DOSE that study critically ill, mechanically ventilated children are needed. Despite the many obstacles faced, the DOSE trial presents challenges from which the greater research community can learn and use to optimize future therapeutic trials in children.

NEI 2022 Abstracts

The proceedings contain 96 papers. The topics discussed include: practical pharmacotherapy for opioid use disorder in the age of fentanyl;can COVID-19 cause acute psychosis in pediatric patients? a case report;a survey of bullying experiences in a child and adolescent psychiatric clinic population;acute emergence of suicidal thoughts following Lemborexant initiation: an adverse reaction case report;assessing the unmet clinical need and opportunity for digital therapeutic intervention in schizophrenia: perspective from people with schizophrenia;rapid antidepressant effects and MADRS item improvements with AXS-05 (DEXTROMETHORPHAN-BUPROPION), an oral NMDA receptor antagonist in major depressive disorder: results from two randomized double-blind, controlled trials;targeting lncRNA NEAT1 impedes Alzheimers disease progression via MicroRNA-193a mediated CREB/BDNF and NRF2/NQO1 pathways;and impact of AXS-05 (DEXTROMETHORPHAN-BUPROPION), an Oral NMDA receptor antagonist, on Anhedonic symptoms in major depressive disorder.

Insights from Drug Checking Programs: Practicing Bootstrap Public Health Whilst Tailoring to Local Drug User Needs.

The year 2021 was the most deadly year for overdose deaths in the USA and Canada. The stress and social isolation stemming from the COVID-19 pandemic coupled with a flood of fentanyl into local drug markets created conditions in which people who use drugs were more susceptible to accidental overdose. Within territorial, state, and local policy communities, there have been longstanding efforts to reduce morbidity and mortality within this population; however, the current overdose crisis clearly indicates an urgent need for additional, easily accessible, and innovative services. Street-based drug testing programs allow individuals to learn the composition of their substances prior to use, averting unintended overdoses while also creating low threshold opportunities for individuals to connect to other harm reduction services, including substance use treatment programs. We sought to capture perspectives from service providers to document best practices around fielding community-based drug testing programs, including optimizing their position within a constellation of other harm reduction services to best serve local communities. We conducted 11 in-depth interviews from June to November 2022 via Zoom with harm reduction service providers to explore barriers and facilitators around the implementation of drug checking programs, the potential for integration with other health promotion services, and best practices for sustaining these programs, taking the local community and policy landscape into account. Interviews lasted 45-60 min and were recorded and transcribed. Thematic analysis was used to reduce the data, and transcripts were discussed by a team of trained analysts. Several key themes emerged from our interviews: (1) the instability of drug markets amid an inconsistent and dangerous drug supply; (2) implementing drug checking services in dynamic environments in response to the rapidly changing needs of local communities; (3) training and ongoing capacity building needed to create sustainable programs; and (4) the potential for integrating drug checking programs into other services. There are opportunities for this service to make a difference in overdose deaths as the contours of the drug market itself have changed over time, but a number of challenges remain to implement them effectively and sustain the service over time. Drug checking itself represents a paradox within the larger policy context, putting the sustainability of these programs at risk and challenging the potential to scale these programs as the overdose epidemic worsens.

Low Barrier Tele-Buprenorphine in the Time of COVID-19: A Case Report

Background: To reduce the spread of coronavirus disease 2019 (COVID-19), many substance use disorder treatment programs have transitioned to telemedicine. Emergency regulatory changes allow buprenorphine initiation without an in-person visit. We describe the use of videoconferencing for buprenorphine initiation combined with street outreach to engage 2 patients experiencing homelessness with severe opioid use disorder (OUD). Case Presentation: Patient 1 was a 30-year-old man with severe OUD who had relapsed to injection heroin/fentanyl after incarceration. A community drop-in center outreach harm reduction specialist facilitated a videoconference with an addiction specialist at an OUD bridge clinic. The patient completed a community buprenorphine/naloxone initiation and self-titrated to his prior dose, 8/2 mg twice daily. One week later, he reconnected with the outreach team for a follow-up videoconference visit. Patient 2, a 36-year-old man with severe OUD, connected to the addiction specialist via a syringe service program harm reduction specialist. He had been trying to connect to a community buprenorphine/naloxone provider, but access was limited due to COVID-19, so he was using diverted buprenorphine/naloxone to reduce opioid use. He was restarted on his previous dose of 12/3 mg daily which was continued via phone follow-up 16 days later. Conclusion(s): COVID-19-related regulatory changes allow buprenorphine initiation via telemedicine. We describe 2 cases where telemedicine was combined with street outreach to connect patients experiencing homelessness with OUD to treatment. These cases highlight an important opportunity to provide access to life-saving OUD treatment for vulnerable patients in the setting of a pandemic that mandates reduced face-to-face clinical interactions.Copyright © 2020 Lippincott Williams and Wilkins. All rights reserved.

Dexmedetomidine sedation reduces the incidence of atrial fibrillation in mechanically ventilated patients with COVID-19 pneumonia: A randomized controlled trial

Background: Atrial fibrillation (AF) is a cardiac complication commonly associated with COVID-19 infection, especially in severe cases. The sedative agent dexmedetomidine is known to cause bradycardia. In this study, we are testing whether dexmedetomidine could reduce the occurrence of AF in mechanically ventilated COVID-19 patients. Method(s): This prospective trial included 144 patients who were randomly allocated to one of two groups: Group C patients were sedated with propofol and fentanyl. Group D patients were sedated with the same medications in addition to dexmedetomidine infusion. Result(s): Demographic, clinical, and cardiac characteristics of all patients did not significantly differ between the two groups. The duration of intensive care unit (ICU) stay was comparable between the two groups. However, both propofol and fentanyl consumption significantly declined in Group D. The number of AF attacks showed a significant decline in association with dexmedetomidine administration (mean = 12.5% in Group D vs. 29.2% in Group C). Dexmedetomidine also reduced the amount of required electrical cardioversion episodes. Additionally, antiarrhythmic medication needed reduced significantly in Group D. Mortality rates did not differ between the two study groups (58.3% and 63.8% in Groups D and C, respectively). Conclusion(s): Dexmedetomidine is associated with a significant reduction in the burden of AF in patients with severe COVID-19 infection, manifested by fewer AF attacks, the need for electrical cardioversion shocks, and the consumption of antiarrhythmic medication without impact on mortality.Copyright © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

Spinal Versus General Anesthesia for Spine Surgery During the COVID-19 Pandemic: A Case Series

Background: Hospitals are one of the primary resources for disease transmission, so many guidelines were published, and neuro-surgeons were advised to postpone elective spine surgeries during the COVID-19 pandemic. Objective(s): To avoid pulmonary complications and reduce the risk of spreading the virus and contracting the disease during the COVID-19 era, we operated a group of our patients under spinal anesthesia rather than general anesthesia. Method(s): We retrospectively analyzed all patients who underwent discectomy surgery for lumbar spinal disc herniation under SA between September 2020 and 2021. Result(s): Sixty-four patients diagnosed with lumbar disc herniation underwent lumbar discectomy with SA. All patients except three were male. The mean age was 44.52 +/- 7.95 years (28 to 64 years). The mean procedure time for SA was 10 minutes. The duration of the surgery was 40 to 90 minutes per each level of disc herniation. The mean blood loss was 350 cc (200 to 600 cc). The most common involved level was L4/L5 intervertebral disc (n = 40 patients;63.5%). The mean recovery time was 20 minutes. Only three patients requested more analgesics for relief of their pain postoperatively. All patients with discectomy were discharged a day after surgery, and in the case of fusion, two days after surgery. All the patients were followed up for six months, showing no recurrence symptoms, good pain relief, satisfaction with the surgery, and no bad memory of the surgery. Conclusion(s): Spinal anesthesia is a good alternative or even the main anesthesia route for patients with lumbar disc herniation. More studies are needed to elucidate the best candidate for SA in patients with lumbar pathology.Copyright © 2023, Author(s).

Acceptability of a Fentanyl Vaccine to Prevent Opioid Overdose and Need for Personalized Decision-Making.

BACKGROUND: The opioid epidemic worsened during the coronavirus disease 2019 (COVID-19) pandemic. Synthetic opioids (primarily fentanyl) comprise the most common drugs involved in overdose (OD) death. A vaccine that blocks fentanyl from reaching the brain to prevent OD is under development, and insight is needed into its acceptability. METHODS: Using a semi-structured interview guide, persons with opioid use disorder (OUD), family, professionals, and the public were interviewed about attitudes and concerns regarding a fentanyl vaccine. Reactions to fictional clinical vignettes of persons at risk of OUD because of pain and/or substance use histories were collected, analyzed, and quantified for favorability. Interviews were transcribed, coded, and analyzed thematically. RESULTS: Among N = 64 participants, (70.3% female, average age 32.4 years), attitudes were favorable toward a fentanyl vaccine, with preference for lifelong durability (76% of n = 55 asked). Perceived benefits centered on the potential for a life-saving intervention, suffering averted, healthcare dollars saved, and the utility of a passive harm reduction strategy. Concerns centered on uncertainty regarding vaccine safety, questions about efficacy, worry about implications for future pain management, stigma, and need for supportive counseling and guidance to personalize decision making. Reactions to vignettes revealed complex attitudes toward fentanyl vaccination when considering recipient age, health history, and future risks for addiction and pain. CONCLUSIONS: Positive responses to a fentanyl vaccine were found along with appreciation for the complexity of a vaccine strategy to prevent OD in the setting of pain and uncertain durability. Further research is needed to elucidate operational, ethical, and communications strategies to advance the model.

The opioid epidemic.

An opioid epidemic has been happening across the world since the 1990s and continues impact individuals, families, communities and societies around the globe. The epidemic has evolved from heroin misuse to the use of synthetic opioids that are easily manufactured and are readily available. Reasons for the continuing opioid epidemic are complex, and include factors related to mental health, addiction, chronic pain relief, and, now, the COVID-19 pandemic. Women have been disproportionally affected by the opioid epidemic and the physical and biosocial effects of opioid use specific to women are an important consideration for healthcare providers. Recent data show that the effects of the opioid epidemic on rates of opioid use disorder (OUD), overdoses, and the economy continue to rise, despite global efforts to understand the drivers and develop effective prevention and intervention strategies, programs, and policies.

Prevalence of adverse drug reactions associated with emergency department visits and risk factors for hospitalization

Objective: Adverse drug reactions increase morbidity and mortality, prolong hospital stay and increase healthcare costs. The primary objective of this study was to determine the prevalence of emergency department visits for adverse drug reactions and to describe their characteristics. The secondary objective was to determine the predictor variables of hospitalization for adverse drug reactions associated with emergency department visits. Method(s): Observational and retrospective study of adverse drug reactions registered in an emergency department, carried out from November 15th to December 15th, 2021. The demographic and clinical characteristics of the patients, the drugs involved and the adverse drug reactions were described. Logistic regression was performed to identify factors related to hospitalization for adverse drug reactions. Result(s): 10,799 patients visited the emergency department and 216 (2%) patients with adverse drug reactions were included. The mean age was 70 +/- 17.5 (18-98) years and 47.7% of the patients were male. A total of 54.6% of patients required hospitalization and 1.6% died from adverse drug reactions. The total number of drugs involved was 315 with 149 different drugs. The pharmacological group corresponding to the nervous system constituted the most representative group (n = 81). High-risk medications, such as antithrombotic agents (n = 53), were the subgroup of medications that caused the most emergency department visits and hospitalization. Acenocumarol (n = 20) was the main drug involved. Gastrointestinal (n = 62) disorders were the most common. Diarrhea (n = 16) was the most frequent adverse drug reaction, while gastrointestinal bleeding (n = 13) caused the highest number of hospitalizations. Charlson comorbidity index behaved as an independent risk factor for hospitalization (aOR 3.24, 95% CI: 1.47-7.13, p = 0.003, in Charlson comorbidity index 4-6;and aOR 20.07, 95% CI: 6.87-58.64, p = 0.000, in Charlson comorbidity index >= 10). Conclusion(s): The prevalence of emergency department visits for adverse drug reactions continues to be a non-negligible health problem. High-risk drugs such as antithrombotic agents were the main therapeutic subgroup involved. Charlson comorbidity index was an independent factor in hospitalization, while gastrointestinal bleeding was the adverse drug reaction with the highest number of hospital admissions.Copyright © 2022 Sociedad Espanola de Farmacia Hospitalaria (S.E.F.H)

Evaluation of anxiety and pain levels in patients undergoing colonoscopy in the COVID-19 pandemic

Aim: In this study, we aimed to evaluate factors affecting the anxiety and pain of patients undergoing colonoscopy during the COVID-19 period. Material(s) and Method(s): Before the colonoscopy, patients aged 18-80 years were asked to fill out the Spielberger State-Trait Anxiety Inventory Scale (STAI), along with a personal data form in which demographic data and medical history were questioned, and their pain was questioned with the Visual Analogue Scale (VAS). The pain was questioned in patients who underwent colonoscopy under sedoanalgesia according to VAS after full recovery (Modified Aldrete Score >=8). Result(s): Three hundred and thirty patients (M/F=53/47) with a mean age of 53.41+/-14.75 years participated in the study. 22.7% of the patients had COVID-19 infection. COVID-19 vaccine was administered to 47.6% of the patients. 85.5% were concerned about COVID-19 transmission during colonoscopy. The mean STAI-S (STAI-State) was 47.49+/-8.86, and STAI-T (STAI-Trait) was 39.84+/-8.94 in the patients. The mean VAS score was 2 (0-10) before colonoscopy and 4 (0-10) after colonoscopy. There was no difference in STAI-S, STAI-T, pre and post-colonoscopy VAS scores between those who had COVID-19 and those who did not (p=0.134, p=0.155, p=0.891, p=0.953). There was no difference in STAI-S, STAI-T, and VAS scores between those vaccinated with the COVID-19 vaccine and those not vaccinated (p=0.127, p=0.527, p=0.932, p=0.983). Gender, educational status, STAI-S, STAI-T scores, and colonoscopy waiting time affected VAS scores. Discussion(s): Being infected with COVID-19 and being vaccinated with COVID-19 vaccine are not among the factors affecting patients' anxiety and pain.Copyright © 2023, Derman Medical Publishing. All rights reserved.

Effectiveness and Safety of Nirmatrelvir/ Ritonavir in Real Life Setting

Background and Importance On March 28th 2022, nirmatrelvir/ ritonavir was marketed in Spain. The Spanish Agency for Medicines and Medical Devices (AEMPS) established criteria to prioritise its administration in patients at high risk of progression to severe COVID. Data regarding the effectiveness and safety of nirmatrelvir in preventing severe coronavirus disease outcomes are limited. Aim and Objectives To assess the effectiveness and safety of nirmatrelvir/ritonavir in patients at high risk for severe COVID-19. Material and Methods Prospective descriptive study from April to August 2022 of patients treated with nirmatrelvir/ritonavir. Sociodemographic variables, vaccination status, hospital admission, high risk factors for progression and concomitant treatment were recorded. Readmissions were recorded within 30 days of the end of antiviral treatment. Results 53 patients were included with a mean age of 64 years, 51% women and 49% men. 57% were vaccinated with 3 doses, 17% with 2 doses, 9% with 4 doses, 6% with 1 dose and 11% were not vaccinated. 34% (18/53) were hospitalised at the time of initiation of treatment. The most prevalent high-risk criteria were: 24% active treatment with myelotoxic chemotherapy, 21% treatment in the previous 6 months with anti-CD20 drugs, 14% over 80 years vaccinated with some risk factor for progression, 7% patients with onco-haematological treatment and 7% in treatment in the previous 3 months with inhibitors of the proteinkinase. 3 treatments were performed off-label for persistent covid. The mean number of days from the onset of symptoms to the start of treatment was 1.6 days. 23% of patients required dose adjustment due to renal impairment. 53% required adjustment of chronic treatment for interactions, mainly with metamizole, statins, fentanyl and diazepam. 2 patients received remdesivir and sotrovimab, 2 remdesivir and another two sotrovimab. 4 (7%) patients were readmitted within 30 days after the end of treatment with nirmatrelvir ritonavir, 1 of them with persistent covid. One patient stopped treatment for hives. Conclusion and Relevance Nirmatrelvir ritonavir has been shown to be a safe and effective drug in high-risk patients of progression to severe covid.

Idiopathic anomalous congenital band causing small intestinal obstruction in a 5-month-old dog

A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.

Monitored Anesthesia Care in Uterine Artery Embolization for Leiomyomas and Adenomyosis

Background: Patients undergoing an interventional radiology procedure report some degree of anxiety. Therefore, procedure-related anxiety needs to be managed. The aim of our study was to investigate patient satisfaction with monitored anesthesia care (MAC) for uterine artery embolization (UAE)-related procedural anxiety in symptomatic uterine fibroids or adenomyosis. Method(s): Between May 2021 and June 2022, 36 patients with symptomatic fibroids or adenomyosis underwent UAE with MAC. Follow-up evaluations consisted of clinical symptoms, degree of satisfaction with MAC in UAE, and complications. Result(s): MAC in UAE was successfully performed in all patients. UAE significantly reduced patients' complaints such as bleeding and pain: the scores for bleeding and pain were significantly reduced after 3 months of UAE compared with those before UAE, indicating the effectiveness of UAE. The mean score of satisfaction with MAC in UAE was 4.3 points, meaning that 94.4% of women were satisfied or very satisfied. No major complications were observed. Conclusion(s): MAC in UAE for symptomatic uterine fibroids or adenomyosis can be emotionally effective and safe for patients who are anxious about the procedure.Copyright © 2023 The Author(s).

Fatal drug use in the COVID-19 pandemic response: Changing trends in drug-involved deaths before and after stay-at-home orders in Louisiana.

The effect of disaster events on increasing drug-involved deaths has been clearly shown in previous literature. As the COVID-19 pandemic led to stay-at-home orders throughout the United States, there was a simultaneous spike in drug-involved deaths around the country. The landscape of a preexisting epidemic of drug-involved deaths in the United States is one which is not geographically homogenous. Given this unequal distribution of mortality, state-specific analysis of changing trends in drug use and drug-involved deaths is vital to inform both care for people who use drugs and local policy. An analysis of public health surveillance data from the state of Louisiana, both before and after the initial stay-at-home order of the COVID-19 pandemic, was used to determine the effect the pandemic may have had on the drug-involved deaths within this state. Using the linear regression analysis of total drug-involved deaths, as well as drug-specific subgroups, trends were measured based on quarterly (Qly) deaths. With the initial stay-at-home order as the change point, trends measured through quarter 1 (Q1) of 2020 were compared to trends measured from quarter 2 (Q2) of 2020 through quarter 3 (Q3) of 2021. The significantly increased rate of change in Qly drug-involved deaths, synthetic opioid-involved deaths, stimulant-involved deaths, and psychostimulant-involved deaths indicates a long-term change following the initial response to the COVID-19 pandemic. Changes in the delivery of mental health services, harm reduction services, medication for opioid use disorder (MOUD), treatment services, withdrawal management services, addiction counseling, shelters, housing, and food supplies further limited drug-involved prevention support, all of which were exacerbated by the new stress of living in a pandemic and economic uncertainty.

"A lotta people switched playing hard ball to playing Russian roulette": Experiences with rising overdose incidence caused by drug supply changes during the COVID-19 pandemic in the San Diego-Tijuana border metroplex.

Background: People who use drugs (PWUD) in the San Diego, USA and Tijuana, Mexico metroplex face high overdose risk related to historic methamphetamine use and relatively recent fentanyl introduction into local drug supplies. The personal overdose experiences of PWUD in this region are understudied, however, and may have been influenced by the COVID pandemic. Methods: From September-November 2021, we conducted 28 qualitative interviews among PWUD ≥18 years old sampled from an ongoing cohort study in the San Diego-Tijuana metroplex. Interviews explored overdose experiences and changes in the drug supply. Thematic analysis of coded interview transcripts explored overdose experiences, perspectives on drug supply changes, interactions with harm reduction services, and naloxone access. Results: Among 28 participants, 13 had experienced an overdose. Participants discussed rising levels of fentanyl in local drug supplies and increasing overdose incidents in their social networks. Participants discussed a general shift from injecting heroin to smoking fentanyl in their networks. Participants' most common concerns included having consistent access to a safe and potent drug supply and naloxone. Conclusion: Participants prioritized adapting to drug supply changes and preventing overdose compared to other health concerns, such as HIV and COVID-19. Efforts to address overdose in this region could benefit from drug checking services and expanded, equitable delivery of naloxone.

Localized Syndemic Assemblages: COVID-19, Substance Use Disorder, and Overdose Risk in Small-Town America

Pandemics do not exist in isolation and COVID-19 is no exception. We argue that existing health crises, notably substance use disorder (SUD), developed syndemic relationships with COVID-19 that produced compounding deleterious effects. Combining Merrill Singer's theory of syndemics and assemblage theory, we analyze the combinatory impact of overdose and COVID-19 within a localized context. We focus on Sandusky, Ohio, where we combine police reports, in-depth interviews with area residents, and ethnographic data to compare conditions before and after the emergence of COVID-19. We find dramatic shifts in relevant local contexts due to COVID-19, inhibiting existing systems of law and public policy aimed at overdose prevention and SUD treatment. Further, our findings provide evidence of complications in the COVID-19 response originating from the overdose epidemic.

Anesthetic management of toxic epidermal necrolysis: a report of two cases

Toxic epidermal necrolysis (TEN), is an acute, life-threatening emergent disease involving the skin and mucous membranes with serious systemic complications. It is characterized by widespread epidermal sloughing. Drugs are the most common triggers of TEN, but infection, vaccination, radiation therapy and malignant neoplasms can all induce it in susceptible patients. We report two cases in whom a hair dye and a COVID-19 vaccine (BioNTech, Pfizer) were believed to be the causative agents. These patients have to undergo repeated debridements of the necrotic tissue. In this manuscript the anesthetic management of TEN patients is discussed. Detailed preoperative evaluation, aggressive fluid and electrolyte replacement, avoidance of hypothermia during debridement, minimizing anesthetic agents and limiting traumatic procedures are key points in the management.Copyright © 2023 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.

Enumerating contributions of fentanyls and other factors to the unprecedented 2020 rise in opioid overdose deaths: model-based analysis.

In 2020, the ongoing US opioid overdose crisis collided with the emerging COVID-19 pandemic. Opioid overdose deaths (OODs) rose an unprecedented 38%, due to a combination of COVID-19 disrupting services essential to people who use drugs, continued increases in fentanyls in the illicit drug supply, and other factors. How much did these factors contribute to increased OODs? We used a validated simulation model of the opioid overdose crisis, SOURCE, to estimate excess OODs in 2020 and the distribution of that excess attributable to various factors. Factors affecting OODs that could have been disrupted by COVID-19, and for which data were available, included opioid prescribing, naloxone distribution, and receipt of medications for opioid use disorder. We also accounted for fentanyls' presence in the heroin supply. We estimated a total of 18,276 potential excess OODs, including 1,792 lives saved due to increases in buprenorphine receipt and naloxone distribution and decreases in opioid prescribing. Critically, growth in fentanyls drove 43% (7,879) of the excess OODs. A further 8% is attributable to first-ever declines in methadone maintenance treatment and extended-released injectable naltrexone treatment, most likely due to COVID-19-related disruptions. In all, 49% of potential excess OODs remain unexplained, at least some of which are likely due to additional COVID-19-related disruptions. While the confluence of various COVID-19-related factors could have been responsible for more than half of excess OODs, fentanyls continued to play a singular role in excess OODs, highlighting the urgency of mitigating their effects on overdoses.

Trends and correlated outcomes in population-level prescription opioid and transdermal fentanyl use in Israel.

BACKGROUND: In the last twenty years, there was a documented increase in prescription opioid procurement in Israel. However, there is still little evidence of the association between opioid procurement rates, health service utilisation in secondary care, and enrollment rates to substance use disorder treatment programmes. In this study, we show trends in the reports of opioid-related hospitalisations, emergency department visits, enrollment to community-based outpatient treatment for Prescription Opioid Use Disorder and opioid-related mortality rates. Additionally, we examine potential correlations between these health service utilisation rates and prescription opioid procurement rates at the population level, with a focus on transdermal fentanyl. METHODS: A longitudinal study at the population level. We used seven-year data on indicators of opioid-related morbidity, prescription opioid procurement data for 2015-2021, and six-year opioid-related mortality data for 2015-2020. We measure the correlation between procurement rates of prescription opioids in Oral Morphine Equivalent per capita, and aggregated rates obtained from hospital administrative data for hospitalisations, emergency department visits, and patient enrolment in specialised prescription opioid use disorder outpatient treatment in the community setting. RESULTS: Between 2015 and 2021, procurement rates in primary care per capita for all prescription opioids increased by 85%, while rates of transdermal fentanyl procurement increased by 162%. We found a significant positive correlation at the population level, between annual opioid procurement rates, and rates per population of opioid-related visits to emergency departments (r = 0.96, p value < 0.01, [CI 0.74-0.99]), as well as a positive correlation with the rates per population of patient enrolment in specialised prescription opioid use disorder outpatient treatment (r = 0.93, p value = 0.02, [CI 0.58-0.99]). Opioid-related mortality peaked in 2019 at 0.31 deaths per 100,000 but decreased to 0.20 deaths per 100,000 in 2020. CONCLUSION: Data shows that all-opioid and transdermal fentanyl procurement has increased yearly between 2015 and 2021. This increase is positively correlated with a growing demand for community-based Prescription Opioid Use Disorder outpatient treatment. Efforts to reduce opioid-related morbidity may require effective approaches toward appropriate prescribing, monitoring, and further increasing access to prescription opioid outpatient treatment.