Optimizing Medication Treatment of Opioid Use Disorder During COVID-19 (SARS-CoV-2)

The COVID-19 health crisis joined, rather than supplanted, the opioid crisis as the most acutely pressing threats to US public health. In the setting of COVID-19, opioid use disorder treatment paradigms are being disrupted, including the fact that methadone clinics are scrambling to give "take-home"doses where they would typically not. The rapid transition away from in-person examination, dosing and group therapy in an era of social isolation calls for adjustments to clinical practice, including emphasizing patient-provider communication, favoring new inductees on buprenorphine and leveraging technology to optimize safety of medication treatment. Copyright © 2020 American Society of Addiction Medicine.

COVID-19 and pulmonary Tubercuiosis coinfection: three case reports from Iran

Tubercuiosis is still a significant problem worldwide. Until the COVID-19 pandemic, tuberculosis was the leading cause of mortality from a single infectious agent. Pulmonary Tubercuiosis patients are more tending to be co-infected with COVID-19 notably when they have a history of exposure. There are some case reports relating to pulmonary TB and COVID-19 coinfection but the information about TB and COVID-19 was still little. We report three coinfected patients. Case one and two were both middle-aged Iranian mans with history of opium addiction, case one presented with dyspnea and weakness and case two presented with progressive weakness. Case three was a healthy young man with history of progressive dyspnea, productive cough and hemoptysis. Case one and case three were improved. In conclusion, COVID-19 is still an important issue and can coexist with other lung infections such as Pulmonary Tubercuiosis, so we should be aware of the advancement of the Tubercuiosis epidemic after the COVID-19 pandemic.Copyright © 2023 Tuberculosis Association of India

Clinical applications of transcutaneous auricular neurostimulation for opioid use disorder and pain

Symposium title: Addressing chronic pain and the opioid epidemic using auricular neuromodulation Symposium description: Our proposed symposium integrates a diverse group of scientist and clinician experts (Drs. Cunningham, Wilkes, Khodaparast, Badran) who have committed to exploring the anti-nociceptive and opioid sparing effects of auricular neuromodulation to progress toward non-opioid interventions for chronic pain and opioid use disorders. The demand for chronic pain therapies has increased at an unprecedented rate over the last several decades, contributing in part to a surge in prescription and illicit opioid demand. Countless patients were escalated to prolonged, high-dose opioid regimens over years of treatment. By 2014, 5.4% of U.S. adults were estimated to use prescription opioids on a long-term basis. As the harms of opioid proliferation became increasingly clear, a dramatic paradigm shift occurred in which these drugs are now perceived as more dangerous than beneficial for chronic pain. New clinical guidelines highlight the risks of high-dose regimens as well as the limited benefits, particularly insufficient analgesia and hyperalgesia, associated with long-term use. According to this new perspective, the preferred therapeutic modality for many patients is to safely taper, or even completely stop, using opioids. Transcutaneous auricular neurostimulation (tAN) is a novel therapeutic paradigm that includes stimulation of both the auricular branch of the vagus nerve and auriculotemporal nerve (branch of trigeminal). tAN therapy results in clinically significant reductions in opioid withdrawal symptoms associated with opioid detoxification and tapering. Either adjunctive vagal or trigeminal stimulation modulates pain transmission suggesting overlapping common effector pathways, possibly targeting the endogenous opioid system, which could lead to a synergistic therapeutic benefit for pain. This symposium will explore the scientific basis for this hypothesis across targeted and interconnected topics, including fundamental neuropharmacological mechanisms underlying pain and opioids, clinical challenges of tapering opioids, managing opioid withdrawal symptoms with tAN, and the prospects for tAN to deliver a safe alternative treatment option for pain disorders. The United States is experiencing an epidemic for prescription and non-prescription opioids, which have continued to rise since the 1990s. During 2015, approximately 2.1 million people were severely dependent on prescription opioids, and 513,000 on heroin. In 2020, the Centers for Disease Control reported 93,331 substance use overdose deaths. The continuing increase in opioid-related deaths from 2015 (18%) to 2020 (60%) is partly attributed to the mental health crisis during the Covid-19 pandemic. Aside from pain mitigation, individuals with opioid use disorder (OUD) may be motivated to continue drug-seeking by both the positive reinforcement of the euphoric effects of opioids and the negative reinforcement of opioid withdrawal symptoms due to cessation. Alternative approaches for OUD are a major priority for government agencies given the substantial impact on health, social, and economic welfare. Transcutaneous auricular neurostimulation (tAN) is a non-invasive form of vagus and trigeminal neuromodulation that was recently proven to be an efficacious non-pharmacologic based treatment for reducing opioid withdrawal symptoms. In 2021, tAN therapy received FDA clearance as an adjunctive treatment for opioid withdrawal symptoms in adults. tAN therapy was also proven safe and effective in reducing symptoms of neonatal opioid withdrawal syndrome (NOWS) in neonates. tAN as an adjuvant was safe, well-tolerated, while facilitating the successful rapid weaning of oral morphine and decreasing length of stay in the neonatal ICU. Based on these preliminary findings, tAN therapy is currently in two NIH-funded pivotal clinical trials to: 1) evaluate the long-term effects of tAN on opioid use relapse prevention and cravings in adults with OUD, and 2) determine f tAN therapy can reduce withdrawal symptoms and reduce morphine length of treatment for neonates with NOWS. Lastly, we will explore how tAN could be utilized as neuromodulatory approach for opioid sparing, and ultimately pain mitigation. Research Category and Technology and Methods Clinical Research: 12. Vagus Nerve Stimulation (VNS) Keywords: Vagus Nerve Stimulation, Opioid Use Disorder, Pain, NeurostimulationCopyright © 2023

The Promise and Challenges of Integrating Real-World Evidence in Clinical Research

The role of real-world evidence (RWE) in regulatory, drug development, and healthcare decision-making is rapidly expanding. While RWE cannot substitute the evidence obtained from randomized controlled studies (RCTs), the two can be viewed as complementary sources with the same goal of understanding and improving patient's outcomes. However, the hopes of RWE have been tempered by several critical aspects/ challenges such as quality of data sources, potential for systematic bias, or formulating a research question using causal inference framework. In this session, we will discuss commonly encountered issues and recommend key methodological considerations and potential solutions for (1) assessing representativeness and generalizing results from experimental to non-experimental studies, (2) identifying under-represented groups in clinical trials for pharmacotherapy for opioid use disorder, (3) characterizing and increasing diversity in clinical trials, and (4) assessing biases and constructing valid ''synthetic control'' arms for (oncology) clinical trials. Each speaker will have 15-20 min each, followed by a 10-min discussion. Additional Q&A time will be allocated at the end of the session. The individual s are described in more detail below. (1) Ben Ackerman;Title: Using real-world data to assess representativeness and improve generalizations of study findings Randomized trials are considered the gold standard for estimating causal effects. Trial findings are often used to inform policy and programming efforts, yet their results may not generalize well to a relevant target population if the trial sample is not representative of the population of interest. More specifically, generalizations will be hindered if a trial is not similar to the population with respect to characteristics that moderate the treatment effect. Statistical methods have been developed to assess representativeness and improve generalizability by combining trials with data from non-experimental studies. Real-world datasets derived from electronic health records are promising resources that can supplement trial data when applying such methods. However, identifying the right real-world data source with the appropriate characteristics captured can be challenging in practice. In this talk, we will articulate a framework for combining trial and real-world data to assess representativeness and ultimately addressing concerns of generalizability. Through this framework, we will provide guidance on defining the target population of interest, identifying a suitable real-world data source describing that population, harmonizing across the data sources, and drawing meaningful comparisons between the trial and target population. This work will provide researchers with methods and tools to contextualize trial findings within the target population of interest through the use of real-world data. (2) Kara Rudolph;Title: Characterizing subgroups that are under-represented in clinical trials for pharmacotherapy for opioid use disorder The opioid epidemic in the United States is a public health emergency, exacerbated by the Covid-19 pandemic. Medications for opioid use disorder (MOUD)- injection naltrexone, buprenorphine, and methadone- are the most effective tools for improving outcomes and preventing overdose among persons with opioid use disorder (OUD), but engagement in MOUD, especially long-term engagement typically required for a successful outcome, is unacceptably low. Long-term engagement rates tend to be even lower in real-world settings-what National Institute on Drug Abuse (NIDA) has termed the research-to-practice gap. This discrepancy between trial and real-world MOUD effectiveness could be partially attributable to differences between clinical trial and real-world population characteristics (e.g. in terms of psychiatric and substance use comorbidities, previous treatment experience, and immigration status) if treatment effects are modified (increased/decreased) by some of these characteristics that also relate to trial participation. We identif and characterize clinically meaningful, interpretable subgroups of persons seeking OUD treatment in US usualcare settings who are not represented or underrepresented in MOUD trials based on multiple characteristics simultaneously. This moves us beyond existing approaches for assessing representation that have generally been limited to considering one individual-level characteristic at a time (e.g. race/ethnicity). (3) Madison Stoms;Title: Minority representation in clinical trials: generalizing trial results to diverse populations Since its origin, medical research has persistently lacked minority representation. In 2020 alone, the US Food and Drug Administration (FDA) reported that a mere 6% and 11% of clinical trial participants report Black and Hispanic race, respectively. Along with efforts to directly increase representation, via revised recruitment strategies, methods are being developed to leverage external data containing information on under-represented populations. The field from which these methods arise, real-world evidence (RWE), is rapidly emerging and aims to address clinical questions outside the scope of clinical trials. In this talk, we focus on generalizability and transportability methods, which can be used to extrapolate results from mostly racially homogeneous samples to diverse populations. We will also discuss the current state of diversity in clinical trials, important assumptions of generalizability and transportability methods, and applications relevant to increasing racial/ethnic representation. (4) Elizabeth Garrett-Mayer;Title: Leveraging RWD for new indications for FDA-approved anticancer agents: are we there yet? Vast amounts of health outcome data are available in real-world datasets (RWDs), like electronic health record databases and medical claim databases. In rare disease settings, performing randomized trials may be resource-intensive and inefficient due to accrual challenges. Efforts have been made to derive ''control arms'' from RWDs, representing a standard of care treatment arm, so all (or most) patients prospectively enrolled in a trial can be assigned to an experimental arm. Major challenges exist in ensuring that comparisons between the arms are meaningful, valid, and unbiased. This talk will discuss challenges, including potential for biases, harmonizing outcome measures, and efforts moving forward that will facilitate supplementing clinical trial data with RWD.

The Virtues of Osteopathic Manipulative Treatments in Patients with Opioid Use Disorder

As America continues to face the opioid epidemic, numerous people have made great strides in receiving formal treatment for their opioid use disorder (OUD). This research seeks to examine the effects of providing osteopathic manipulative treatment (OMT) along with traditional OUD pharmacological methods in providing results for patients. By using prior research on OMT techniques, we were able to uncover how effective OMT can be in reducing the time and discomfort associated with seeking opioid recovery. Osteopathic manipulative treatment, in combination with traditional pharmacology, was associated with reduction of somatic pain, higher success with medication-assisted treatment and lower costs. This research also highlights the importance of OMT in the era of COVID-19 social distancing, as well as special considerations when treating those with trauma histories associated with their disorder. We argue the benefit of OMT in combination with pharmacological methods can be successful at reducing the overall burden of prior OUDs.Copyright © 2023 by the American College of Osteopathic Family Physicians. All rights reserved.

Pneumopericardium in COVID-19 Infection

Pneumopericardium is a rare medical condition that occurs following trauma, surgery, or other medical interventions. The presence of pneumopericardium after COVID-19 pneumonia has been reported in some cases, and it has been explained that most cases could be self-limited. Here, we describe a 51-year-old man afflicted by pneumopericardium with COVID-19 infection. The patient had pneumopericardium and massive pericardial effusions, necessitating surgical strategies such as pericardial windows. This case highlights the potential severity of COVID-19. We also suggest that cardiologists pay attention to the possibility of pneumopericardium in cases with COVID-19 infection. © 2023, Iranian Heart Association. All rights reserved.

Confronting the devastating 'Twindemic': Drug overdose deaths and the COVID-19

The last 25 years have seen a dramatic increase in drug overdose related deaths in both the industrialized and developing countries. Hundreds of thousands of people die every year. This human tragedy has recently been complicated by the COVID-19 epidemic, sidelining the minimal effort that was being implemented. As a global community, the governments, medical institutions, NGOs and the general public need to focus on this devastating human tragedy before more lives are lost senselessly, and unnecessarily. Increased public awareness about new approaches to manage the already afflicted ones including targeted, minimally invasive procedures is required. In addition, the focus needs to be on aggressive research and development of innovative and safer medications and newer modalities for those suffering from chronic pain. This paper offers a perspective, context and a vision for future. Copyright © 2022 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.

Fentanyl Hits Social Media: Lethally Laced Pills Are Causing Crisis for Youth in America

Objectives: Rates of illicit prescription pill use are increasingly high among young people, and overdoses are among the leading causes of preventable death. The authors aimed to review recent literature on the use of controlled substances, such as opioids and benzodiazepines, among teenagers and young adults in the United States. Specifically, the authors explored how these drugs are being obtained via social media platforms. The authors sought to determine how common, and how dangerous, this practice has been since the start of the COVID-19 pandemic. Resources were also reviewed for education and treatment of substance use to combat this ongoing crisis. Method(s): A literature search was conducted using the MEDLINE/PubMed database to identify papers describing the use of controlled substances among teenagers and young adults in the United States. The authors identified studies and reviewed articles published in English between 2018 and 2022 (inclusive), searching keywords including "fentanyl," "opioids," "benzodiazepines," "substance abuse," and "social media." Results: The initial search resulted in over 1000 papers. After careful review, the authors focused on a subset of data that included adolescent and young adult populations, during the time period since the start of the COVID-19 pandemic, and including evidence of drug access via internet and social media platforms. While there are multiple examples of substance use and overdose-associated deaths in adolescent populations, data are limited about the prevalence of fentanyl-induced overdose from substances obtained by youth through social media. Federal data included the striking statistic that, while overall substance use by teenagers has decreased over the past decade, the rate of fentanyl-associated deaths has more than doubled in the past 3 years. Conclusion(s): With the pandemic-associated isolation syndemic and the abundance of social media platforms at the fingertips of adolescents and young adults, the opioid crisis continues now as fentanyl, a synthetic opioid drug, surreptitiously leads to lethal overdoses. More research, and more awareness, is needed to educate our youth, caretakers, teachers, and providers about life-threatening consequences associated with substance use, including in the form of pills obtained via social media. SUD, ADOL, MED Copyright © 2022

BLUE FINGERS, EOSINOPHILIC LUNGS: ACUTE EOSINOPHILIC PNEUMONIA FOLLOWING COVID-19 INFECTION

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Acute eosinophilic pneumonia is a rare illness characterized by eosinophilic infiltration of the lung parenchyma. Cases often present with fever, severe dyspnea, bilateral infiltrates, and eosinophilia on BAL exams. The cause of eosinophilic pneumonia is unknown, but is thought to be related to inhalational exposure of an irritant or toxin. Most cases are responsive to steroid treatment. This case demonstrates acute eosinophilic pneumonia in a patient who recently recovered from COVID-19 pneumonia. CASE PRESENTATION: A 50 year old female with a history of multiple sclerosis, seizure disorder secondary to MS, Irritable Bowel Syndrome, and a distant history of tobacco smoking and opiate dependence on chronic suboxone therapy, presented with dyspnea secondary to respiratory failure. The patient was urged to present by her husband after findings of hypoxia to 79% on room air with cyanosis of the lips and fingers. She recently recovered from COVID-19 1 month prior, at which time she had symptoms of cough productive of red mucus, fever, and exhaustion;but states she never returned to her baseline. With ongoing hypoxia, the patient was intubated for mechanical ventilation. Subsequent bronchoscopy with BAL resulted in a elevated eosinophil count to 76%, with fungal elements and PCR positive for HSV-1. The patient was initiated on high dose glucocorticoid therapy in addition to Acyclovir and Voriconazole. A CT with IV contrast revealed extensive bilateral pulmonary emboli involving the segmental and subsegmental branches throughout both lungs and extension into the right pulmonary artery;the patient was started on anticoagulation. Shortly after beginning glucocorticoid therapy, the patient had significant improvement and was able to be weaned off ventilation to simple nasal cannula. She was able to be safely discharged home with two liters of supplemental oxygen and steroid taper. DISCUSSION: Acute Eosinophilic pneumonia is a rare condition with an unknown acute disease process. The diagnostic criteria for acute eosinophilic pneumonia includes: a duration of febrile illness less than one month, hypoxia with an SpO2 <90%, diffuse pulmonary opacities, and otherwise absence of inciting causes of pulmonary eosinophilia (including asthma, atopic disease, or infection). Diagnosis of eosinophilic pneumonia is attained after meeting clinical criteria with a BAL sample demonstrating an eosinophilia differential of >25%. The mainstay of treatment for this condition is glucocorticoid therapy with most cases resolving rapidly after treatment. CONCLUSIONS: Fewer than 200 cases of acute eosinophilic pneumonia have been reported in medical literature. It is imperative to keep a wide differential as critical illness may be rapidly improved with appropriate therapy. The cause of acute eosinophilic pneumonia is largely unknown, it is unclear what role COVID-19 may have played in the development of this pneumonia. Reference #1: Allen J. Acute eosinophilic pneumonia. Semin Respir Crit Care Med. 2006 Apr;27(2):142-7. doi: 10.1055/s-2006-939517. PMID: 16612765. Reference #2: Nakagome K, Nagata M. Possible Mechanisms of Eosinophil Accumulation in Eosinophilic Pneumonia. Biomolecules. 2020 Apr 21;10(4):638. doi: 10.3390/biom10040638. PMID: 32326200;PMCID: PMC7226607. Reference #3: Yuzo Suzuki, Takafumi Suda, Eosinophilic pneumonia: A review of the previous literature, causes, diagnosis, and management, Allergology International, Volume 68, Issue 4, 2019, Pages 413-419, ISSN 1323-8930 DISCLOSURES: No relevant relationships by Tayler Acton No relevant relationships by Calli Bertschy No relevant relationships by Stewart Caskey No relevant relationships by Shekhar Ghamande No relevant relationships by Tyler Houston No relevant relationships by Zenia Sattar No relevant relationships by Heather Villarreal

Hybrid Pain Management Strategy Attenuated Acute Pain and Reduced Left-Over Opioid Doses

Problem: Clinicians treating postprocedure acute pain after third molar removal face a twofold challenge: attenuating pain levels while simultaneously limiting leftover opioid doses. Strategies for achieving the dual goals range from “letting patients decide,” which can lead to leftover doses and misuse, or “letting clinicians decide,” only prescribing opioids for those predicted to experience severe discomfort, which risks under-managing acute pain. A hybrid strategy relies on joint decision-making between the patient and clinician. The hypothesis for this IRB-approved prospective study was that a hybrid-strategy would be successful in moderating acute pain and reducing leftover opioid doses. Methods and Materials: This study included patients who met the American Society of Anesthesiologists, risk classification I or II, ages 18 to 35 years, with at least 2 mandibular third molars removed. Patients being treated for opioid addiction/abuse were excluded. All enrolled subject patients were consented and treated with a multimodal analgesic protocol consisting of intraoperative IV preventive antibiotics, dexamethasone, ketorolac, ondansetron, local anesthetics including liposomal bupivacaine and postoperative cold therapy, and scheduled ibuprofen. Patients were given 2 prescriptions (Rx), each for 4 doses of Hydrocodone/APAP 5/325, to be taken as needed for pain;1 Rx could be filled on the day of surgery, the second on any subsequent day. Opioid Rx data were retrieved from patient records and North Carolina Controlled Substances Reporting System. Pain scores and opioid-use data for each postsurgery day (PSD) were derived from a 14-day diary recorded by subjects. For the patients in this series, the goal was median pain levels ranked 1 or 2 on a 7-point scale, meaning no pain and minimal pain by postoperative day (POD) 3. Descriptive statistics were used for analyses. Results: Data were analyzed from 96 eligible patients treated consecutively from 2018 to 22, with a 15-month hiatus from COVID-19. Fifty-two patients (54%) did not fill an opioid prescription. Twenty-seven patients (28%) filled 1 opioid prescription and 17 patients (18%) filled 2 of the prescriptions. The patients who filled 1 prescription had 72 leftover doses (67% of possible doses), and the patients who filled 2 prescriptions had 50 leftover doses (74% of possible doses). Median worst pain levels reached 1 to 2 out of 7 on POD 4;median average pain on POD 3. Conclusions: The hybrid strategy reduced the number of opioid doses in circulation without compromising the patient's postoperative pain level. Decreasing the number of leftover opioid doses is an important step toward addressing opioid addiction and overdose. References: 1 Magraw CBL, Pham M, Neal T, Kendell B, Reside G, Phillips C, White RP Jr: A multimodal analgesic protocol may reduce opioid use after third molar surgery: A pilot study. Oral Surg Oral Med Oral Path Oral Radiol 126:214, 2018. 2 Pham M, Magraw C, Neal T, Kendell B, Reside G, Phillips C, White R: A Multi-modal Analgesic Protocol reduced opioid use/misuse after 3rd Molar Surgery: An Exploratory Study. Submitted Oral Surg Oral Med Oral Path Oral Radiol March 2019 3 Pham M, Magraw C, Neal T, Kendell B, Reside G, Phillips C, White R: A Multimodal Analgesic Protocol reduced acute pain levels after 3rd molar surgery. In preparation JOMS 4 White RP Jr, Shugars DA, Shafer DM, Laskin DM, Buckley MJ, Phillips C: Recovery after third molar surgery: clinical and health-related quality of life outcomes. J Oral and Maxillofacial Surgery 61:535, 2003. 5 American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 116:248, 2012 6-Savarese JJ, Tabler NG Jr: Multimodal analgesia as an alternative to the risks of opioid monotherapy in surgical pain management. J Health Care Risk Manag 37:24, 2017

Donation after circulatory death liver transplants are higher and unevenly distributed in the United States after the implementation of the acuity circle allocation policy

Background: This study aimed to assess the impact of the recently (02/2020) implemented Acuity Circles (AC) liver allograft allocation policy on MELD at transplant and Donation after Circulatory Death (DCD) rates. Methods: Study period: 01/2016- 08/2021. Data retrieved from SRTR database. Inclusion criteria: All DCD liver transplants (LT). The cohort was dichotomized into a pre- and post-AC era. DCD rate (defined as DCD/ 50k population/year) was calculated for each State. The change (Δ) on the DCD rate (ΔDCD) and the MELD (ΔMELD) between the two periods was also calculated. Results: 1. Total LT increased in the post-AC era (26%/50k vs. 15%/50k, p=0.0567). 2. DCD LT increased in the post-AC era (15%/50k vs.10%/50k, p=0.0885). 3. MELD increased in the post-AC era in nearly all States (ΔMELD, fig.1, 2 & 3). 4. Uneven distribution of pre- & post-AC DCD activity, with a few States driving DCD LT in the US (fig.4 & 5). 5. Arizona and Louisiana had the highest pre-AC DCD rates (58%/50k & 31%/50k, respectively;fig.3). 6. The top post-AC DCD rate was reached in Arizona (78%/50k, fig.5). 7. Top post-AC ΔDCD was noted in Arkansas & Arizona (fig.6). 8. The highest ΔMELD was noted in low DCD/ negative ΔDCD areas (fig.7). 9. The lowest ΔMELD was noted in areas with the highest DCD rate (fig.7) 10. The State with the highest DCD rates pre-AC had the highest ΔDCD (fig.5). 11. 10/11 States with negative ΔDCD were located North of the 35o. Conclusions: AC implementation coincided with an increase in the overall LT & DCD LT activity. However, causation remains to be clarified, given the concurrent opioid crisis and SARS-CoV-2 pandemic. There was remarkable DCD rate variation. States with high DCD rates/ΔDCD demonstrated greater adaptability in the allocation change, maintaining low ΔMELD across eras. (Figure Presented).

A Retrospective Cohort Study of SARS-CoV-2 Mortality Rate in Individuals with Opioid Use Disorder in Ilam (Southwest of Iran)

Background & Objective: Individuals with opioid use disorder are a marginalized population in any society. They commonly have a weaker immune system, greater stress vulnerability, poorer health, more high-risk behaviors, and less access to healthcare services compared to the general population, which can expose them to a risk of severe COVID-19 complications. This study aimed to evaluate the effects of opioid use disorder on mortality in patients with SARS-CoV-2. Materials & Methods: This registry-based retrospective cohort study was conducted on 2362 consecutive inpatients with a confirmed diagnosis of SARS-CoV-2 between March 5, 2020 and March 21, 2021, presenting to a university hospital in Ilam in the southwest of Iran. Forty-five patients with opioid use disorder were identified in this study and matched to 100 patients without opium addiction. All patients with a history of opium addiction were included in the study group, and age-and sex-matched patients without opioid use disorder were randomly recruited as the controls. After adjusting for the effects of age and comorbidities, data were analyzed in STATA version 10, using logistic regression models. Results: The mortality of patients with opioid use disorder increased following COVID-19 (adjusted OR: 6.59;95% CI: 1.84–23.59;P=0.004). Hypertension (adjusted OR: 8.17;95% CI: 2.21–30.15;P=0.002) and advancing age (OR: 1.06;95% CI: 1.01–1.11;P=0.01) were significantly associated with increased COVID-19 mortality. Conclusion: Based on the present findings, opioid use disorder is a possible risk factor for mortality following COVID-19. The findings of the present study can be applied in the implementation of preventive measures and policies and prioritization of COVID-19 vaccination. However, further relevant research is recommended.

Evaluation of Psychiatric Counseling for Patients Hospitalized with COVID-19 in a University-Affiliated General Hospital in Tehran, Iran

Background: Coronavirus disease 2019 (COVID-19) is associated with a number of psychiatric problems in patients;however, mental healthcare in these patients does not appear to be adequate. Objectives: This study aimed to evaluate the extent of psychological care provided to COVID-19 patients admitted to the hospital and the most common reasons for psychiatric counseling. Methods: This study examined the electronic medical records of all COVID-19-positive patients admitted to Rasoul-e-Akram hospital in Tehran, Iran, within April 1 and September 30, 2020 (approximately 2200 cases). Results: Psychiatric consultation was requested for 5.45% of admitted patients with COVID-19 diagnosis based on a positive real-time reverse transcription-polymerase chain reaction. More than half of those who received psychiatric counseling had a previous psychiatric disorder. The most common reason for requesting psychiatric counseling in patients with a previous psychiatric disorder was the patient’s evaluation and management;the most common reason in patients without a psychiatric disorder was agitation and lack of cooperation. The most common diagnosis in patients with a positive history of psychiatric disorder was bipolar disorders (33.9%), followed by opioid use disorder (29%). Adjustment disorder (54%) and delirium (26%) were the most common diagnoses in patients without a history of psychiatric disease. Conclusions: The current study showed that psychiatric counseling in COVID-19 patients was limited to a small number, including those with a positive history of psychiatric illnesses and prominent psychiatric symptoms.

UTILIZATION OF DRUG OVERDOSE DONORS FOR LIVER TRANSPLANTATION DURING COVID-19 PANDEMIC

Background: The increasing number of deceased drug overdose donors (DOD) has paralleled the recent rise in the opioid epidemic, which has been further exacerbated by the COVID- 19 pandemic. While the transplant community has seen a rise in allografts donated by victims of drug overdose, we aim to characterize the recent shifts in DOD utilization during the pre-COVID and COVID eras. Methods: Using the United Network for Organ Sharing (UNOS) registry, we analyzed all adult recipients that underwent solid organ transplantation (SOT) including liver transplant (LT) in the United States from January 1, 2017 through June 30, 2021. The pre-COVID era was defined from January 1, 2019 to February 29, 2020 and the COVID era was defined from May 1, 2020 to June 30, 2021 (14 months each). We excluded March and April 2020 because transplant volume was adversely affected due to diversion of resources. DOD were identified using the UNOS variable that characterizes the mechanism of death of the donor. Tests of proportions and unpaired T-tests were performed to compare demographic information and clinical characteristics of DOD from the pre-COVID and COVID eras. Results: The number of donors for all SOT remained stable in the pre-COVID and COVID eras (14,029 vs 15,547). Likewise, the number of LTs remained stable (9,687 vs 10,096), reflected by a rise in DOD utilization. From the pre- COVID to the COVID eras, the utilization of DOD for SOT increased by 33% from 13.7% (n=1924) to 16.4% (n=2553) as shown in Table 1. This increase in DOD utilization during the pandemic was seen across all organ types with a significant rise for LT (pre-COVID n= 1465, 15.1% vs COVID n=1846, 18.3%;P<0.001). Among DOD, the percentage of young adult donors < 30 declined (31.2% vs 28.0%;P=0.022) in the COVID era. Similarly, the percentage of DOD with HCV seropositivity and HCV viremia decreased by 5.2% (34.3% vs 29.1%;P<0.001) and 4.3% (22.1% vs 17.8%;P<0.001) respectively. Regionally, there was a significant increase in DOD utilization in the South and Midwest (Table 1). Conclusion: The continued rise in the opioid epidemic has led to increased utilization of otherwise healthy DOD. This increase in DOD utilization has contributed to the steady transplant volume during the pandemic for all organ types, including LT. Fewer DOD with HCV during the pandemic reflects recent national trends. Unlike the early phases of the opioid epidemic, there is less of a regional distribution of utilization of allografts from DOD. (Table Presented)

Challenges and solutions for opioid dependence therapy during the SARS-COV-2 pandemic in Germany

The SARS-CoV-2 pandemic poses new challenges and requires new solutions for problems previously not faced by our generation. This particularly applies to the field of opioid dependence therapy due to the physical and psychological vulnerability of patients and the treatment model that often requires daily attendance. An overview is given of the responses of the physicians and the recommendations of medical societies in Germany during the year 2020 with a special focus on the lockdown periods and the challenges and guidelines for the patients, patient organizations and physicians, both outpatient and in prison. Reduced travel and empty inner cities led to reduced patient income combined with closed patient organizations during lockdown, leading to a temporary increase of patients in opioid dependence therapy. New hygiene procedures had to be implemented. A temporary change in the German Narcotics Prescription Ordinance, including longer periods for take-home prescriptions, allowed for ongoing supply with improved social distancing. Depot buprenorphine significantly reduces the risk of infection by avoiding the daily commute and presence at the practice with many other patients. This is even more favourable in prison settings by greatly reducing the movement of prisoners and diversion of drugs.