The Cyclical and Evolving Nature of Methamphetamine Use: An Evaluation of Near Real-time Urine Drug Test Results.

OBJECTIVE: To determine methamphetamine positivity and copositivity with other drugs in urine drug test (UDT) results geographically through time. METHODS: This cross-sectional study of UDT results from January 1, 2014, through December 31, 2019, included patient specimens submitted by health care professionals across the United States. The analysis used LC-MS/MS to detect cocaine, heroin, alcohol, marijuana and nonprescribed methamphetamine, fentanyl, methadone, buprenorphine, benzodiazepines, and other opioids. Logistic regression was used to evaluate association of demographic features and model yearly methamphetamine detection patterns across US census divisions. Odds ratios (OR) from logistic modeling were used to evaluate the impact of methamphetamine positivity on the spatio-temporal detection patterns of additional nonprescribed or illicit drugs. RESULTS: The probability of being positive for methamphetamine increased nationally from 0.010 [0.010-0.011] in 2014 to 0.044 [0.042-0.046] in 2019, a 340% increase after correction for demographic covariates. The highest predicted positivity rate was in male patients, 25- to 34-years-old, from the West North Central division and from substance use disorder treatment centers. Nationally, copositivity ORs for fentanyl, heroin, and other opioids with methamphetamine were highest in 2019. Increases in ORs from 2014 through 2019 were statistically significant for heroin (P = 0.024) and fentanyl (P = 0.0085). Copositivity ORs for methamphetamine and other substances varied by census division. CONCLUSIONS: The probability of being positive for methamphetamine in UDT increased nationwide between 2014 and 2019. Not all census divisions are increasing at the same rate. Copositivity with additional substances is increasing in some census divisions, which further increases the risk of overdose and poor treatment outcomes.

An Examination of State and Federal Opioid Analgesic and Continuing Education Policies: 2016-2018.

INTRODUCTION: Opioid overdose deaths in the United States have climbed sharply over the past two decades. Simultaneously, increased awareness of inadequately treated chronic pain has resulted in increased opioid analgesic prescribing. The correlation between these two phenomena has led policymakers to posit that they are causally linked, and to implement policy changes supporting safe opioid prescribing. PURPOSE: To evaluate the impact of its Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS) program, the US Food and Drug Administration (FDA) requested the opioid manufacturers responsible for implementing that program provide information regarding opioid policy changes from 2016 to 2018. FDA also requested a survey of state requirements for pain and opioid prescribing continuing education (CE), the number of prescribers affected by those requirements, the extent to which a REMS-compliant CE program would meet each state's requirements, and the number of relevant CE programs available. RESULTS: Results indicate that 527 federal and state opioid-related policies (statutes, rules/regulations, and guidelines) were approved during the 2016-2018 study period. While the largest number of these policies focused on prescription drug monitoring programs, 170 specifically imposed limits on opioid prescribing and an additional 35 specifically referred to, or incorporated, the Centers for Disease Control and Prevention opioid prescribing guideline. We also found that 46 states and the District of Columbia mandated some amount of pain or opioid prescribing CE for prescribers renewing their licenses. These mandates potentially affected as many as 1.7 million prescribers. In 69% of cases, a REMS-compliant CE program would fully meet the state mandates for various types of prescribers. CONCLUSION: The severity and complexity of the problems of pain management and opioid overdose have led to large-scale intervention by policymakers. Assessing the impact of these changes is difficult, at best, but will be necessary if interventions are to be refined to increase their effectiveness.

Rate of Fentanyl Positivity Among Urine Drug Test Results Positive for Cocaine or Methamphetamine.

Importance: Drug overdose deaths continue to increase, despite the leveling off of prescription opioid use and policy changes limiting opioid prescribing. Illicit fentanyl is the leading cause of drug overdose death, and it is important to characterize the emerging combination of other illicit drugs with fentanyl, which increases the risk of overdose. Objective: To determine whether rates of the combination of nonprescribed fentanyl with cocaine or methamphetamine have changed in urine drug test (UDT) results through time. Design, Setting, and Participants: This cross-sectional study of UDT results from January 1, 2013, through September 30, 2018, included patient specimens submitted for UDTs by health care professionals as part of routine care. Patients were selected from health care practices across the United States, including substance use disorder treatment centers, pain management practices, primary care practices, behavioral health practices, obstetrics and gynecology practices, and multispecialty groups. The UDT analysis used liquid chromatography-tandem mass spectrometry to detect benzoylecgonine (cocaine metabolite), methamphetamine, fentanyl, and norfentanyl. Specimens from individuals reported to have been prescribed fentanyl were excluded. A convenience sample approach was used to randomly select 1 million unique patient UDT specimens from Millennium Health's UDT database for further analysis. Each specimen had associated cocaine, methamphetamine, and fentanyl UDT results. Exposures: Medically necessary UDT to detect benzoylecgonine (cocaine metabolite), methamphetamine, fentanyl, and norfentanyl, ordered by a health care professional as part of routine patient care. Main Outcomes and Measures: Rates of nonprescribed fentanyl positivity among cocaine- or methamphetamine-positive UDT results, quantified through time. Results: In a sampling of 1 million unique patients' UDT specimens analyzed for cocaine and fentanyl (median [interquartile range] age, 44 [19-69] years; 55.0% women), positivity rates for nonprescribed fentanyl among the cocaine-positive results increased significantly, from 0.9% (n = 84) (95% CI, 0.7%-1.1%) in 2013 to 17.6% (n = 427) (95% CI, 16.1%-19.1%) in 2018, a 1850% increase (τ = 0.78; z = 9.45; P < .001). In the same sampling of 1 million specimens, positivity rates for nonprescribed fentanyl among the methamphetamine-positive results also increased significantly, from 0.9% (n = 29) (95% CI, 0.6%-1.2%) in 2013 to 7.9% (n = 344) (95% CI, 7.1%-8.7%) in 2018, a 798% increase (τ = 0.72; z = 8.75; P < .001). Conclusions and Relevance: An increasing number of UDT results positive for cocaine or methamphetamine were also positive for nonprescribed fentanyl. This provides additional insight into recently reported increases in cocaine- and methamphetamine-related overdoses. Stimulant users who may be opioid naive are at a heightened risk of overdose when exposed to fentanyl. Clinicians need to be aware that patients presenting for treatment of suspected drug overdose or substance use disorder may have been exposed, knowingly or unknowingly, to multiple substances, including the combination of stimulants and opioids.

Impact of opioid dose reduction on individuals with chronic pain: results of an online survey.

BACKGROUND: In 2016, the Centers for Disease Control and Prevention (CDC) released a guideline on opioid prescribing for primary care physicians. Patients with chronic pain receiving long-term opioid therapy were surveyed to assess the incidence and impact of opioid dose reduction following this guideline's promulgation. METHODS: Members of an advocacy organization for people with chronic pain were invited to participate in a 16-item, anonymous, online survey conducted in September/October 2017. Eligibility requirements included current treatment of ≥7 months' duration for chronic pain with the same extended-release (ER)/long-acting (LA) opioid. The final sample consisted of respondents who reported being on the same ER/LA opioid for ≥1 year and excluded respondents whose 1) ER/LA opioid dose increased; 2) ER/LA opioid dose decreased and immediate-release (IR) opioid dose increased; and 3) ER/LA opioid dose was unchanged and IR opioid dose was changed. Survey results were analyzed using z-test to ascertain differences between proportion of responses for ER/LA opioid dose decreased vs dose unchanged groups. RESULTS: Of the 511 eligible respondents, 362 respondents were included in the final sample. In the final sample, the subgroup with decreased ER/LA opioid dose (n=149) was significantly more likely (P≤ 0.05) than those who reported no dose change (n=213) to rate their condition as "worse" for level of pain (73.2 vs 33.3%), level of function (67.8 vs 31.5%), mental health (64.4 vs 32.9%), ability to work (62.9% of 97 respondents vs 33.8% of 145 respondents), and interpersonal relationships (48.3 vs 25.8%) during the previous 6 months. CONCLUSION: In this Internet-based survey of people with chronic pain, reduction of ER/LA opioid dose was associated with reduced pain control and diminished function. These results indicate a need for further guidance on how to apply the CDC guideline to patients with chronic pain who are stable on long-term opioid therapy.

The Role of Continuing Medical Education in Increasing Enrollment in Prescription Drug Monitoring Programs.

PURPOSE: Opioid diversion, misuse, and abuse are rapidly growing problems in the United States; >60% of all drug overdose deaths involve an opioid. At least 49 states now have fully operational prescription drug monitoring programs (PDMPs) to support legitimate medical use of controlled substances; however, there is considerable underutilization of such programs. METHODS: To increase awareness of PDMPs and their use, a continuing medical education program including 2 webcasts and a series of newsletters was offered to health care providers. FINDINGS: Four hundred and sixty-five clinicians participated in 1 of 2 webcasts. Of those, 207 clinicians responded to a pre-survey and 64 responded to a post-survey. Slightly more than half of clinicians were registered for their state's PDMP program before the educational intervention, and although significantly more clinicians reported increased likelihood to access their state PDMP after participation, the number that actually registered only trended toward a statistically significant increase to 74% after the education (P = 0.06). Immediate post-activity evaluation also indicated that the education significantly improved clinician knowledge of the characteristics of addiction, findings in a PDMP that would suggest diversion or abuse, and strategies to complement the use of a PDMP (P < 0.001). IMPLICATIONS: Continuing medical education is effective for improving clinician knowledge and confidence related to opioid misuse, abuse, and diversion and effective use of a PDMP; however, the education did not result in a significant increase in enrollment in state PDMPs.

State Policies Regulating the Practice of Pain Management: Statutes, Rules, and Guidelines That Shape Pain Care.

In response to increased awareness of prescription opioid misuse, abuse, addiction, diversion, and overdose, states have promulgated a large number of public policies intended to regulate the practice of pain medicine. Nearly every state now has at least 1 type of policy; others only provide recommendations to physicians. This article reviews the existing policies and extracts specific provisions within each of them. Although there are many similarities across policies, unique features are found in some and are specifically reviewed. This review can serve as a quick reference for policymakers and as a guide for researchers interested in the impacts of such policies.

An Online Survey of Patients' Experiences Since the Rescheduling of Hydrocodone: The First 100 Days.

OBJECTIVE: To conduct an Internet patient survey through the National Fibromyalgia & Chronic Pain Association on reactions to the first 100 days following the rescheduling of hydrocodone. METHODS: Face-valid survey questions were created with expert consensus along with repurposed questions used on previous NFMCPA surveys covering domains such as demographics and symptoms. The questionnaire was designed to be administered over the Internet. RESULTS: 6,420 responders met screening criteria and completed the survey. Most (5,181, or 82.5%) had been prescribed hydrocodone for more than 1 year. 2,296, (39.0%) reported no changes in access to hydrocodone, while the majority experienced some barriers. Of those who could no longer get hydrocodone, 1,067 (18.1%) borrowed pain medications, 1,007 (17.1%) turned to marijuana, 773 (13.1%) used alcohol, and 135 (2.3%) used illicit drugs. Most respondents had to visit their healthcare providers more often (N = 3,699, 64.2%) and 1,735 (30.3%) reported some type of issue interacting with their pharmacy. Most felt that the rescheduling was neither a fair nor appropriate solution to the abuse of hydrocodone (N = 4,938, 88.3%). For those still working, 801 (46.2%) reported that they had missed work because of the stricter regulations. 1,462 (27.2%) reported having thoughts of suicide since the rescheduling. SIGNIFICANCE: The unintended consequences for people with chronic pain that have been caused by the rescheduling effort to impede hydrocodone abuse are negatively impacting thousands. These consequences include suffering from being placed on less effective drugs, increased cost, inconvenience, and negative influence on physician-patient and pharmacist-patient relationships.

FDA/DEA/PDMP/UDT: alphabet soup or sensible and integrated risk management?

OBJECTIVE: Both prescription drug monitoring programs (PDMP) and urine drug testing (UDT) are recommended as parts of an ongoing risk management approach for controlled substance prescribing. The authors provide an editorial and commentary to discuss the unique contributions of each to promote better clinical decision making for prescribers. DESIGN: A commentary is employed along with brief discussion comparing four states with an active PDMP in place to three states without an active PDMP as it relates back to findings on UDT in those states from a laboratory conducting liquid chromatography tandem mass spectrometry. CONCLUSIONS: The commentary focuses on the place of both tools (UDT and PDMP) in risk management efforts. The argument is made that relying on a PDMP alone would lead to clinical decisions that may miss a great deal of problematic or aberrant behaviors.

Mental disorders in chronic pain patients.

Prominent and distressing emotions, cognitions, and behaviors frequently accompany chronic pain. In many cases, these psychological symptoms will be sufficiently severe to qualify the patient for a diagnosis of a mental disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). This article introduces mental disorders that are frequently diagnosed in patients with chronic pain. Mental disorders are common co-morbidities with chronic pain. This paper presents an overview of the extent and nature of co-morbidity between mental disorders and chronic pain, as well as an outline of the structure of DSM-IV-TR, especially with respect to its use of a five-axis system for structuring mental disorder diagnoses.

What do I have to lose? Effects of a psycho-educational intervention on cancer patient preference for resuscitation.

This original empirical study examined effects of a psycho-educational intervention on cancer patients' knowledge, concern, and preferences for cardiopulmonary resuscitation (CPR). We examined message framing as one factor that might impact subsequent decision making. In addition, we examined personality and coping style as predictors and moderators of patients' reactions to an informational intervention. As hypothesized, participants initially underestimated CPR complications and overestimated survival rates. The intervention significantly increased concern, improved knowledge, and decreased preference for CPR, particularly for participants receiving both numerical and descriptive information. Message framing of survival data did not uniquely affect CPR preference. Higher optimism predicted less increase in concern about CPR, and higher hope predicted greater decrease in preference for CPR. More approach coping related to increased concern about CPR and decreased preference for CPR.

Report on the second joint scientific meeting of the American Pain Society and the Canadian Pain Society.

The American and Canadian Pain Societies held their annual scientific meetings jointly in May 2004 in Vancouver, British Columbia, Canada. This report summarizes highlights of the meeting.

Report from the 10th World Congress on Pain.

The 10th World Congress on Pain, the triennial meeting of the International Association for the Study of Pain, continued the series' tradition as one of the premier international meetings for pain clinicians and scientists. At this meeting, held in August 2002 in San Diego, California, a broad spectrum of topics was presented, with substantial representation in both the clinical and basic science realms. Increased understanding of basic pain mechanisms, potential new targets for drug treatment of pain, ethical issues, and psychological interventions for pain were all areas of considerable interest.