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Abstract

The recent death from a heroin overdose of actor Philip Seymour Hoffman at the age of 46 highlights the danger of opioid addiction. However, according to the U.S. Centers for Disease Control, prescription opioids such as OxyContin, Percocet, and Vicodin may be gateway drugs for heroin addiction and are responsible for five times as many deaths. ''The main driver of overdoses right now in our country is from opioid medications, more than from heroin,'' said Nora Volkow, director of the National Institute on Drug Abuse (NIDA). 1 Prescription drug overdose rates have more than tripled since 1990, paralleling a 300% increase in sales of strong prescription opioids. What is being done about this growing problem, and how can virtual reality (VR)-assisted behavioral interventions help? The paper presents a possible answer.
EDITORIAL
How Can Virtual Reality Interventions Help Reduce
Prescription Opioid Drug Misuse?
Brenda K. Wiederhold, PhD, MBA, BCB, BCN,
1,2
Giuseppe Riva, PhD,
3,4
and Mark D. Wiederhold, MD, PhD, FACP
5
The recent death from a heroin overdose of actor
Philip Seymour Hoffman at the age of 46 highlights the
danger of opioid addiction. However, according to the U.S.
Centers for Disease Control, prescription opioids such as
OxyContin, Percocet, and Vicodin may be gateway drugs for
heroin addiction and are responsible for five times as many
deaths. ‘‘The main driver of overdoses right now in our
country is from opioid medications, more than from heroin,’’
said Nora Volkow, director of the National Institute on Drug
Abuse (NIDA).
1
Prescription drug overdose rates have more
than tripled since 1990, paralleling a 300% increase in sales
of strong prescription opioids.
2
What is being done about this growing problem, and how
can virtual reality (VR)-assisted behavioral interventions
help? In addition to NIDA, other U.S. agencies involved in
the fight against prescription opioid abuse and misuse in-
clude the Drug Enforcement Administration and the Food
and Drug Administration. In February, the DEA launched a
new texting initiative, TIP411, which helps the public report
suspicious activity such as seeing a pharmacy tech drive off
in an expensive car. Tipsters can use the keyword PILLTIP
to report anomalies that may indicate illegal prescription
drug activity, and the message will be forwarded to a DEA
agent for investigation. The FDA is proposing to reclassify
hydrocodone combination pills such as Vicodin from Sche-
dule III to Schedule II. Adoption of the proposal would mean
that prescriptions for this type of drug couldn’t be called in
over the phone and would require reauthorization from the
physician before being refilled.
3
Studies have concluded that only a small percentage of
people who are prescribed opioids for medical reasons will
go on to develop addictions to these drugs, and that one of the
ways to prevent addiction is to preselect for no previous
history of or current problems with drug or alcohol abuse or
addiction.
4
Consistent with other studies on the subject, one
study using Medicaid data found that about 3% of individ-
uals will graduate to abuse or dependence, with the popu-
lation most vulnerable to addiction being those younger than
40.
5
Studies suggest similar rates of prescription opioid misuse
in the EU, although direct United States–Europe comparisons
are difficult because of different physician prescribing pat-
terns.
6
Another study found that ‘‘Native Americans had
significantly greater rates of nonmedical prescription drug use
and drug use disorders, highlighting the need for culturally-
sensitive prevention and intervention programs.’
7
In addition to humanitarian reasons, there are significant
financial incentives to find ways to reduce the incidence of
prescription opioid misuse. One study found that ‘‘mean
annual direct health care costs for opioid abusers were more
than eight times higher than for nonabusers.’’
8
Another study
noted, ‘‘The total cost of prescription opioid abuse in 2001
was estimated at $8.6 billion, including workplace, health
care, and criminal justice expenditures.’’
9
Of course, this amount is a drop in the bucket compared to
the total cost to the U.S. economy of chronic pain, recently
estimated by the Institute of Medicine at between $560 and
$630 billion annually.
10
The European Federation of Inter-
national Association for the Study of Pain (IASP) Chapters
notes that to date, ‘‘there is no comprehensive pan-European
epidemiological survey laying out the scope of the pain
problem.’’
11
However, a 2010 report noted that ‘‘chronic
pain costs Europe billions of euros every year, with national
costs ranging from 1.1 billion to nearly 50 billion Euros.’’
12
Combinations of prescription opioids with other drugs have a
modest additive effect on pain relief, while combinations of
prescription opioids with behavioral interventions have been
shown to be effective, for example, in reducing headache
pain. As we researchers in the field of VR-assisted therapy
have been saying for many years, it would be most helpful if
we could identify predictors of who will be likely treatment
responders.
12
The editor and others involved in VR research have made
strides in showing the effectiveness of ‘‘various psycholog-
ical techniques, including distraction by virtual reality en-
vironments and the playing of video games, [which] are
being employed to treat pain.’’
13
Perhaps if additional dollars
were directed to support evidence-based research on both the
psychological and neurophysiological mechanisms related to
pain, and the effectiveness of these nondrug modalities, we
would be able to make a significant contribution to reducing
1
Virtual Reality Medical Institute, Brussels, Belgium.
2
Interactive Media Institute, San Diego, California.
3
Department of Psychology, Catholic University of Milan, Italy.
4
Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Milan, Italy.
5
The Virtual Reality Medical Center (VRMC), San Diego, California.
CYBERPSYCHOLOGY,BEHAVIOR,AND SOCIAL NETWORKING
Volume 17, Number 6, 2014
ªMary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.1512
331
the need for opioid prescriptions and the deadly conse-
quences of their abuse. As recently suggested by Herta Flor,
‘‘The analysis of neurophysiological mechanisms may also
lead to the development of new psychological interventions
that can target these changes in a much more specific manner
than pharmacological interventions.’’
14
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Profs. Brenda K. Wiederhold, Giuseppe Riva,
and Mark D. Wiederhold
332 EDITORIAL
... 22 Given the effectiveness of VR therapy for pain management, VR as an adjunctive non-pharmacologic pain therapy program has potential to reduce opioid utilization. 23 Other possible benefits of inpatient VR therapy include reduction in hospital LOS and increased patient satisfaction. 24,25 While the use of VR in the hospital is promising, no study to our knowledge has yet examined the cost and effectiveness thresholds required for an inpatient VR program to be cost-saving. ...
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To present nationally representative data on the prevalence, sociodemographic correlates, and disability of 7 of the 10 DSM-IV personality disorders. The data were derived from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (N = 43,093). Diagnoses were made using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version, and associations between personality disorders and sociodemographic correlates were determined. The relationship between personality disorders and 3 emotional disability scores (Short-Form 12, version 2) was also examined. Overall, 14.79% of adult Americans (95% CI = 14.08 to 15.50), or 30.8 million, had at least 1 personality disorder. The most prevalent personality disorder in the general population was obsessive-compulsive personality disorder, 7.88% (95% CI = 7.43 to 8.33), followed by paranoid personality disorder 4.41% (95% CI = 4.12 to 4.70), antisocial personality disorder 3.63% (95% CI = 3.34 to 3.92), schizoid personality disorder 3.13% (95% CI = 2.89 to 3.37), avoidant personality disorder 2.36% (95% CI = 2.14 to 2.58), histrionic personality disorder 1.84% (95% CI = 1.66 to 2.02), and dependent personality disorder 0.49% (95% CI = 0.40 to 0.58). The risk of avoidant, dependent, and paranoid personality disorders was significantly greater among women than men (p <.05); the risk of antisocial personality disorder was greater among men compared with women (p <.05); and no sex differences were observed in the risk of obsessive-compulsive, schizoid, or histrionic personality disorders. In general, risk factors for personality disorders included being Native American or black, being a young adult, having low socioeconomic status, and being divorced, separated, widowed, or never married. Avoidant, dependent, schizoid, paranoid, and antisocial personality disorders (p <.02 to p <.0001) were each statistically significant predictors of disability. Obsessive-compulsive personality disorder was inconsistently related to disability. In contrast, disability was not significantly different among individuals with histrionic personality disorder compared with those without the disorder. Personality disorders are prevalent in the general population and are generally highly associated with disability. This study highlights the need to develop more effective and targeted prevention and intervention initiatives for personality disorders.
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To (a) describe the demographics of opioid abusers; (b) compare the prevalence rates of selected comorbidities and the medical and drug utilization patterns of opioid abusers with patients from a control group, for the period from 1998 to 2002; and (c) calculate the mean annual per-patient total health care costs (e.g., inpatient, outpatient, emergency room, drug, other) from the perspective of a private payer. An administrative database of medical and pharmacy claims from 1998 to 2002 of 16 self-insured employer health plans with approximately 2 million lives was used to identify "opioid abusers"--patients with claims associated with ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) codes for opioid abuse (304.0, 304.7, 305.5, and 965.0 [excluding 965.01]). A control group of nonabusers was selected using a matched sample (by age, gender, employment status, and census region) in a 3:1 ratio. Per-patient annual health care costs (mean total medical and drug costs) were measured in 2003 U.S. dollars. Multivariate regression techniques were also used to control for comorbidities and to compare costs with a benchmark of depressed patients. 740 patients were identified as opioid abusers, a prevalence of 8 in 10,000 persons aged 12 to 64 years continuously enrolled in health care plans for whom 12 months of data were available for calculating costs. Opioid abusers, compared with nonabusers, had significantly higher prevalence rates for a number of specific comorbidities, including nonopioid poisoning, hepatitis (A, B, or C), psychiatric illnesses, and pancreatitis, which were approximately 78, 36, 9, and 21 (P<0.01) times higher, respectively, compared with nonabusers. Opioid abusers also had higher levels of medical and prescription drug utilization. Almost 60% of opioid abusers had prescription drug claims for opioids compared with approximately 20% for nonabusers. Prevalence rates for hospital inpatient visits for opioid abusers were more than 12 times higher compared with nonabusers (P<0.01). Mean annual direct health care costs for opioid abusers were more than 8 times higher than for nonabusers ($15,884 versus $1,830, respectively, P < 0.01). Hospital inpatient and physician-outpatient costs accounted for 46% ($7,239) and 31% ($5,000) of opioid abusers. health care costs, compared with 17% ($310) and 50% ($906), respectively, for nonabusers. Mean drug costs for opioid abusers were more than 5 times higher than costs for nonabusers ($2,034 vs. $386, respectively, P<0.01), driven by higher drug utilization (including opioids) for opioid abusers. Even when controlling for comorbidities using a multivariate regression model of a matched control of depressed patients, the average health care costs of opioid abusers were 1.8 times higher than the average health care costs of depressed patients. The high costs of opioid abuse were driven primarily by high prevalence rates of costly comorbidites and high utilization rates of medical services and prescription drugs.
Article
To present national data on the prevalence, correlates, and comorbidity of nonmedical prescription drug use and drug use disorders for sedatives, tranquilizers, opioids, and amphetamines. Data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a face-to-face nationally representative survey of 43,093 adults conducted during 2001 and 2002. Lifetime prevalences of nonmedical use of sedatives, tranquilizers, opioids, and amphetamines were 4.1%, 3.4%, 4.7%, and 4.7%, respectively. Corresponding rates of abuse and/or dependence on these substances were 1.1%, 1.0%, 1.4%, and 2.0%. The odds of nonmedical prescription drug use and drug use disorders were generally greater among men, Native Americans, young and middle-aged, those who were widowed/ separated/divorced or never married, and those residing in the West. Abuse/dependence liability was greatest for amphetamines, and nonmedical prescription drug use disorders were highly comorbid with other Axis I and II disorders. The majority of individuals with non-medical prescription drug use disorders never received treatment. Nonmedical prescription drug use and disorders are pervasive in the U.S. population and highly comorbid with other psychiatric disorders. Native Americans had significantly greater rates of nonmedical prescription drug use and drug use disorders, highlighting the need for culturally-sensitive prevention and intervention programs. Unprecedented comorbidity between nonmedical prescription drug use disorders and between nonmedical prescription drug use disorders and illicit drug use disorders suggests that the typical individual abusing or dependent on these drugs obtained them illegally, rather than through a physician. Amphetamines had the greatest abuse/dependence liability, and recent increases in the potency of illegally manufactured amphetamines may portend an epidemic in the youngest NESARC cohort.