ArticlePDF Available

Prescription opioids (substitution medications and pain medications) in patients looking for Opioid Agonist Treatment in Northern and Southern Italy, using a 18-month survey methodology

Authors:
Icro Maremmani at Azienda Ospedaliero-Universitaria Pisana (Pensionato)
Icro Maremmani
  • Azienda Ospedaliero-Universitaria Pisana (Pensionato)
M. Guareschi
M. Guareschi
M. Guareschi
  • This person is not on ResearchGate, or hasn't claimed this research yet.
G. Deruvo
G. Deruvo
G. Deruvo
  • This person is not on ResearchGate, or hasn't claimed this research yet.
L. Somain
L. Somain
L. Somain
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Show all 8 authorsHide
Download full-text PDFDownload full-text PDFDownload full-text PDF
Read full-text
Download citation

Abstract

Background: In many countries, the broad availability of prescription pain medications (PPMs) and prescription substitution medications (PSMs), coupled with public misconceptions about their safety and addictive potential, have contributed to the recent surge in the non-medical use of prescription opioids (POs), and corresponding increases in treatment admissions for problems related to opioid misuse. This Italian study has aimed to assess the prevalence of the primary substance of abuse, the differences between heroin use and the use of POs in the previous month and the prevalence of combined use (heroin, PSMs and PPMs), while stressing the geographical differences between Northern and Southern Italy. Methods: This has been a cross-sectional, observational study. The data were collected prospectively, over an 18-month period in 2012 e 2013. The Survey Questionnaire on Opioids was administered during an 18-month survey to all patients entering Opioid Agonist Treatment (OAT) in two National Health Drug Addiction Units – the first in Northern and the second in Southern Italy. Results: 317 subjects requested OAT at Drug Addiction Units in the cities of Cossato and Bitonto, in Southern and in Northern Italy, respectively. Heroin was named most frequently as the primary substance of abuse, followed by PSMs (buprenorphine and methadone). Heroin was the substance most used in the previous 30 days, followed by PSMs. About half of the patients were only using heroin, approximately a quarter PSMs only, 15% heroin and PSMs together, and 10% PPMs only. Northern Italian patients were characterized by the combined use of heroin and PSMs (OR=0.025), but also by using PPMs – in order of importance, codeine (OR=0.008), oxycodone (OR=0.011), and tramadol (OR=0.013) – as their primary substance of abuse. Conclusions: In Italy, in patients requesting OAT, the most frequent primary substance of abuse and the most frequently used substance in the previous 30 days is still heroin. As in many other countries, however, the use of POs is increasing, especially if we consider the combined use of heroin and PSMs. In Italy, the dreaded transition from PPMs to heroin still seems almost non-existent, and is just beginning to appear, but only in Northern Italy.
Prescription Opioi
ds.pdf
Content uploaded by Angelo GI Maremmani
Author content
All content in this area was uploaded by Angelo GI Maremmani on Jun 26, 2015
Content may be subject to copyright.
Prescription Opioi
ds.pdf
Content uploaded by Angelo GI Maremmani
Author content
All content in this area was uploaded by Angelo GI Maremmani on Jun 26, 2015
Content may be subject to copyright.
Prescription Opioi
ds.pdf
Content uploaded by Angelo GI Maremmani
Author content
All content in this area was uploaded by Angelo GI Maremmani on Jun 26, 2015
Content may be subject to copyright.
A preview of the PDF is not available
... In a recent study conducted in Italy we assessed the prevalence of the PSA, the differences between heroin use and the use of POs in the previous month and the prevalence of combined use (heroin, AOT medications and opioid analgesic medications), while stressing the geographical differences between Northern and Southern Italy [25]. ...
Opioid misuse in the 30 days prior to entering Agonist Opioid Treatment in four European Countries. A pilot study
Article
Full-text available
  • Jun 2016
Introduction: The broad availability of opioid analgesics (OAs) probably complicates the misuse of Agonist Opioid Treatment (AOT) medications, or even pave the way to dependence on heroin. Methods: In this observational study, based on a thorough survey of new AOT enrollees, our main aim was to determine the extent to which the problem of prescription opioid (PO) misuse that is currently evident in the US is also a concern in the EU. We assessed the prevalence of primary substances of abuse (PSAs), and differences in patterns of PO misuse in the previous month, by reviewing the situations to be found in four European countries. Results: In the centers investigated by us, heroin was preferred as PSA in Spain, buprenorphine and opioid analgesics were the prevalent PSAs in France, while methadone and fentanyl prevailed in Germany. Heroin alone frequently proved to be the substance used in Italy and Spain. AOT medications only were used more frequently in Italy, less so in Spain. Opioid analgesics only were used more frequently in France. Combined use occurred more frequent in Italy, with special reference to heroin and AOT medications; in Germany especially with heroin and opioid analgesics; in France especially with opioid analgesics and AOT medications. The combined use of heroin, AOT medications and opioid analgesics was a frequent finding in Germany. Conclusions: In Europe, the combined use of opioid analgesics, AOT medications and heroin-already dreaded in the US, and rightly so-is just beginning to appear, notably in Germany and in France.
View
Access to Medications for Opioid Use Disorder and Associated Factors Among Adolescents and Young Adults: A Systematic Review
Article
Full-text available
  • Dec 2021
IMPORTANCE: The ongoing overdose crisis continues to adversely affect adolescents and young adults (AYAs) and has led to numerous preventable deaths. Medications for opioid use disorder (MOUD), such as methadone, buprenorphine, and naltrexone, have the potential to reduce opioid use and associated harms; however, there are concerns that AYAs lack access to these potentially life-saving medications. OBJECTIVE: To systematically review peer-reviewed literature on MOUD access and associated factors to synthesize strategies that can improve MOUD access for AYAs who use opioids. EVIDENCE REVIEW: The MEDLINE, Embase, PsycINFO, CINAHL, Sociological Abstracts, Web of Science, and Global Dissertations & Theses databases were searched from database inception until May 3, 2021. English, French, Russian, or Spanish peer-reviewed studies that evaluated the availability, prescription receipt, or initiation of MOUD were eligible for inclusion. FINDINGS: This systematic review identified 37 cohort (n = 17), cross-sectional (n = 15), and qualitative (n = 5) studies that accounted for 179 785 AYAs (mean [SD] age, 24.4 [3.9] years; 148 779 [85%] were female; 67 771 [84%] were White) and examined access to methadone (30 studies), buprenorphine (26 studies), and naltrexone (10 studies). Findings reinforce concerns that AYAs were less likely to access MOUD and suggest that adolescents were more likely to receive naltrexone or buprenorphine-naloxone, which have a lower potential for abuse, in comparison with young adults. This review also identified other factors that were associated with MOUD access, including criminal justice involvement, residing in the US South, living in a limited-income area, Black race, and Hispanic or Latino ethnicity, suggesting ways in which treatment services may be improved to increase MOUD access and meet the treatment goals of AYAs. CONCLUSION AND RELEVANCE: This systematic review found gaps in MOUD access between AYAs and non-AYA populations in addition to differences in MOUD access between adolescents and young adults. Considering that existing clinical guidelines recommend the use of MOUD among AYAs, and in light of the increasing number of opioid toxicity deaths, there is a need to improve MOUD access among AYAs by reducing barriers to MOUD and providing AYAs with a continuum of health and social supports alongside MOUD. Future research into ways to encourage MOUD uptake among AYAs may improve the treatment and health outcomes for this population.
View
Effect of methadone maintenance treatment of Opioid-Dependent fathers on the mental health and perceived family functioning of their children in Iran
Article
Full-text available
  • Jun 2016
Background: Substance abuse has negative effects on the mental and social adaptation of children living with the adults who are involved in this behaviour. This study was carried out with the aim of assessing the effects of methadone maintenance treatment (MMT) of opioid-dependent fathers on the mental health and perceived family functioning of their children. Methods: In this clinical trial, 40 children (with ages ranging from 11 to 18 years) whose fathers were in methadone maintenance treatment in two MMT clinics in Shahrekord, Iran, were assessed using the Strengths and Difficulties Questionnaire (self-and parent report), Family Assessment Device (FAD), and Parent-Child Relationship Survey (PCRS) conducted prior to, and then 3 and 6 months after the intervention. The collected data were analysed by applying repeated measure tests using SPSS16 software. Results: There were significant differences between the data collected initially at baseline, and then 3 and 6 months after the intervention measurements that were based on SDQ mean difficulty scores in the parent and child versions (p=0.001 and p<0.001, respectively), and on the pro-social behaviour subscale in the form prepared for parents (p=0.003), but not in that prepared for children (p=0.085). Mean total score and subscale scores of FAD did not change significantly (p=0.064), except for the emotional involvement subscale (p=0.032). PCRS mean scores did not change significantly, either (p=0.108). Conclusions: The emotional and behavioural difficulties of children of substance-abusing fathers improved during 6 months of methadone maintenance treatment, but neither perceived family functioning nor the parent-child relationships involved changed significantly. Family-based psychological interventions such as training in parenting skills, communication training, and problem solving may be necessary to improve the family and parenting functions of fathers on MMT.
View
The Changing Face of Heroin Use in the United States A Retrospective Analysis of the Past 50 Years
Article
Full-text available
  • May 2014
Importance Over the past several years, there have been a number of mainstream media reports that the abuse of heroin has migrated from low-income urban areas with large minority populations to more affluent suburban and rural areas with primarily white populations.Objective To examine the veracity of these anecdotal reports and define the relationship between the abuse of prescription opioids and the abuse of heroin.Design, Setting, and Participants Using a mixed-methods approach, we analyzed (1) data from an ongoing study that uses structured, self-administered surveys to gather retrospective data on past drug use patterns among patients entering substance abuse treatment programs across the country who received a primary (DSM-IV) diagnosis of heroin use/dependence (n = 2797) and (2) data from unstructured qualitative interviews with a subset of patients (n = 54) who completed the structured interview.Main Outcomes and Measures In addition to data on population demographics and current residential location, we used cross-tabulations to assess prevalence rates as a function of the decade of the initiation of abuse for (1) first opioid used (prescription opioid or heroin), (2) sex, (3) race/ethnicity, and (4) age at first use. Respondents indicated in an open-ended format why they chose heroin as their primary drug and the interrelationship between their use of heroin and their use of prescription opioids.Results Approximately 85% of treatment-seeking patients approached to complete the Survey of Key Informants’ Patients Program did so. Respondents who began using heroin in the 1960s were predominantly young men (82.8%; mean age, 16.5 years) whose first opioid of abuse was heroin (80%). However, more recent users were older (mean age, 22.9 years) men and women living in less urban areas (75.2%) who were introduced to opioids through prescription drugs (75.0%). Whites and nonwhites were equally represented in those initiating use prior to the 1980s, but nearly 90% of respondents who began use in the last decade were white. Although the “high” produced by heroin was described as a significant factor in its selection, it was often used because it was more readily accessible and much less expensive than prescription opioids.Conclusion and Relevance Our data show that the demographic composition of heroin users entering treatment has shifted over the last 50 years such that heroin use has changed from an inner-city, minority-centered problem to one that has a more widespread geographical distribution, involving primarily white men and women in their late 20s living outside of large urban areas.
View
Predictors of Painkiller Dependence among People with Pain in the General Population
Article
Full-text available
  • Oct 2013
  • PAIN MED
Self-medication with painkillers is widespread and increasing, and evidence about influences on painkiller dependence is needed to inform efforts to prevent and treat problem painkiller use. Online questionnaire survey. People in the general population who had pain and used painkillers in the last month (N = 112). Pain frequency and intensity, use of over-the-counter and prescription painkillers, risk of substance abuse (Screener and Opioid Assessment for Patients with Pain [SOAPP] scale), depression, anxiety, stress, alexithymia, pain catastrophizing, pain anxiety, pain self-efficacy, pain acceptance, mindfulness, self-compassion, and painkiller dependence (Leeds Dependence Questionnaire). In multiple regression, the independent predictors of painkiller dependence were prescription painkiller use (β 0.21), SOAPP score (β 0.31), and pain acceptance (β -0.29). Prescription painkiller use mediated the influence of pain intensity. Alexithymia, anxiety, and pain acceptance all moderated the influence of pain. The people most at risk of developing painkiller dependence are those who use prescription painkillers more frequently, who have a prior history of substance-related problems more generally, and who are less accepting of pain. Based on these findings, a preliminary model is presented with three types of influence on the development of painkiller dependence: 1) pain leading to painkiller use, 2) risk factors for substance-related problems irrespective of pain, and 3) psychological factors related to pain. The model could guide further research among the general population and high-risk groups, and acceptance-based interventions could be adapted and evaluated as methods to prevent and treat painkiller dependence.
View
Intertwined Epidemics: National Demographic Trends in Hospitalizations for Heroin- and Opioid-Related Overdoses, 1993–2009
Article
Full-text available
The historical patterns of opiate use show that sources and methods of access greatly influence who is at risk. Today, there is evidence that an enormous increase in the availability of prescription opiates is fuelling a rise in addiction nationally, drawing in new initiates to these drugs and changing the geography of opiate overdoses. Recent efforts at supply-based reductions in prescription opiates may reduce harm, but addicted individuals may switch to other opiates such as heroin. In this analysis, we test the hypothesis that changes in the rates of Prescription Opiate Overdoses (POD) are correlated with changes in the rate of heroin overdoses (HOD). ICD9 codes from the Nationwide Inpatient Sample and population data from the Census were used to estimate overall and demographic specific rates of POD and HOD hospital admissions between 1993 and 2009. Regression models were used to test for linear trends and lagged negative binomial regression models were used to model the interrelationship between POD and HOD hospital admissions. Findings show that whites, women, and middle-aged individuals had the largest increase in POD and HOD rates over the study period and that HOD rates have increased in since 2007. The lagged models show that increases in a hospitals POD predict an increase in the subsequent years HOD admissions by a factor of 1.26 (p<0.001) and that each increase in HOD admissions increase the subsequent years POD by a factor of 1.57 (p<0.001). Our hypothesis of fungibility between prescription opiates and heroin was supported by these analyses. These findings suggest that focusing on supply-based interventions may simply lead to a shift in use to heroin rather minimizing the reduction in harm. The alternative approach of using drug abuse prevention resources on treatment and demand-side reduction is likely to be more productive at reducing opiate abuse related harm.
View
Understanding the Rural-Urban Differences in Nonmedical Prescription Opioid Use and Abuse in the United States
Article
  • Dec 2013
  • AM J PUBLIC HEALTH
Nonmedical prescription opioid misuse remains a growing public problem in need of action and is concentrated in areas of US states with large rural populations such as Kentucky, West Virginia, Alaska, and Oklahoma. We developed hypotheses regarding the influence of 4 factors: (1) greater opioid prescription in rural areas, creating availability from which illegal markets can arise; (2) an out-migration of young adults; (3) greater rural social and kinship network connections, which may facilitate drug diversion and distribution; and (4) economic stressors that may create vulnerability to drug use more generally. A systematic consideration of the contexts that create differences in availability, access, and preferences is critical to understanding how drug use context varies across geography. (Am J Public Health. Published online ahead of print December 12, 2013: e1-e8. doi:10.2105/AJPH.2013.301709).
View
Increases in the Use of Prescription Opioid Analgesics and the Lack of Improvement in Disability Metrics Among Users
Article
  • Dec 2013
  • REGION ANESTH PAIN M
In the United States, use of oral opioid analgesics has been associated with increasing rates of addiction, abuse, and diversion. However, little is known about the recent national use of non-illicit prescription opioid analgesics (those prescribed in a physician-patient relationship), the primary source of these drugs for the general US population. Our primary objective was to examine trends in the use of prescription opioid analgesics in the United States and to identify defining characteristics of patient users of prescribed opioids from 2000 to 2010. We used the nationally representative Medical Expenditure Panel Survey to examine trends in prescription oral opioid analgesic use from 2000 to 2010. We used survey design methods to make national estimates of adults (18 years and older) who reported receiving an opioid analgesic prescription (referred to as opioid users) and used logistic regression to examine predictors of opioid analgesic use. Our primary outcome measures were national estimates of total users of prescription opioid analgesics and total number of prescriptions. Our secondary outcome was that of observing changes in the disability and health of the users. The estimated total number of opioid analgesic prescriptions in the United States increased by 104%, from 43.8 million in 2000 to 89.2 million in 2010. In 2000, an estimated 7.4% (95% confidence interval, 6.9-7.9) of adult Americans were prescription opioid users compared with 11.8% (95% confidence interval, 11.2-12.4) in 2010. On the basis of estimates adjusted for changes in the general population, each year was associated with a 6% increase in the likelihood of receiving an opioid prescription from 2000 to 2010. Despite the apparent increase in use, there were no demonstrable improvements in the age- or sex-adjusted disability and health status measures of opioid users. The use of prescription opioid analgesics among adult Americans has increased in recent years, and this increase does not seem to be associated with improvements in disability and health status among users. On a public health level, these data suggest that there may be an opportunity to reduce the prescribing of opioid analgesics without worsening of population health metrics.
View
From oxycodone to heroin: Two cases of transitioning opioid use in young Australians
Article
  • Nov 2013
  • DRUG ALCOHOL REV
The non-medical use of pharmaceutical opioids is associated with a range of negative health consequences, including the development of dependence, emergency room presentations and overdose deaths. Drawing on life history data from a broader qualitative study of the non-medical use of painkillers, this brief report presents two cases of transitions from recreational or non-medical pharmaceutical opioid use to intravenous heroin use by young adults in Australia. Although our study was not designed to assess whether recreational oxycodone use is causally linked to transitions to intravenous use, polyopioid use places individuals at high risk for progression to heroin and injecting. Our first case, Jake, used a range of analgesics before he transitioned to intravenous use, and the first drug he injected was methadone. Our second case, Emma, engaged in a broad spectrum of polydrug use, involving a range of opioid preparations, as well as benzodiazepines, cannabis and alcohol. Both cases transitioned from oral to intravenous pharmaceutical opioids use and subsequent intravenous heroin use. These cases represent the first documented reports of transitions from the non-medical or recreational use of oxycodone to intravenous heroin use in Australia. As such, they represent an important starting point for the examination of pharmaceutical opioids as a pathway to injecting drug use among young Australians and highlight the need for further research designed to identify pharmaceutical opioids users at risk of transitions to injecting and to develop interventions designed to prevent or delay these transitions. [Dertadian G, Maher L. From oxycodone to heroin: Two cases of transitioning opioid use in young Australians. Drug Alcohol Rev 2013].
View
Erratum to “Opioid dependence and addiction during opioid treatment of chronic pain” [Pain 129 (2007) 235–255]
Article
  • Oct 2007
  • PAIN
Throughout the long history of opioid drug use by humans, it has been known that opioids are powerful analgesics, but they can cause addiction. It has also been observed, and is now substantiated by multiple reports and studies, that during opioid treatment of severe and short-term pain, addiction arises only rarely. However, when opioids are extended to patients with chronic pain, and therapeutic opioid use is not confined to patients with severe and short-lived pain, compulsive opioid seeking and addiction arising directly from opioid treatment of pain become more visible. Although the epidemiological evidence base currently available is rudimentary, it appears that problematic opioid use arises in some fraction of opioid-treated chronic pain patients, and that problematic behaviors and addiction are problems that need to be addressed. Since the potentially devastating effects of addiction can substantially offset the benefits of opioid pain relief, it seems timely to reexamine addiction mechanisms and their relevance to the practice of long-term opioid treatment for pain. This article reviews the neurobiological and genetic basis of addiction, its terminology and diagnosis, the evidence on addiction rates during opioid treatment of chronic pain and the implications of biological mechanisms in formulating rational opioid treatment regimes.
View
Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain
Article
  • Apr 2013
Background: As a consequence of the substantial rise in the prescription of opioids for the treatment of chronic noncancer pain, greater attention has been paid to the factors that may be associated with an increased risk for prescription opioid misuse. Recently, a growing number of studies have shown that patients with high levels of catastrophizing are at increased risk for prescription opioid misuse. Objective: The primary objective of this study was to examine the variables that might underlie the association between catastrophizing and risk for prescription opioid misuse in patients with chronic pain. Methods: Patients with chronic musculoskeletal pain (n=115) were asked to complete the SOAPP-R, a validated self-report questionnaire designed to identify patients at risk for prescription opioid misuse. Patients were also asked to complete self-report measures of pain intensity, catastrophizing, anxiety, and depression. Results: Consistent with previous research, we found that catastrophizing was associated with an increased risk for prescription opioid misuse. Results also revealed that the association between catastrophizing and risk for opioid misuse was partially mediated by patients' levels of anxiety. Follow-up analyses, however, indicated that catastrophizing remained a significant 'unique' predictor of risk for opioid misuse even when controlling for patients' levels of pain severity, anxiety and depressive symptoms. Discussion: Discussion addresses the factors that might place patients with high levels of catastrophizing at increased risk for prescription opioid misuse. The implications of our findings for the management of patients considered for opioid therapy are also discussed.
View
Characterization of Adolescent Prescription Drug Abuse and Misuse Using the Researched Abuse Diversion and Addiction-Related Surveillance (RADARS (R)) System
Article
  • Feb 2013
To describe the characteristics and health effects of adolescent (age 13-19 years) prescription drug abuse and misuse using the Researched Abuse Diversion and Addiction-Related Surveillance (RADARS(®)) System. Secondary analysis of data collected from RADARS System participating poison centers was performed. Data for all intentional exposures from 2007 through 2009 were used to describe adolescent prescription opioid (oxycodone, fentanyl, hydrocodone, hydromorphone, morphine, methadone, buprenorphine, and tramadol) and stimulant (methylphenidate and amphetamines) exposures. A total of 16,209 intentional adolescent exposures to prescription drugs were identified, 68% to opioids and 32% to stimulants. The mean age was 16.6 years (SD±1.7 years). Slightly more than half (52.4%) of drug mentions involved females. The five most frequently misused or abused drugs were hydrocodone (32%), amphetamines (18%), oxycodone (15%), methylphenidate (14%), and tramadol (11%). Of all exposures, 38% were classified as suspected suicidal. Of adolescents who intentionally exposed themselves to prescription drugs, 30% were treated in a health care facility, 2,792 of whom were admitted to the hospital, including 1,293 to the intensive care unit. A total of 17.2% of intentional exposures were associated with no effect, 38.9% minor effects, 23.3% moderate effects, 3.6% major effects, and 0.1% were associated with death. Oxycodone and methadone were associated with the most deaths. No deaths were associated with exposures to stimulants. Prescription drug misuse and abuse poses an important health problem and results in thousands of hospitalizations of adolescents per year. Further work is needed to develop focused interventions and educational programs to prevent prescription drug abuse and misuse by adolescents.
View
Prescription opioid use among addictions treatment patients: Nonmedical use for pain relief vs. other forms of nonmedical use
Article
  • Nov 2012
Background: Differences between those who engage in nonmedical prescription opioid use for reasons other than pain relief and those who engage in nonmedical use for reasons related to pain only are not well understood. Methods: Adults in a residential treatment program participated in a cross-sectional self-report survey. Participants reported whether they used opioids for reasons other than pain relief (e.g., help sleep, improve mood, or relieve stress). Within those with past-month nonmedical opioid use (n=238), logistic regression tested differences between those who reported use for reasons other than pain relief and those who did not. Results: Nonmedical use of opioids for reasons other than pain relief was more common (66%) than nonmedical use for pain relief only (34%), and those who used for reasons other than pain relief were more likely to report heavy use (43% vs. 11%). Nonmedical use for reasons other than pain relief was associated with having a prior overdose (odds ratio [OR]=2.54, 95% CI: 1.36-4.74) and use of heroin (OR=4.08, 95% CI: 1.89-8.79), barbiturates (OR=6.44, 95% CI: 1.47, 28.11), and other sedatives (OR=5.80, 95% CI: 2.61, 12.87). Individuals who reported nonmedical use for reasons other than pain relief had greater depressive symptoms (13.1 vs. 10.5) and greater pain medication expectancies across all three domains (pleasure/social enhancement, pain reduction, negative experience reduction). Conclusions: Among patients in addictions treatment, individuals who report nonmedical use of prescription opioids for reasons other than pain relief represent an important clinical sub-group with greater substance use severity and poorer mental health functioning.
View