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This review describes what is known about the links between suicide and overdoses, focusing on pathways involved in opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues.

Murine models suggest that opioids alter the gut microbiota, which may impact opioid tolerance and psychopathology. We examined how gut microbiota characteristics related to use of opioid agonists and antagonists among people receiving outpatient addiction treatment. Patients (n = 46) collected stool samples and were grouped by use of opioid agonists (heroin, prescription opioids), antagonists (naltrexone), agonist–antagonist combinations (buprenorphine–naloxone), or neither agonists nor antagonists within the month before enrollment. We sequenced the V4 region of the 16S rRNA gene using Illumina MiSeq to examine how alpha diversity, enterotypes, and relative abundance of bacterial genera varied by opioid agonist and antagonist exposures. Compared to 31 participants who used neither agonists nor antagonists, 5 participants who used opioid agonists (without antagonists) had lower microbiota diversity, Bacteroides enterotypes, and lower relative abundance of Roseburia , a butyrate producing genus, and Bilophila , a bile acid metabolizing genus. There were no differences in gut microbiota features between those using agonist + antagonists (n = 4), antagonists only (n = 6), and neither agonists nor antagonists. Similar to murine morphine exposure models, opioid agonist use was associated with lower microbiota diversity. Lower abundance of Roseburia and Bilophila may relate to the gut inflammation/permeability and dysregulated bile acid metabolism observed in opioid-exposed mice.

In the year after the elimination of a waiver requirement to prescribe buprenorphine, the number of prescribers increased above the anticipated value, but the number of persons who received the drug did not.

Objective To study the association between benzodiazepine prescribing patterns including dose, type, and dosing schedule and the risk of death from drug overdose among US veterans receiving opioid analgesics.Design Case-cohort study.Setting Veterans Health Administration (VHA), 2004-09.Participants US veterans, primarily male, who received opioid analgesics in 2004-09. All veterans who died from a drug overdose (n=2400) while receiving opioid analgesics and a random sample of veterans (n=420 386) who received VHA medical services and opioid analgesics.Main outcome measure Death from drug overdose, defined as any intentional, unintentional, or indeterminate death from poisoning caused by any drug, determined by information on cause of death from the National Death Index.Results During the study period 27% (n=112 069) of veterans who received opioid analgesics also received benzodiazepines. About half of the deaths from drug overdose (n=1185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of death from drug overdose increased with history of benzodiazepine prescription: adjusted hazard ratios were 2.33 (95% confidence interval 2.05 to 2.64) for former prescriptions versus no prescription and 3.86 (3.49 to 4.26) for current prescriptions versus no prescription. Risk of death from drug overdose increased as daily benzodiazepine dose increased. Compared with clonazepam, temazepam was associated with a decreased risk of death from drug overdose (0.63, 0.48 to 0.82). Benzodiazepine dosing schedule was not associated with risk of death from drug overdose.Conclusions Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion.

Depression and Work Hours in First-Year PhysiciansOn the basis of data from the Intern Health Study for the 2009–2020 period, increasing work hours were associated in a dose–response manner with increasing rates of depressive symptoms.

Opioid overdose deaths in the United States continue to increase, reflecting a growing need to treat those with opioid use disorder (OUD). Little is known about counties with high rates of opioid overdose mortality but low availability of OUD treatment. To identify characteristics of US counties with persistently high rates of opioid overdose mortality and low capacity to deliver OUD medications. In this cross-sectional study of data from 3142 US counties from January 1, 2015, to December 31, 2017, rates of opioid overdose mortality were compared with availability in 2017 of OUD medication providers (24 851 buprenorphine-waivered clinicians [physicians, nurse practitioners, and physician assistants], 1517 opioid treatment programs [providing methadone], and 5222 health care professionals who could prescribe extended-release naltrexone). Statistical analysis was performed from April 20, 2018, to May 8, 2019. Demographic, workforce, lack of insurance, road density, urbanicity, opioid prescribing, and regional division county-level characteristics. The outcome variable, \"opioid high-risk county,\" was a binary indicator of a high (above national) rate of opioid overdose mortality with a low (below national) rate of provider availability to deliver OUD medication. Spatial logistic regression models were used to determine associations with being an opioid high-risk county. Of 3142 counties, 751 (23.9%) had high rates of opioid overdose mortality. A total of 1457 counties (46.4%), and 946 of 1328 rural counties (71.2%), lacked a publicly available OUD medication provider in 2017. In adjusted models, compared with the West North Central division, counties in the East North Central, Mountain, and South Atlantic divisions had increased odds of being opioid high-risk counties (East North Central: odds ratio [OR], 2.21; 95% CI, 1.19-4.12; Mountain: OR, 4.15; 95% CI, 1.34-12.89; and South Atlantic: OR, 2.99; 95% CI, 1.26-7.11). A 1% increase in unemployment was associated with increased odds (OR, 1.09; 95% CI, 1.03-1.15) of a county being an opioid high-risk county. Counties with an additional 10 primary care clinicians per 100 000 population had a reduced risk of being opioid high-risk counties (OR, 0.89; 95% CI, 0.85-0.93), as did counties that were micropolitan (vs metropolitan) (OR, 0.67; 95% CI, 0.50-0.90) and those that had an additional 1% of the population younger than 25 years (OR, 0.95; 95% CI, 0.92-0.98). Counties with low availability of OUD medication providers and high rates of opioid overdose mortality were less likely to be micropolitan and have lower primary care clinician density, but were more likely to be in the East North Central, South Atlantic, or Mountain division and have higher rates of unemployment. Strategies to increase medication treatment must account for these factors.

BackgroundEfforts to reduce opioid overdose fatalities have resulted in tapering (i.e., reducing or discontinuing) opioid prescriptions despite a limited understanding of patients’ experiences.ObjectiveTo explore patients’ perspectives on opioid taper experiences to ultimately improve taper processes and outcomes.DesignQualitative study.ParticipantsPatients on long-term opioid therapy for chronic pain who had undergone a reduction of opioid daily prescribed dosage of ≥50% in the past 2 years in two distinct medical systems and regions.ApproachFrom 2019 to 2020, we conducted semi-structured interviews that were audio-recorded, transcribed, systematically coded, and analyzed to summarize the content and identify key themes regarding taper experiences overall and with particular attention to patient-provider relationships and provider communication during tapers.Key ResultsParticipants (n=41) had lived with chronic pain for an average of 17.4 years (range, 3–36 years) and described generally adverse experiences with opioid tapers, the initiation of which was not always adequately justified or explained to them. Consequences of tapers ranged from minor to substantial and included withdrawal, mobility issues, emotional distress, exacerbated mental health symptoms, and feelings of social stigmatization for which adequate supports were typically unavailable. Narratives highlighted the consequential role of patient-provider relationships throughout taper experiences, with most participants describing significant interpersonal challenges including poor provider communication and limited patient engagement in decision making. A few participants identified qualities of providers, relationships, and communication that fostered more positive taper experiences and outcomes.ConclusionsFrom patients’ perspectives, opioid tapers can produce significant physical, emotional, and social consequences, sometimes reducing trust and engagement in healthcare. Patient-provider relationships and communication influence patients’ perceptions of the quality and outcomes of opioid tapers. To improve patients’ experiences of opioid tapers, tapering plans should be based on individualized risk-benefit assessments and involve patient-centered approaches and improved provider communication.

Objectives. To quantify deaths in the United States from 2010 through 2018 that were reported with an underlying cause of death as a psychiatric diagnosis, which do not indicate a clear mechanism of death, and that may be misclassified suicide and overdose deaths. Methods. We used national vital statistics data to identify rates and circumstances of deaths by specific underlying cause of death categories in the US population. Results. There were 115 442 deaths attributed to psychiatric diagnoses and 834 763 deaths attributed to suicide or overdose. The population rate of deaths attributed to psychiatric diagnoses increased from 3.26 to 4.96 per 100 000 US persons between 2010 and 2018. Conclusions. Psychiatric diagnoses may represent a fairly substantial number of misclassified overdose and suicide deaths. Improving mortality surveillance requires improving the accuracy of diagnoses reported on death certificates.