Cardiovascular Risk Associated with Medical Use of Opioids and Cannabinoids: A Systematic Review

Purpose of Review: The long-term use of opioid and cannabinoid medications to control chronic pain and treat opioid use disorders now involves a large proportion of the population in the United States. Yet, the cardiovascular risks of opioids are not well understood. This systematic review summarizes the current literature to assess the potential cardiovascular disease risks associated with opioid and cannabinoid medications. Recent Findings: The role of long-term methadone use in increasing QT interval among people receiving methadone treatment for substance use disorders is well established. Routine electrocardiogram screenings among patients receiving methadone treatment may be helpful in early identification and prevention of ventricular arrhythmias. There is limited, but credible evidence of increased risk for myocardial infarction among patients using opioid medications for chronic pain, and equivocal evidence that opioids may lead to hypotension in the short term. Further, there is no evidence indicating that opioid pain medications increase the risk of stroke or pulmonary embolism. However, the majority of the reviewed studies include limited internal and external validity due to poor confounding control, exposure misclassification, confounding by indication, small sample size, and non-generalizable special populations. We also did not find any human studies evaluating the cardiovascular effects of cannabinoids. Summary: While the effects of methadone on cardiac conduction are well known and interventions at the healthcare practice level may help prevent potential harm, more good quality research is needed to better understand cardiovascular risk associated with the use of opioids and cannabinoids

Trajectories and correlates of opioid prescription receipt among patients experiencing interpersonal violence

Interpersonal violence increases vulnerability to the deleterious effects of opioid use. Increased opioid prescription receipt is a major contributor to the opioid crisis; however, our understanding of prescription patterns and risk factors among those with a history of interpersonal violence remains elusive. This study sought to identify 5-year longitudinal patterns of opioid prescription receipt among patients experiencing interpersonal violence within a large healthcare system and sociodemographic and clinical characteristics associated with prescription patterns. This secondary analysis examined electronic health record data from January 2004-August 2019 for a cohort of patients (N = 1,587) referred for interpersonal violence services. Latent class growth analysis was used to estimate trajectories of opioid prescription receipt over a 5-year period. Standardized differences were calculated to assess variation in sociodemographic and clinical characteristics between classes. Our cohort had a high prevalence of prescription opioid receipt (73.3%) and underlying co-morbidities, including chronic pain (54.6%), substance use disorders (39.0%), and mental health diagnoses (76.9%). Six prescription opioid receipt classes emerged, characterized by probability of any prescription opioid receipt at the start and end of the study period (high, medium, low, never) and change in probability over time (increasing, decreasing, stable). Classes with the highest probability of prescription opioids also had the highest proportions of males, chronic pain diagnoses, substance use disorders, and mental health diagnoses. Black, non-Hispanic and Hispanic patients were more likely to be in low or no prescription opioid receipt classes. These findings highlight the importance of monitoring for synergistic co-morbidities when providing pain management and offering treatment that is trauma-informed, destigmatizing, and integrated into routine care

State firearm laws, race and law enforcement-related deaths in 16 US states: 2010-2016

The aim of this study was to assess the association between state firearm legislation and law enforcement-related deaths (LEDs) and its modification by race. We used secondary data from an ecological cohort of 16 states (2010 to 2016), using the National Violent Death Reporting System (NVDRS), the State Firearm Law Database and additional public sources. Poisson regression with generalised estimating equations and inverse probability of exposure weights to account for time-varying confounding were used to quantify the association. LEDs were also disaggregated by race (Black vs non-Black). A total of 1593 LEDs took place during the 6-year study period. After adjusting for confounders, the IRR among non-Blacks was 0.48 (95% CI 0.26 to 0.89) and 1.53 (95% CI 0.93 to 2.54) among Blacks. Our findings highlight the fact that increased firearm provisions may decrease rates of LED among non-Black American individuals-an association not observed among Black Americans

Volunteering in adolescence and young adulthood crime involvement: a longitudinal analysis from the add health study

Background: Experiences in adolescence may have a lasting impact on adulthood. The objective of this study is to evaluate the association between adolescent (12–18 years of age) volunteerism with the incidence of illegal behaviors, arrests, and convictions in adulthood (>18 years of age). Methods: We conducted a retrospective cohort study using secondary data from the National Longitudinal Study of Adolescent to Adult Health. Students from grades 7–12 were recruited in 1994–1995 (n = 20,745), and then followed in 2001–2002 (n = 14,322) and in 2008–2009 (n = 12,288). In 2000–2001, participants were retrospectively asked about their volunteering experience from 12 to 18 years of age. Consequently, participants were divided into non-volunteers, self-volunteers, adult-required volunteers, and court-ordered volunteers. Groups were compared for rates of illegal behaviors, arrest, and convictions in adulthood (>18 years of age) using weighted generalized linear mixed negative binomial models while accounting for sampling design. Results: Relative to non-volunteers, self-volunteers reported 11 % fewer illegal behaviors (RR: 0.89, 95 % CI: 0.80, 0.99), 31 % fewer arrests (RR: 0.69, 95 %: 0.57, 0.85), and 39 % fewer convictions (RR: 0.61, 95 % CI: 0.47, 0.79) by age 18–28 years, and 28 % fewer illegal behaviors, 53 % fewer arrests, and 36 % fewer convictions by age 24–34. In comparison the adult-required volunteers also reported fewer arrests and convictions; however, they reported more illegal behaviors than the non-volunteers. The court-ordered volunteers reported higher rates of criminal involvement than the non-volunteers, throughout. Conclusion: This study suggests that volunteering in adolescence may reduce crime involvement in adulthood

Management of Pain in the United States—A Brief History and Implications for the Opioid Epidemic

Pain management in the United States reflects attitudes to those in pain. Increased numbers of disabled veterans in the 1940s to 1960s led to an increased focus on pain and its treatment. The view of the person in pain has moved back and forth between a physiological construct to an individual with pain where perception may be related to social, emotional, and cultural factors. Conceptually, pain has both a medical basis and a political context, moving between, for example, objective evidence of disability due to pain and subjective concerns of malingering. In the 20th century, pain management became predominately pharmacologic. Perceptions of undertreatment led to increased use of opioids, at first for those with cancer-related pain and then later for noncancer pain without the multidimensional care that was intended. The increased use was related to exaggerated claims in the medical literature and by the pharmaceutical industry, of a lack of addiction in the setting of noncancer pain for these medications—a claim that was subsequently found to be false and deliberatively deceptive; an epidemic of opioid prescribing began in the 1990s. An alarming rise in deaths due to opioids has led to several efforts to decrease use, both in patients with noncancer conditions and in those with cancer and survivors of cancer

Association of State Firearm Legislation With Female Intimate Partner Homicide

Introduction: The aim of this study was to assess the association between state firearm legislation and female intimate partner homicide. Methods: In 2017, the authors conducted a secondary data analysis of 16 states from 2010 to 2014, using data from the National Violent Death Reporting System, the State Firearm Law Database, and additional public sources. Poisson regression analyses quantified the association between the number of state restrictive firearm legislative provisions and the female population-based intimate partner homicide rate. For etiologic reasons, intimate partner homicide was disaggregated into homicide–suicide (intimate partner homicide followed by perpetrator suicide) and homicide-only intimate partner homicide (intimate partner homicide in the absence of perpetrator suicide). Results: There were 1,693 female intimate partner homicide deaths in the 16 states during 2010–2014; 67% were homicide-only intimate partner homicide. The number of state-level legislative provisions related to firearm restrictions ranged from four (Alaska) to 95 (Massachusetts). The intimate partner homicide rate in states with zero to 39 provisions was 1.16 per 100,000 person years (95% CI=1.10, 1.22) and in states with >40 provisions was 0.68 per 100,000 person years (95% CI=0.61, 0.72). The incidence of female intimate partner homicide was 56% lower in states with ≥40 legislative provisions (adjusted incidence rate ratio=0.44, 95% CI=0.28, 0.68), relative to states with zero to 39 provisions. This protective association was stronger for homicide-only intimate partner homicide than homicide–suicide intimate partner homicide. Conclusions: More state-level restrictive firearm legislation is associated with a lower rate of female intimate partner homicides

Impact of Iowa’s prescription monitoring program on opioid pain reliever prescribing patterns: An interrupted time series study 2003–2014

Objective. To evaluate the impact of Iowa’s prescription monitoring program (PMP), implemented in 2009, on opioid pain reliever (OPR) prescribing patterns. Methods. We conducted interrupted time series analyses using 2003–2014 health insurance claims from a private health insurer in Iowa. OPR prescriptions for all beneficiaries were included. Another data set included only OPR prescription for new opioid users required to have six months of insurance coverage. We evaluate four OPR prescribing patterns: 1) average daily dosage in morphine milligrams equivalents (MME), 2) MME per prescription, 3) average days’ supply per prescription, and 4) prescription rate per 1,000 insured person-years. We examined confounding and effect measure modification of the relationship between PMP and prescribing patterns by age and sex. Results. During the 12 years of follow-up, 1,512,388 insured Iowans contributed 6,169,634.92 person-years of follow-up. Of these, 505,274 patients filled 2,401,818 OPR prescriptions and 360,688 new OPR users filled as many first OPR prescriptions. The increasing trend of OPR prescription rates from 2003 to 2009 declined post-PMP. Similarly, there was a large decline in MME per day and MME per prescription. The OPR days’ supply kept increasing post-PMP implementation, albeit at a slightly slower rate than pre-PMP implementation. There was no confounding by age and sex; however, we observed heterogeneity by age and sex; patients aged 50 years and females received higher doses and more prescriptions pre-PMP and experienced the greatest declines post-PMP. Conclusions. Our study suggests that Iowa PMP implementation may have resulted in declines in OPR prescribing, and this impact varies by patient age and sex

Methodologic limitations of prescription opioid safety research and recommendations for improving the evidence base

Purpose: The ongoing opioid epidemic has claimed more than a quarter million Americans' lives over the past 15 years. The epidemic began with an escalation of prescription opioid deaths and has now evolved to include secondary waves of illicit heroin and fentanyl deaths, while the deaths due to prescription opioid overdoses are still increasing. In response, the Centers for Disease Control and Prevention (CDC) moved to limit opioid prescribing with the release of opioid prescribing guidelines for chronic noncancer pain in March 2016. The guidelines represent a logical and timely federal response to this growing crisis. However, CDC acknowledged that the evidence base linking opioid prescribing to opioid use disorders and overdose was grades 3 and 4. Methods: Motivated by the need to strengthen the evidence base, this review details limitations of the opioid safety studies cited in the CDC guidelines with a focus on methodological limitations related to internal and external validity. Results: Internal validity concerns were related to poor confounding control, variable misclassification, selection bias, competing risks, and potential competing interventions. External validity concerns arose from the use of limited source populations, historical data (in a fast-changing epidemic), and issues with handling of cancer and acute pain patients' data. We provide a nonexhaustive list of 7 recommendations to address these limitations in future opioid safety studies. Conclusion: Strengthening the opioid safety evidence base will aid any future revisions of the CDC guidelines and enhance their prevention impact

Associations between antibullying policies and bullying in 25 states

Importance Bullying is the most widespread form of peer aggression in schools. In an effort to address school bullying, 49 states have passed antibullying statutes. Despite the ubiquity of these policies, there has been limited empirical examination of their effectiveness in reducing students' risk of being bullied. Objective To evaluate the effectiveness of antibullying legislation in reducing students' risk of being bullied and cyberbullied, using data from 25 states in the United States. Design, Setting, and Participants A cross-sectional observational studywas conducted using a population-based survey of 63 635 adolescents in grades 9 to 12 from 25 states participating in the 2011 Youth Risk Behavior Surveillance System study (September 2010-December 2011). Data on antibullying legislation were obtained from the US Department of Education (DOE), which commissioned a systematic review of state laws in 2011. The report identified 16 key components that were divided into the following 4 broad categories: purpose and definition of the law, district policy development and review, school district policy components (eg, responsibilities for reporting bullying incidents), and additional components (eg, how policies are communicated). Policy variables from 25 states were linked to individual-level data from the Youth Risk Behavior Surveillance System on experiencing bullying and cyberbullying. Analyses were conducted between March 1, 2014, and December 1, 2014. Exposure State antibullying legislation. Main Outcomes and Measures Exposure to bullying and cyberbullying in the past 12 months. Results There was substantial variation in the rates of bullying and cyberbullying across states. After controlling for relevant state-level confounders, students in states with at least 1 DOE legislative component in the antibullying law had a 24%(95%CI, 15%-32%) reduced odds of reporting bullying and 20%(95%CI, 9%-29%) reduced odds of reporting cyberbullying compared with students in states whose laws had no DOE legislative components. Three individual components of antibullying legislation were consistently associated with decreased odds of exposure to both bullying and cyberbullying: statement of scope, description of prohibited behaviors, and requirements for school districts to develop and implement local policies. Conclusions and Relevance Antibullying policiesmay represent effective intervention strategies for reducing students' risk of being bullied and cyberbullied in schools. Copyright 2015 American Medical Association. All rights reserved

Immigration Policy and the Health of Latina Mothers and Their Infants

Restrictive immigration policies may adversely affect the health of Latina mothers and their infants. We hypothesized that undocumented Latina mothers and their US born children would have worse birth outcomes and healthcare utilization following the November 2016 election. We used a controlled interrupted time series to estimate the impact of the 2016 presidential election on low birth weight (LBW), preterm birth, maternal depression, well child visit attendance, cancelled visits, and emergency department (ED) visits among infants born to Latina mothers on emergency Medicaid, a proxy for undocumented immigration status. There was a 5.8% (95% CI: −0.99%, 12.5%) increase in LBW and 4.6% (95% CI: −1.8%, 10.9%) increase in preterm births immediately after the 2016 election compared to controls. While these findings were not statistically significant at p < 0.05, the majority of our data suggest worsened birth outcomes among undocumented Latina mothers after the election, consistent with larger prior studies. There was no difference in well child or ED visits. While restrictive policies may have contributed to worse birth outcomes among undocumented Latina mothers, our findings suggest that Latino families still attend infants’ scheduled visits. © 2023, The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature