Publications by authors named "Suzanne Nielsen"

147 Publications

Naloxone for opioid toxicity and overdose in the community.

Aust Prescr 2021 Apr 1;44(2):38-39. Epub 2021 Apr 1.

Uniting Medically Supervised Injecting Centre, Sydney.

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http://dx.doi.org/10.18773/austprescr.2021.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8075742PMC
April 2021

Embedding brief interventions for alcohol in general practice: a study protocol for the REACH project feasibility trial.

BJGP Open 2021 Apr 28. Epub 2021 Apr 28.

Department of General Practice, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia.

Background: Alcohol is a major source of harm in Australia that disproportionately affects low-income communities. Alcohol brief interventions (ABIs) combine an assessment of a person's alcohol use with advice to reduce health risks. Despite their effectiveness, clinicians do not routinely perform ABIs. This article presents a protocol for a feasibility trial of pragmatic implementation strategies and a new set of resources to support clinicians to complete ABIs in Australian general practices.

Aim: To explore the facilitators and barriers to increasing the uptake of ABIs in primary care including acceptability, reach, adoption, fidelity, and sustainability.

Design & Setting: A mixed-methods evaluation of the uptake of ABIs in general practice clinics serving low-income communities in Melbourne, Australia. The approach is informed by the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT).

Method: The implementation strategies and resources will be trailled in five general practices over 12 months. The primary outcome will be change in the proportion of adult patients with a complete alcohol history in their electronic medical records. Baseline data collection includes a practice survey to describe practice routines for ABIs and de-identified patient medical record data on completed alcohol histories (repeated at 3, 6, 9, and 12-months post-intervention). Survey and interview data will also be collected from clinicians, patients, and primary health network staff to assess acceptability and feasibility of the intervention.

Conclusion: The study will explore how the implementation strategies and resources can improve alcohol screening and management among low-income patients in general practice.
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http://dx.doi.org/10.3399/BJGPO.2021.0037DOI Listing
April 2021

Should we be routinely co-prescribing naloxone for patients on long term opioids?

Med J Aust 2021 Apr 25. Epub 2021 Apr 25.

Monash Addiction Research Centre, Monash University, Melbourne, VIC.

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http://dx.doi.org/10.5694/mja2.51026DOI Listing
April 2021

Pharmaceutical Opioid Use Patterns and Indicators of Extramedical Use and Harm in Adults With Chronic Noncancer Pain, 2012-2018.

JAMA Netw Open 2021 Apr 1;4(4):e213059. Epub 2021 Apr 1.

National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.

Importance: Despite concern about harms related to long-term prescribed opioid use among individuals with chronic noncancer pain (CNCP), no study has examined whether the same patients engage in a risky pattern of use consistently for the long term.

Objective: To examine the prevalence, incidence, persistence, and cessation of a range of opioid behaviors, indicators of extramedical use, and harm among individuals who are prescribed opioids.

Design, Setting, And Participants: This 5-year prospective cohort study in communities across Australia included 1514 adults who were prescribed opioids for CNCP. Data collection took place from August 2012 to December 2018, and data analysis took place from February to November 2020.

Exposure: Prescription opioid use.

Main Outcomes And Measures: High-dose opioid use (≥200 oral morphine equivalent [OME] mg/d); requesting an increase in opioid dose; requesting an early prescription renewal; tampering with opioid medication; diversion of medication to others; and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision opioid dependence. Cessation of opioid use was also assessed.

Results: Of the 1514 participants, 672 (44.39%) were men, the mean (SD) age was 58 (19) years, and 737 (48.68%) were unemployed. At each annual interview, approximately 1 in 8 people (10.98% [95% CI, 10.33%-11.63%] to 14.73% [95% CI, 13.98%-15.48%] at any given interview) were taking more than 200 OME mg/d; comparatively more had requested an increased dosage in the previous 3 months (8.46% [95% CI, 7.89%-9.03%] to 23.77% [95% CI, 22.82%-24.73%]); and fewer asked for an early prescription renewal (4.61% [95% CI, 4.19%-5.03%] to 13.97% [95% CI, 13.24%-14.70%]). In any given interview, between 3.06% (95% CI, 2.72%-3.40%) and 7.86% (95% CI, 7.31%-8.41%) of respondents reported tampering and between 0.47% (95% CI, 0.33%-0.60%) and 1.39% (95% CI, 1.16%-1.62%) reported diversion to others. Between 8.28% (95% CI, 7.71%-8.84%) and 13.06% (95% CI, 12.35%-13.77%) met criteria for opioid dependence at each interview. Opioid cessation increased across interviews, from year 1 (9.15% [95% CI, 8.55%-9.74%]) to year 5 (20.02% [19.14%-20.89%]). There was considerable incidence and cessation in all behaviors from 1 interview to the next: most who engaged in any of these behaviors only did so at only 1 interview. For pharmaceutical opioid dependence, between 55.26% (95% CI, 53.81%-56.71%) and 64.44% (95% CI, 62.87%-66.00%) of cases in 1 interview did not meet dependence criteria in the following interview.

Conclusions And Relevance: These findings suggest considerable fluidity in opioid use, extramedical behaviors, and opioid dependence among people with CNCP. This reinforces the need for reassessment of the effectiveness and safety of prescription opioid use over time.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.3059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8035647PMC
April 2021

Adapting harm reduction services during COVID-19: lessons from the supervised injecting facilities in Australia.

Harm Reduct J 2021 02 17;18(1):20. Epub 2021 Feb 17.

North Richmond Community Health Medically Supervised Injecting Room, Melbourne, Australia.

The COVID-19 crisis has had profound impacts on health service provision, particularly those providing client facing services. Supervised injecting facilities and drug consumption rooms across the world have been particularly challenged during the pandemic, as have their client group-people who consume drugs. Several services across Europe and North America closed due to difficulties complying with physical distancing requirements. In contrast, the two supervised injecting facilities in Australia (the Uniting Medically Supervised Injecting Centre-MSIC-in Sydney and the North Richmond Community Health Medically Supervised Injecting Room-MSIR-in Melbourne) remained open (as at the time of writing-December 2020). Both services have implemented a comprehensive range of strategies to continue providing safer injecting spaces as well as communicating crucial health information and facilitating access to ancillary services (such as accommodation) and drug treatment for their clients. This paper documents these strategies and the challenges both services are facing during the pandemic. Remaining open poses potential risks relating to COVID-19 transmission for both staff and clients. However, given the harms associated with closing these services, which include the potential loss of life from injecting in unsafe/unsupervised environments, the public and individual health benefits of remaining open are greater. Both services are deemed 'essential health services', and their continued operation has important benefits for people who inject drugs in Sydney and Melbourne.
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http://dx.doi.org/10.1186/s12954-021-00471-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887539PMC
February 2021

Clinical correlates and outcomes associated with pregabalin use among people prescribed opioids for chronic non-cancer pain: A five-year prospective cohort study.

Br J Clin Pharmacol 2020 Dec 28. Epub 2020 Dec 28.

National Drug and Alcohol Research Centre, UNSW, Sydney, Australia.

Aims: Pregabalin has become widely used as an alternative to opioids in treating certain types of chronic non-cancer pain, but few studies have examined its clinical efficacy outside trials. We address this gap by examining the utilization, correlates and clinical outcomes of pregabalin use among an Australian community-based cohort of people prescribed opioids for chronic non-cancer pain.

Methods: Through a five-year prospective cohort study (n = 1514) we examined associations between pregabalin use and pain severity and interference, mental health, opioid dose and past month use of ambulance and emergency department services. We used fixed-effects regression models to examine within-participant differences, and random-effects regression models to examine within- and between-participant differences in clinical outcomes.

Results: In an analysis of cases with complete data over five-years (n = 896), the prevalence of pregabalin use ranged from 16% at cohort entry to 29% at 36- and 48-months, and 46% reported pregabalin use at any time during the five years. Pregabalin use was associated with greater pain severity and interference and greater use of high-risk opioid doses (>90 oral morphine equivalents/day). Pregabalin use was not associated with changes in mental health symptoms, ambulance or emergency department attendance in the fixed or random effects models.

Conclusions: Pregabalin use was common, but for most people use was not associated with clinically meaningful improvements in pain or functioning.
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http://dx.doi.org/10.1111/bcp.14715DOI Listing
December 2020

Retention of opioid agonist treatment prescribers across New South Wales, Australia, 2001-2018: Implications for treatment systems and potential impact on client outcomes.

Drug Alcohol Depend 2021 02 19;219:108464. Epub 2020 Dec 19.

National Drug and Alcohol Research Centre, University of NSW, Sydney NSW 2052, Australia. Electronic address:

Background: There has been much research on the efficacy and effectiveness of opioid agonist treatment (OAT), but less on its implementation and sustainability. A challenge internationally has been recruiting and retaining prescribers. This paper aims to characterise the prescribers in terms of OAT prescribing behaviours.

Methods: Retrospective cohort study in New South Wales, Australia. Participants were 2199 OAT prescribers between 1 st August 2001-19th September 2018.We examined trends in initiation and cessation of OAT prescribers. Adjusted hazard ratios were calculated to estimate prescriber retention, adjusting for year of initiation, practice type, client load and treatment prescribed.

Results: The rate of prescribers ceasing OAT prescribing has been increasing over time: a prescriber who initiated between 2016-2017 had over four times the risk of cessation compared with one who initiated before 2001, AHR: 4.77; [3.67-6.21]. The highest prescriber cessation rate was in prescribers who had prescribed for shorter time periods. The annual percentage of prescribers who ceased prescribing among those who prescribed for ≤5 years increased from 3% in 2001 to 20 % in 2017. By 2017 more prescribers were discontinuing prescribing than new prescribers were starting. Approximately 87 % (n = 25,167) of OAT clients were under the care of 20 % of OAT prescribers (n = 202); half had been prescribing OAT for 17+ years.

Conclusions: OAT prescribing is increasingly concentrated in a small group of mature prescribers, and new prescribers are not being retained. There is a need to identify and respond to the reasons that contribute to newer prescribers to cease prescribing and put in place strategies to increase retention and broaden the base of doctors involved in such prescribing.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108464DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855715PMC
February 2021

Using the behaviour change wheel to understand and address barriers to pharmacy naloxone supply in Australia.

Int J Drug Policy 2021 Apr 11;90:103061. Epub 2020 Dec 11.

Medical School, The Australian National University, Florey Building 54 Mills Road, Acton 2601, Canberra, Australia.

Background: There has been low community pharmacy-based naloxone supply in Australia despite its over-the-counter status. The Behaviour Change Wheel (BCW) is a method used to understand individual and system-level barriers and facilitators to a particular behaviour to inform program implementation. The BCW is focused on three essential conditions of behaviour change (capability, opportunity, and motivation (termed the COM-B)) which we use to assess pharmacists perceptions and experiences of naloxone provision with the aim of using informing targets for interventions to improve naloxone distribution.

Method: Qualitative interviews with community pharmacists (n = 37) from four Australian jurisdictions explored naloxone knowledge, expectations and experiences dispensing the medicine. Audio-recorded interviews were transcribed verbatim and coded against the a priori domains in the COM-B (capability, opportunity, and motivation). Results were analysed to identify key barriers and facilitators to naloxone provision within each domain. Finally, we mapped our analysis against the intervention functions and policy-level strategies provided in the BCW to identify example intervention strategies.

Results: Underlying all pharmacists' descriptions of naloxone were structural impediments to dispensing including poor communication regarding pharmacists' role and disrupted supply chains. Mapped across the three COM-B domains, we find two divergent groups of pharmacists. Pharmacists' capability and motivation to supply naloxone was higher amongst those who did not problematize people who inject drugs and who worked in pharmacies already supplying harm reduction services. Pharmacists were less likely to discuss capabilities and opportunities for naloxone dispensing when harm reduction was not normalised in their workplace and/or they described people who inject drugs using negative and stigmatising language.

Conclusions: Analysis using the COM-B framework reveals key areas where implementation and policy strategies are needed to increase naloxone supply. Individual- and structural-level supports are needed to improve pharmacists' knowledge of naloxone and address other logistical and cultural barriers that limit naloxone provision in pharmacy settings.
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http://dx.doi.org/10.1016/j.drugpo.2020.103061DOI Listing
April 2021

Characteristics of oxycodone-related ambulance attendances: analysis of temporal trends and the effect of reformulation in Victoria, Australia from 2013 to 2018.

Addiction 2020 Dec 9. Epub 2020 Dec 9.

Monash Adiction Research Centre, Eastern Health Clinical School, Victoria, Australia.

Background And Aims: In Australia, oxycodone has been associated with increasing rates of harm over time, despite reduced use, reformulation to a tamper-resistant form and in contrast to most prescription opioids. We explored characteristics of oxycodone-related ambulance attendances to understand whether presentation characteristics could explain increasing oxycodone harm.

Design: Retrospective study of coded ambulance patient care records related to extramedical oxycodone use, January 2013 to September 2018.

Setting: Victoria, Australia.

Cases: A total of 2788 oxycodone-related ambulance attendances.

Measurements: Primary outcomes were temporal changes in characteristics of oxycodone presentations over time (from 2013 to 2018) and following reformulation. Covariates include demographic characteristics, presentation severity, mental health, substance use and poisoning intent.

Findings: Average age was 41.3 (± 16.4) years with females comprising 56.4% of attendances (n = 2788). The proportion of females in oxycodone-related attendances increased over time [an average increase in the odds ratios of 5% per year (OR) = 1.05, 95% confidence interval (CI) = 1.01-1.10]. Other temporal trends included a reduced likelihood of naloxone administration (OR = 0.92, 95% CI = 0.85-1.00), heroin involvement (OR = 0.81, 95% CI = 0.66-0.99), comorbid mental health symptoms (OR = 0.87, 95% CI = 0.82-0.92) and unknown intent poisoning (OR = 0.91, 95% CI = 0.85-0.96); and a greater risk of alcohol involvement (OR = 1.06, 95% CI = 1.01-1.11), non-opioid extramedical pharmaceutical use (OR = 1.05, 95% CI = 1.01-1.10), comorbid suicidal thoughts or behaviours (OR = 1.10, 95% CI = 1.05-1.15) and past history of psychiatric issues (OR = 1.22, 95% CI = 1.16-1.27). Interrupted time-series analysis showed that reformulation was associated with an immediate effect on sex, severity, accidental poisoning and unknown intent poisoning, although these were not sustained over time. Alcohol involvement in the attendance (OR = 1.43, 95% CI = 1.17-1.74, i.e. an average increase in the odds of 43% per year), Glasgow Coma Scale (OR = 1.28, 95%CI 1.04 - 1.57), a previous history of psychiatric issues (OR = 0.80, 95% CI = 0.70-0.92, i.e. an average decrease in the odds of 20% per year, heroin involvement (OR = 0.22, 95% CI = 0.05 - 0.98) and illicit drug use (OR = 0.45, 95% CI = 0.23 - 0.87) showed statistically significant relative changes following the reformulation.

Conclusions: The characteristics of oxycodone presentations in Australian ambulances attendances appear to be changing over time, including more female presentations; increasing alcohol use, extramedical use of non-opioid pharmaceuticals and suicidal thoughts or behaviours and decreasing heroin and illicit drug involvement.
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http://dx.doi.org/10.1111/add.15365DOI Listing
December 2020

Risk factors for indicators of opioid-related harms amongst people living with chronic non-cancer pain: Findings from a 5-year prospective cohort study.

EClinicalMedicine 2020 Nov 16;28:100592. Epub 2020 Oct 16.

National Drug and Alcohol Research Centre, UNSW, Sydney, Australia.

Background: The literature suggests patient characteristics and higher opioid doses and long-term duration are associated with problematic opioid behaviours but no one study has examined the role of all these factors simultaneously in a long-term prospective cohort study.

Methods: Five-year, community-based, prospective cohort of people prescribed opioids for chronic non-cancer pain (CNCP). Logistic mixed effect models with multiple imputation were used to address missing data. Oral morphine equivalent (OME) mg per day was categorised as: 0 mg OME/day, 1-49 mg OME/day (reference), 50-89 mg OME/day, 90-199 mg OME/day and 200mg+ OME/day. Patient risk factors included: age, gender, substance use, mental health history and pain-related factors. Main outcomes included: Prescribed Opioids Difficulties Scale (PODS), Opioid-Related Behaviours In Treatment (ORBIT) scale, and ICD-10 opioid dependence. Multiple confounders for problematic opioid behaviours were assessed.

Findings: Of 1,514 participants 44.4% were male (95%CI 41.9-46.9) and their mean age was 58 years (IQR 48-67). Participants had a mean duration of pain of 10 years (IQR 4.5-20.0) and had been taking strong opioids for a median of four years (IQR 1.0-10.0). At baseline, median OME/day was 73 (IQR 35-148). At 5-years, 85% were still taking strong opioids. PODS moderate-high scores reduced from 59.9% (95%CI 58.8-61.0) at baseline to 51.5% (95%CI 50.0-53.0) at 5-years. Around 9% met criteria for ICD-10 opioid dependence at each wave. In adjusted mixed effect models, the risk factors most consistently associated with problematic opioid use were: younger age, substance dependence, mental health histories and higher opioid doses.

Interpretation: Both patient risk factors and opioid dose are associated with problematic opioid use behaviours.
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http://dx.doi.org/10.1016/j.eclinm.2020.100592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7700907PMC
November 2020

Risk of discharge against medical advice among hospital inpatients with a history of opioid agonist therapy in New South Wales, Australia: A cohort study and nested crossover-cohort analysis.

Drug Alcohol Depend 2020 12 12;217:108343. Epub 2020 Oct 12.

National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia.

Background: People who use illicit opioids have high rates of hospital admission. We aimed to measure the risk of discharge against medical advice among inpatients with a history of opioid agonist therapy (OAT), and test whether OAT is associated with lower risk of discharge against medical advice.

Methods: We conducted a cohort study of patients admitted to hospital in an emergency between 1 August 2001 and 30 April 2018 in New South Wales, Australia. All patients had a previous episode of OAT in the community. The main outcome was discharge against medical advice, and the main exposure was whether patients had an active OAT permit at the time of admission.

Results: 14,035/116,957 admissions (12 %) ended in discharge against medical advice. Admissions during periods of OAT had 0.79 (0.76-0.83; p < 0.001) times the risk of discharge against medical advice, corresponding to an absolute risk reduction of 3.0 percentage points. Risk of discharge against medical advice was higher among patients who were younger, male, identified as Aboriginal and/or Torres Strait Islander, and those admitted for accidents, drug-related reasons, or injecting-related injuries (such as cutaneous abscesses). In a subsample of 7793 patients included in a crossover-cohort analysis, OAT was associated with 0.84 (95 % CI 0.76-0.93; p < 0.001) times the risk of discharge against medical advice.

Conclusions: Among patients with a history of OAT, one in eight emergency hospital admissions ends in discharge against medical advice. OAT enrolment at the time of admission is associated with a reduction of this risk.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736124PMC
December 2020

Hospitalisations for non-fatal overdose among people with a history of opioid dependence in New South Wales, Australia, 2001-2018: Findings from the OATS retrospective cohort study.

Drug Alcohol Depend 2021 01 18;218:108354. Epub 2020 Oct 18.

National Drug and Alcohol Research Centre, University of NSW, Sydney, NSW, 2052, Australia. Electronic address:

Background: To examine, among a cohort of opioid dependent people with a history of opioid agonist treatment (OAT), the frequency and incidence rates of non-fatal overdose (NFOD) hospital separations over time, by age and sex.

Methods: Retrospective cohort study of people with a history of OAT using state-wide linked New South Wales (NSW) data. The incidence of NFOD hospital separations involving an opioid, sedative, stimulant or alcohol was defined according to the singular or combination of poisoning/toxic effect using ICD-10-AM codes. Crude incidence rates were calculated by gender, age group and calendar year.

Results: There were 31.8 (31.3-32.3) NFOD per 1,000 person-years (PY). Opioid NFOD incidence was higher in women than men: incidence rate ratio (IRR) 1.11 per 1,000PY; 95 %CI: [1.06-1.17]; women had higher sedative NFOD rates than men, IRR 1.27 per 1,000PY [1.21-1.34]. Participants ≤25 years, 26-30yrs, and 31-35yrs had higher incidence of opioid NFOD compared to 46+yrs, with IRRs of: 1.45 per 1,000PY; [1.32-1.59]; 1.20 per 1,000PY; [1.11-1.30] and 1.22 per 1,000PY; [1.13-1.32], respectively. Between 2006-7 and 2016-17, the cohort accounted for 19 % of NSW opioid NFOD episodes, 12 % of sedative, 14 % of stimulant and 5 % of acute alcohol-related NFOD.

Conclusions: Hospital stays due to NFOD are a relatively frequent occurrence among opioid-dependent people. There are clear differences in rates and substances involved by sex, age and over time. Evidence-based interventions that prevent overdose among people who are opioid dependent need to be delivered to scale, including widespread community provision of naloxone.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108354DOI Listing
January 2021

Validity and Reliability of the Computer-Administered Routine Opioid Outcome Monitoring (ROOM) Tool.

Pain Med 2020 12;21(12):3645-3654

Monash Addiction Research Centre, Monash University Peninsula Campus, Frankston, Victoria, Australia.

Objective: The Routine Opioid Outcome Monitoring (ROOM) tool measures outcomes with opioids using an established framework which includes domains such as pain, mood, opioid use disorder, alcohol use, and constipation. This study aims to validate and establish the test-retest reliability of the computer-administered ROOM tool.

Design And Setting: Cross-sectional analysis of an online sample.

Subjects: Participants comprised those with chronic noncancer pain who regularly used prescription opioids.

Methods: Participants self-completed the online ROOM tool along with other validated measures (validation questionnaire), and those who were agreeable also completed the online test-retest questionnaire approximately two weeks later. Subcomponents of the ROOM tool (i.e., pain, mood, alcohol use, opioid use disorder, and constipation) were validated against longer measures of the same construct using Pearson correlation coefficients. Intraclass correlation coefficients were used to assess the stability of the ROOM tool over time.

Results: A total of 324 participants completed the validation questionnaire, of whom 260 also completed the test-retest questionnaire. The opioid use disorder domain showed good sensitivity (73.6) and specificity (75.8) against the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, any opioid use disorder. All ROOM components showed moderate correlation (r = 0.55-0.73) with their longer counterparts. Test-retest reliability was fair (0.58-0.75), indicating that responses were relatively stable over time. Reliability did vary, however, based on the components being measured and how certain tools were scored.

Conclusion: The computer-administered ROOM tool is a valid approach for brief monitoring of outcomes with prescribed opioids in primary care settings and appears to be acceptable to people who are using prescribed opioids for chronic pain.
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http://dx.doi.org/10.1093/pm/pnaa297DOI Listing
December 2020

Perceptions of injectable opioid agonist treatment (iOAT) among people who regularly use opioids in Australia: findings from a cross-sectional study in three Australian cities.

Addiction 2020 Oct 17. Epub 2020 Oct 17.

National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.

Background And Aims: Not all people experiencing opioid dependence benefit from oral opioid agonist treatment. The aim of this study was to examine perceptions of (supervised) injectable opioid agonist treatment (iOAT) (described as 'an opioid similar to heroin self-injected at a clinic several times a day') among people who regularly use opioids and determine how common iOAT eligibility criteria accord with interest in iOAT.

Design: Cross-sectional survey SETTING: Sydney, Melbourne and Hobart, Australia PARTICIPANTS: A total of 344 people (63% male) who use opioids regularly and had ever injected opioids, interviewed December 2017-March 2018. The mean age of participants was 41.5 years [standard deviation (SD) = 8.5].

Measurements: Primary outcome measures were interest in iOAT, factors associated with interest and the proportion of participants who would be eligible using common criteria from trials and guidelines. We examined willingness to travel for iOAT, medication preferences and perspectives on whom should receive iOAT.

Findings: Overall, 53% of participants (n = 182) believed that iOAT would be a good treatment option for them. Participants who believed that iOAT was a good treatment option for them were more likely to be male [adjusted odds ratio (aOR) = 1.76, 95% confidence interval (CI) = 1.10-2.82], have used heroin in the past month (aOR = 6.03, 95% CI = 2.86-12.71), currently regularly inject opioids (aOR = 1.84, 95% CI = 1.16-2.91) and have met ICD-10 criteria for opioid dependence (aOR = 3.46, 95% CI = 1.65-7.24). Those interested in iOAT had commenced more treatment episodes (aOR =1.06, 95% CI = 1.00-1.12). Among those interested in iOAT (n = 182), 26% (n = 48) met common eligibility criteria for iOAT.

Conclusions: Interest in injectable opioid agonist treatment does not appear to be universal among people who regularly use opioids. Among study participants who expressed interest in injectable opioid agonist treatment, most did not meet common eligibility criteria.
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http://dx.doi.org/10.1111/add.15297DOI Listing
October 2020

Comparing rates and characteristics of emergency department presentations related to pharmaceutical opioid poisoning in Australia: a study protocol for a retrospective observational study.

BMJ Open 2020 09 29;10(9):e038979. Epub 2020 Sep 29.

Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia

Introduction And Aims: Pharmaceutical opioids are an important contributor to the global 'opioid crisis', and are implicated in 70% of Australia's opioid-related mortality. However, there have been few studies which consider the relative contribution of different pharmaceutical opioids to harm.We aim to compare commonly used pharmaceutical opioids in terms of (1) rates of harm, and (2) demographic and clinical characteristics associated with that harm.

Method And Analysis: Observational study of emergency department presentations for non-fatal poisoning related to pharmaceutical opioid use. Data from 2009 to 2019 will be extracted from the Victorian Emergency Minimum Dataset which contains data from public hospitals with dedicated emergency departments in Victoria, Australia's second most populous state. A combination of free-text and International Classification of Diseases 10th Revision codes will be used to identify relevant cases, with manual screening of each case to confirm relevance. We will calculate supply-adjusted rates of presentations using Poisson regression for all pharmaceutical opioid cases identified, separately for nine commonly prescribed pharmaceutical opioids (buprenorphine, codeine, fentanyl, methadone, morphine, oxycodone, oxycodone-naloxone, tapentadol, tramadol), and for a multiple opioid category. We will use multinomial logistic regression to compare demographic and clinical characteristics, such as triage category, across opioid types.

Ethics And Dissemination: This work is conducted under approval 21427 from the Monash University Human Research Ethics Committee for ongoing injury surveillance. As per conditions of approval, cells of <5 will not be reported, though zeroes will be preserved. We will present project findings in a peer-reviewed journal article as well as at relevant scientific conferences.
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http://dx.doi.org/10.1136/bmjopen-2020-038979DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526272PMC
September 2020

Community pharmacists' preparedness to intervene with concerns around prescription opioids: findings from a nationally representative survey.

Int J Clin Pharm 2021 Apr 20;43(2):411-419. Epub 2020 Sep 20.

Monash Addiction Research Centre, Monash University Peninsula Campus, 47-49 Moorooduc Hwy, Frankston, VIC, 3199, Australia.

Background Prescription opioid use and related harms have dramatically increased in many countries. Objective To investigate pharmacists' preparedness and confidence to intervene when concerned about supplying prescription opioids and strategies used when concerned about supplying these opioids. Setting Online survey among a representative sample of Australian community pharmacists. Method Pharmacists completed an online survey about their concerns, comfort and strategies used when supplying prescription opioids. Correlates of comfort to intervene and active intervention strategies were explored using multivariable ordered logistic regression and adjusted odd ratios (aOR) and 95% confidence intervals were reported. Main outcome measures Comfort to intervene when concerned about supplying prescription opioids and pharmacists' discussing these concerns with the patient, and the prescriber. Results Most pharmacists were concerned about supplying prescription opioids to patients in the past week. Being female [adjusted odds ratio (aOR) 0.63; 95% confidence interval (CI) 0.47-0.85] was associated with reduced comfort, while practicing within a large chain pharmacy (aOR 1.52, 95% CI 1.08-2.15) was associated with greater comfort to intervene when concerned about prescription opioid supply. Pharmacists practicing in rural areas were significantly less likely than those in capital cities to discuss concerns with patients (aOR 0.66, 95% CI 0.45-0.97). Post-graduate education about substance use disorders was associated with increased likelihood of discussing concerns with patients (aOR 1.54, 95% CI 1.12-2.13). Pharmacists that indicated greater comfort in intervening when concerned about prescription opioids were more likely to discuss concerns with both patients and prescribers. Females were significantly more likely to discuss concerns with prescribers (aOR 1.67, 95% CI 1.22-2.29), whereas years of practice reduced the odds of discussing concerns with prescribers (aOR 0.98, 95% CI 0.97-0.99). Conclusion Considering specific factors such as gender and years of practice to help target pharmacist training may lead to increased comfort in discussing concerns related to prescription opioids, which in turn may improve communication with prescribers and patients.
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http://dx.doi.org/10.1007/s11096-020-01152-8DOI Listing
April 2021

Life expectancy of people who are dependent on opioids: A cohort study in New South Wales, Australia.

J Psychiatr Res 2020 11 23;130:435-440. Epub 2020 Aug 23.

National Drug and Alcohol Research Centre, 22-32 King St, Randwick, NSW, 2031, Australia.

Background: People who are dependent on opioids have increased risk of premature death, but there are few estimates of life expectancy.

Methods: We calculated age-specific mortality rates in a cohort of people who had at least one prescription of an opioid agonist (methadone or buprenorphine) between 2001 and 2018 in New South Wales, Australia. We used life tables to estimate life expectancy at age 18. We also estimated the potential years of life lost before age 75, decomposed by cause of death.

Results: The cohort included 47,197 people, with a median of 9.8 years of follow-up. 5097 participants died, and the standardised mortality ratio (compared to the general population of New South Wales) was 6.06 (95% CI 5.90-6.23). Life expectancy at age 18 was an additional 47.5 years (95% CI 42.9-50.5) for men and 50.7 years (95% CI 45.4-54.8) for women; deficits of 14.7 and 15.8 years respectively when compared to the general population. The largest cause of death was non-communicable physical diseases, which accounted for 47% of deaths in life tables for men and 42% for women. Drug-related deaths accounted for 16% of deaths for men and 19% for women, but due to the young age at which these deaths occur, they contributed approximately one third of potential years of life lost.

Conclusion: In common with people with serious mental illnesses, people who are dependent on opioids have substantially reduced life expectancy. In both populations most excess deaths relate to non-communicable physical diseases.
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http://dx.doi.org/10.1016/j.jpsychires.2020.08.013DOI Listing
November 2020

Validation of the OWLS, a Screening Tool for Measuring Prescription Opioid Use Disorder in Primary Care.

Pain Med 2020 11;21(11):2757-2764

Monash Addiction Research Centre, Monash University Peninsula Campus, Frankston, Victoria, Australia.

Objective: The OWLS is a screening tool for prescription opioid use disorder designed for use in primary care. This study aimed to confirm the optimal wording, scoring methods, and cutoff for the OWLS.

Design And Setting: Cross-sectional analysis of an online sample.

Subjects: Participants comprised those with chronic noncancer pain who regularly used prescription opioids.

Methods: Eligible participants self-completed an online version of the OWLS prescription opioid use disorder screening tool and the Composite International Diagnostic Interview Substance Abuse module. Receiver operating characteristics were calculated for three scoring methods for the OWLS, and these were compared with DSM-5 classification of any use disorder and moderate to severe opioid use disorder.

Results: Among the sample (N = 324), utilizing scoring method (i) (i.e., positive endorsement ≥ response option "a little bit") and a cutoff of 3 increased the percentage of correctly classified participants, with concurrent increases in specificity and decreases in false discovery rate, and false positive rate.

Conclusion: OWLS utilizing scoring method (i) with a cutoff of 3 was shown to be the optimal version and scoring method of this tool. This represents a time-efficient, simple scoring method, allowing for quick and accurate screening for opioid use disorder to occur.
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http://dx.doi.org/10.1093/pm/pnaa275DOI Listing
November 2020

Feasibility and acceptability of take-home naloxone for people released from prison in New South Wales, Australia.

Drug Alcohol Rev 2021 Jan 17;40(1):98-108. Epub 2020 Aug 17.

National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.

Introduction And Aims: To assess the feasibility and acceptability of a take-home naloxone program for people with a history of opioid use released from prison in New South Wales, Australia.

Design And Methods: Cross-sectional interviews with people with a history of opioid use who were recently released from prison (n = 105), and semi-structured interviews with key clinical and operational staff of Justice Health and Forensic Mental Health Network and Corrective Services NSW (n = 9).

Results: Among people with a history of opioid use who had recently left prison, there was very high awareness of the elevated risk of overdose following release from prison (95%) and the potential for naloxone to reverse an opioid overdose (97%). Participants considered that their personal risk of overdose was low, despite ongoing opioid use being common. Participants were largely supportive of take-home naloxone, but the majority (83%) stated that proactively obtaining naloxone would be a low priority for them following release. Key informants were supportive of introducing naloxone training and supply and identified barriers to implementation, including adequate resourcing, identifying the population for training, and developing an appropriate model of training and implementation.

Discussion And Conclusion: There was widespread support for naloxone training in custody and distribution at release among people recently released from prison and key stakeholders in health-care provision and prisons administration. As proactively accessing naloxone is a low priority for patients, naloxone supply at release may be more effective than programs that refer releasees to local pharmacies, but developing a sustainable supply model requires consideration of several barriers.
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http://dx.doi.org/10.1111/dar.13144DOI Listing
January 2021

Open-label, multicentre, single-arm trial of monthly injections of depot buprenorphine in people with opioid dependence: protocol for the CoLAB study.

BMJ Open 2020 07 31;10(7):e034389. Epub 2020 Jul 31.

National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia

Introduction: Opioid agonist treatment is effective for opioid dependence and newer extended-release buprenorphine (BUP-XR) injections represent a significant development. The Community Long-Acting Buprenorphine (CoLAB) study aims to evaluate client outcomes among people with opioid dependence receiving 48 weeks of BUP-XR treatment, and examines the implementation of BUP-XR in diverse community healthcare settings in Australia.

Methods And Analysis: The CoLAB study is a prospective single-arm, multicentre, open-label trial of monthly BUP-XR injections in people with opioid dependence. Participants are being recruited from a network of general practitioner and specialist drug treatment services located in the states of New South Wales, Victoria and South Australia in Australia. Following a minimum 7 days on 8-32 mg of sublingual buprenorphine (±naloxone), participants will receive monthly subcutaneous BUP-XR injections administered by a healthcare practitioner at intervals of 28 days (-2/+14 days). The primary endpoint is participant retention in treatment at 48 weeks after treatment initiation. Secondary endpoints will evaluate dosing schedule variations, craving, withdrawal, substance use, health and well-being, and client-reported treatment experience. Qualitative and costing substudies will examine implementation barriers and facilitators at the client and provider level.

Ethics And Dissemination: The study has received ethics approval from the St Vincent's Hospital Sydney Human Research Ethics Committee (Ref. HREC/18/SVH/221). The findings will be disseminated via publication in peer-reviewed journals, presentations at national and international scientific conferences, and in relevant community organisation publications and forums.

Trial Registration Number: NCT03809143 PROTOCOL IDENTIFIER: CoLAB1801, V.4.0 dated 01 August 2019.
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http://dx.doi.org/10.1136/bmjopen-2019-034389DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7398105PMC
July 2020

'Extreme personal stress' and 'a lot of pain': Exploring the physical, mental and social contexts of extramedical pharmaceutical opioid use in Australian paramedic case descriptions.

Drug Alcohol Rev 2020 11 7;39(7):870-878. Epub 2020 Jul 7.

Turning Point, Eastern Health, Melbourne, Australia.

Introduction And Aims: Despite growing concerns over the extramedical use of pharmaceutical opioids, few studies have focused on the contexts that shape this use or how it might lead to harm. There is also limited research examining how contexts might vary across different opioids, such as those with well-established abuse liabilities (e.g. oxycodone) and newer 'atypical' opioids (e.g. tapentadol). We aimed to address these gaps.

Design And Methods: We analysed Australian paramedic case descriptions for tapentadol cases (n = 82) and a representative sample of oxycodone cases (n = 82) from a 6-year period (2013-2018). We used framework analysis to identify 'contexts' shaping extramedical use from cases where use of tapentadol or oxycodone was assessed to have significantly contributed to the attendances.

Results: Demographically, case descriptions from both drug types were broadly similar (approximately 55% female, 44% were 35-54 years old), as were the contextual factors. The most prevalent contexts common to both oxycodone and tapentadol cases were psychological distress, physical pain and social stressors. Suicidal intent was present across multiple contexts.

Discussion And Conclusions: This study is one of the first to explore the contexts of extramedical pharmaceutical opioid use leading to acute harm. Our analysis found patients in complex, emergency situations, seeking rapid relief from physical pain, psychological distress, social issues and/or suicidal thoughts. These data highlight the complex needs of those experiencing harm from extramedical pharmaceutical opioid use, regardless of opioid type, and the importance of contextual factors shaping both use and subsequent harm.
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http://dx.doi.org/10.1111/dar.13118DOI Listing
November 2020

A systematic review of opioid overdose interventions delivered within emergency departments.

Drug Alcohol Depend 2020 May 23;213:108009. Epub 2020 May 23.

Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Peninsula Campus, Moorooduc Hwy, Frankston, 3199, Victoria, Australia. Electronic address:

Background: People with opioid use disorders are at higher risk of fatal opioid overdose and attend emergency departments (ED) more frequently compared to the general population. This review aimed to synthesise evidence on the ED-based delivery of opioid overdose prevention interventions.

Methods: Using the PRISMA guidelines, four databases (Medline; Embase; Scopus; PsycINFO) were searched for peer-reviewed articles on ED based interventions to prevent opioid overdose, published January 1998 to October 2018.

Results: The 13 identified studies were grouped into four main intervention types. Seven focused on provision of take-home naloxone (THN) and overdose education. These described the successful delivery of THN by ED staff; in collaboration with community partners; and barriers to delivery. Three studies examined medication safety interventions. These generally delivered positive outcomes on overdose-risk knowledge, but not consistently on behaviour change. One study examined buprenorphine-naloxone treatment initiation within the ED, finding positive outcomes on reported illicit drug use and treatment engagement compared to those randomised to brief intervention and referral, or referral only. Two studies explored psychosocial interventions, including motivational interviewing, which demonstrated lower non-medical prescription opioid use at follow up compared to control.

Conclusions: ED provision of a range of opioid overdose prevention interventions is feasible, acceptable to patients and ED personnel. Interventions require adequate staffing/role responsibility for sustainable implementation. Most evidence was for THN, with an emerging evidence base for other intervention types reducing opioid-overdose risks in ED settings. Further research on implementation and sustainability may assist in translation of effective interventions into the ED setting.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108009DOI Listing
May 2020

Efficacy of cannabinoids for treating paediatric spasticity in cerebral palsy or traumatic brain injury: what is the evidence?

Dev Med Child Neurol 2020 09 20;62(9):1007. Epub 2020 Jun 20.

Centre for Youth Substance Abuse Research, The University of Queensland, St Lucia, Australia.

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http://dx.doi.org/10.1111/dmcn.14606DOI Listing
September 2020

What predicts pharmacists' engagement with opioid-outcome screening? Secondary analysis from an implementation study in community pharmacy.

Int J Clin Pharm 2021 Apr 12;43(2):420-429. Epub 2020 Jun 12.

National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.

Background Pharmacists have a key role to play in identifying and responding to emerging clinical problems with prescribed opioids. A pilot study in Australia examined the implementation of screening and brief intervention (Routine Opioid Outcome Monitoring [ROOM]) to identify and respond to opioid-related problems in community pharmacies. In this implementation study, the rate of screening varied considerably between pharmacies. Objective The aim of this study was to examine pharmacist characteristics associated with implementation of ROOM. Setting Community pharmacies in Victoria and New South Wales, Australia. Methods We implemented a validated computer-facilitated screening (ROOM), combined with brief intervention for opioid-related problems based on a widely accepted framework for monitoring outcomes. In this analysis, we examined the correlates of ROOM completion for individual pharmacists. Negative binomial regression was used to identify baseline predictors of greater screening, with the number of ROOM screens as the dependent (outcome) variable and pharmacist demographics, knowledge, confidence and comfort responding to prescription opioids problems, and attitudes towards evidence based practice examined as independent (predictor) variables. Main outcome measure Number of screens completed by an individual pharmacist as reported in follow-up surveys by pharmacist. Results Fewer years of practice was associated with a greater number of screenings conducted. On average, each additional decade of practice was associated with a 31% (95% CI 0%, 53%) reduction in the number of screenings undertaken by pharmacists. A multivariable analysis revealed that each additional decade practicing, lower knowledge of naloxone and lower confidence in identifying unmanaged pain were all independently associated with reduced engagement in screening after controlling for other variables. Conclusion Findings from this pilot study identified potential barriers to implementing opioid outcome monitoring. Further studies could test different groups of community pharmacists' experience of different barriers when implementing monitoring outcomes with prescribed opioids, to inform future implementation and clinical practice.
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http://dx.doi.org/10.1007/s11096-020-01074-5DOI Listing
April 2021

Core competencies for Australian pharmacists when supplying prescribed opioids: a modified Delphi study.

Int J Clin Pharm 2021 Apr 23;43(2):430-438. Epub 2020 May 23.

Department of Pharmacy and Biomedical Science, College of Science, Health and Engineering, La Trobe University, PO Box 199, Bendigo, VIC, 3552, Australia.

Background In the past decade, there has been an increase in prescription opioid related harms. These include dependence, non-fatal and fatal overdose. Pharmacists play a an important role in safe opioid supply. As most opioids are supplied through pharmacies, pharmacists are in a prime position to reduce harms associated with opioid use. Development of specific core competencies for pharmacists may facilitate consistent and safer opioid supply. Objective To reach consensus on which competency items identified by the Association of Faculties of Pharmacy of Canada's Opioid Working Group are considered core competencies for Australian pharmacists in opioid supply and assess expert pharmacists' perceptions of how well these competencies are currently met by practicing pharmacists. Setting Expert pharmacists in the area of opioid supply from across Australia. Method A series of questionnaires were presented to Australian opioid expert pharmacists via a modified Delphi study, with the aim to reach consensus on which items should be considered competencies for opioid supply by Australian pharmacists. Items were rated on a 6-point Likert scale and analysed using Statistical Package for the Social Sciences (SPSS). Participants were also asked to rate how well they perceived that currently practicing pharmacists met each of these competency items. Main outcome measure Consensus on competency items for pharmacists when supplying prescribed opioids. Results All competency items presented to participants reached immediate agreement. When rating whether participants perceived currently practicing pharmacists met these competencies, results were variable. The competencies that participants rated practicing pharmacist met to a higher degree reflected knowledge and skills items that can be applied to all medications and were not opioid specific. The lower rated competencies appeared to be related to newer or more complex or specialised areas of opioid supply. Conclusion There was strong agreement by participants on what should be considered core competencies for Australian pharmacists in opioid supply. Given the large number of items identified, further research may help determine priorities for training and education.
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http://dx.doi.org/10.1007/s11096-020-01060-xDOI Listing
April 2021

Unintended consequences of using real time prescription monitoring systems.

Med J Aust 2020 08 21;213(3):142-142.e1. Epub 2020 May 21.

Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC.

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http://dx.doi.org/10.5694/mja2.50616DOI Listing
August 2020

Alprazolam use among a sample of Australians who inject drugs: Trends up to six years post regulatory changes.

Int J Drug Policy 2020 Apr 11;79:102721. Epub 2020 Apr 11.

National Drug and Alcohol Research Centre, University of NSW, Sydney, NSW 2052, Australia; School of Psychology, University of Tasmania, Australia.

Introduction: Alprazolam is a high potency triazolobenzodiazepine that is associated with a disproportionate amount of harm compared to other benzodiazepines. In Australia, amid growing concerns of extra-medical use and harms, alprazolam was up-scheduled from Schedule 4 (prescription only) to Schedule 8 (controlled drug) on 1 February 2014, with further restrictions introduced on 1 February 2017. This study aims to examine the impact of these regulatory changes among cross-sectional samples of people who inject drugs (PWID), from 2011-2019.

Methods: Data were obtained from the 2011-2019 Illicit Drug Reporting System, comprising cross-sectional samples of PWID recruited annually from Australian capital cities (approximately ~900 per year).

Results: By 2019, the proportion of PWID who reported past six-month use of non-prescribed (17%) and prescribed (4%) alprazolam had halved compared to 2011 (39% and 13%, respectively), with no evidence of an increase in use of other sedative substances. Following the up-scheduling of alprazolam in 2014, there was an increase in the median last price paid for 2 mg of diverted alprazolam ($5AUD pre-rescheduling versus $7AUD post rescheduling), with 61% of those able to answer reporting that diverted alprazolam had become 'more difficult' to obtain post versus pre-rescheduling. The correlates associated with non-prescribed alprazolam use remained relatively consistent pre- and post-regulatory change, with past-month criminal activity, past six-month opioid agonist therapy and past six-month use of non-prescribed other benzodiazepines associated with non-prescribed alprazolam use in both the 2013 and 2018 samples.

Conclusions: Regulatory changes appear to have resulted in sustained reductions in alprazolam use amongst our annual cross-sectional sentinel samples of PWID, although a considerable minority (17%) continued to report non-prescribed use in 2019. To achieve further reductions in non-prescribed use and associated harms, these regulatory changes need to be coupled with other interventions, such as direct consumer engagement and harm reduction messaging. Our findings suggest that people receiving opioid agonist therapy remain a key target population for such interventions.
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http://dx.doi.org/10.1016/j.drugpo.2020.102721DOI Listing
April 2020