Indiana University-Purdue University Indianapolis (IUPUI) / Opioid misuse and addiction has been widely identified as a public health problem, contributing substantially to the nation’s morbidity and mortality. Over the past two decades, misuse of prescription opioids pain relievers has substantially increased; heroin use has resurged; and, more recently, abuse of high-potency synthetic opioids such as fentanyl have fueled the epidemic. Nearly 12 million Americans (or 4.4%) aged 12 and older misused some type of opioid (prescribed or illegal) in the past year. Furthermore, the percentage of substance use treatment admissions attributable to opioids nearly doubled in the U.S., from 20.8% in 2000 to 40.5% in 2015. The purpose of this dissertation research was to investigate associations between prescription pain reliever use and subsequent negative health outcomes, including opioid misuse or addiction, and neonatal abstinence syndrome. This research focused on three specific aims: Specific Aim #1: Examine heroin use among Indiana’s substance use treatment population to measure the extent, trends, and patterns of use, as well as to assess the relationship between prescription opioids and subsequent heroin use; Specific Aim #2: Analyze 2014 INSPECT (Indiana’s prescription drug monitoring program) data to identify factors that increase patients’ likelihood to engage in opioidrelated risk behaviors; and Specific Aim #3: Review U.S. trends in neonatal abstinence syndrome (NAS) incidence from 2008-2014, measure regional variability, and identify personal and environmental risk factors associated with NAS. / 2020-08-09

PURPOSE: The purpose of this feasibility study was to explore the use of an online video intervention to prepare surgical patients to properly dispose of unused opioids. SPECIFIC AIMS: Describe the feasibility of recruiting, enrolling, randomizing and retaining participants who recently had a general surgery into the study. Describe the differences in opioid disposal by age, sex, education, and type of surgery for the entire sample and by treatment assignment. Describe the preliminary change in knowledge, behavioral beliefs, normative beliefs and disposal of opioids from baseline to post-intervention by group. Describe the relationship between social desirability and behavioral beliefs, normative beliefs and disposal of opioids. FRAMEWORK: The Theory of Reasoned Action was used to guide both the intervention and the measures. DESIGN: This study used a randomized controlled feasibility study to explore a novel video intervention to teach safe storage and disposal of unused opioids after general surgery. RESULTS: A total of 40 participants were enrolled in the study, average age was 44.7 (range 21-75 years), most were White, educated and employed. Recruitment took 11 weeks and the retention rate was excellent at 85%. Differences in opioid disposal was not significantly different by age, sex, education or type of surgery. The video intervention was positively received, but the majority (80%) still stored their pills unsecured. CONCLUSION: The results demonstrate that a video intervention addressing safe storage and disposal practices of unused opioids is feasible and more research is needed to determine efficacy in increasing rates of secure storage and disposal of unused opioid pills KEYWORDS: Opioids, opioid disposal, general surgery, video education

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Opioid overdose deaths in the United States have been steadily increasing for decades. Initially, these deaths were driven by overdoses from prescription opioids. Strict limits were placed on opioid prescriptions to decrease the supply of available opioids. Instead, this prompted a shift toward the illicit opioid market, causing an increase in heroin-related overdoses. Fentanyl, a synthetic opioid that is more potent than heroin, has become commonplace in the illicit supply of opioids. The illicit opioid market is unregulated and unpredictable, and there is no way to know exactly what is in a bag sold as heroin or “dope”. Illicit drug use has been historically dealt with as a crime rather than a public health issue in the United States. Recently, harm reduction has been offered as an alternative to this punitive approach. Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Naloxone distribution and syringe service programs are examples of currently utilized harm reduction strategies in the United States. While these programs are necessary to improve the quality of life of people who use illicit drugs, the rates of death from overdose are continuing to increase. These strategies do not protect people from the toxic and unpredictable drug supply. Safe supply is a relatively new concept, but there have been some small-scale implementations of this practice in Canada. Safe supply refers to a legal and regulated supply of drugs with mind and body-altering properties that traditionally have been accessible only through the illicit drug market. This is a necessary strategy to combat the alarming rise in overdose mortality. In this paper, I will analyze the ethics of this strategy using a principalism approach. This analysis concludes that safe supply is ethically sound, and it should be a part of our approach to the overdose epidemic. Safe supply promotes autonomy, prevents harms, advances well-being, and upholds justice for people who use drugs. / Urban Bioethics

The purpose of this thesis was to explore the literature regarding physicians’ prescriptions of opioid analgesics before and after The Joint Commission Pain Standards for 2001. Opioids are a last resort treatment for chronic pain due to their high potential for tolerance, dependency, and misuse. The establishment of The Joint Commission Pain Standards for 2001 was the culmination of several movements to address the underassessment and undertreatment of pain. The Joint Commission Pain Standards for 2001 focused on improving pain assessment, management, and treatment through a systematic approach. The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is the largest accrediting body for healthcare organizations in the United States and affects thousands of medical care facilities and physicians. Although many physicians were hesitant to prescribe opioids due to addiction concerns, opioid prescriptions rose due to pressures to meet the TJC’s accreditation requirements and maintain patient satisfaction. Pain management seemed to improve for a short period before adverse reactions and unintended consequences emerged. Confusing language within the TJC Pain Standards for 2001 and its supplemental materials and misleading information from researchers and pharmaceutical companies led to unnecessary pain measurement, problematic pain treatment algorithms, and excessive opioid analgesic use. As patient safety concerns emerged, the TJC continuously amended the TJC Pain Standards for 2001. They were revised in 2017 as the opioid epidemic became a national public health emergency. The TJC has since called for better evaluation of research validity, more vigilant examination for conflicts of interest, and more detailed instructions on interpreting and implementing future standards. The medical community, pharmaceutical industry, government, and the public need to coordinate future strategies to combat the opioid epidemic.

SAMMANFATTNING Bakgrund Smärta är en individuell och subjektiv upplevelse och den vanligaste orsaken till att människor uppsöker sjukvården. Att leva med långvarig smärta påverkar människans livskvalitet. Missbruk av beroendeframkallande läkemedel ökar och är idag ett globalt folkhälsoproblem. Det är sjuksköterskans professionella ansvar att bedöma, behandla och lindra smärta. Syfte Syftet var att belysa sjuksköterskans och patientens upplevelse och erfarenhet vid smärta och läkemedelsberoende inom sjukvården. Metod En icke systematisk litteraturöversikt genomfördes och baserades på 15 vetenskapliga artiklar av kvalitativ och kvantitativ design. Artiklarna eftersöktes med hjälp av relevanta sökord i databaserna PubMed och CINAHL samt manuellt för att därefter kvalitetsgranskas utifrån Sophiahemmet Högskolas bedömningsunderlag för vetenskaplig klassificering. Vidare analyserades artiklarna med hjälp av en integrerad analysmetod, vilken resulterade i en sammanställning med två huvudkategorier och sex subkategorier. Resultat Resultatet utgjordes av två huvudkategorier och sex subkategorier. En huvudkategori var sjuksköterskans perspektiv, den andra var patientens perspektiv. De sex subkategorierna var: attityd och förhållningsätt, kunskapsbrist, etiskt dilemma, mötet med sjukvården, att bli tagen på allvar samt partnerskap. Resultatet visade att sjuksköterskor och patienter hade såväl positiva som negativa upplevelser och erfarenheter relaterat till vården av patienter med smärta och läkemedelsberoende. Slutsats Sjuksköterskans bristande kunskap kring begreppet smärta samt sjuksköterskans attityder och förhållningssätt gentemot läkemedelsberoende patienter med smärta, utgör hinder för en god och säker omvårdnad. Mer forskning och utbildning behövs för att inte riskera ett onödigt lidande för denna patientgrupp. / ABSTRACT Background Pain is an individual and subjective experience and the most common cause of people seeking healthcare. Living with chronic pain influences a person’s quality of life. The abuse of dependency developing drugs is increasing and is now a global health problem. It is the nurse’s professional responsibility to appraise, treat and relieve pain. Aim The aim of this study was to explore the patient’s and nurse’s experiences, within the healthcare system, connected to pain and substance use disorder. Method The method was a literature review based on 15 scientific articles and both qualitative and quantitative design where included. Data collection was made in a non-structured and a manual way, in the databases PubMed and CINAHL. Quality assessment was made according to the assessment basis by Sophiahemmet University, which is directed at assessing the quality and scientifically classifying studies. Furthermore, the articles were analysed using an integrated analytical method, resulting in a compilation of two main categories and six subcategories. Results The results were compiled within two main categories and six subcategories. One of the main categories was the nurse’s perspective with the subcategories attitude and approach, lack of knowledge, ethical dilemma. The second main category was the patient’s perspective, with the subcategories the meeting with healthcare, to be taken seriously and partnership. The results showed that nurses and patients both had positive and negative experiences and knowledge related to the healthcare of patients with pain and substance use. Conclusions Nurse’s lack of knowledge about the concept of pain as well as attitudes to, and approach toward patients with substance abuse and in pain, is an obstacle to develop good and safe care. Extended research and education are needed to lower the risk of unnecessary suffering for this group of patients.

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In the US, rural Native American communities (RNACs) experience excess morbidity in mental health disorders and mortality from opioid use disorder (OUD). This study used mixed methods to evaluate and analyze the primary data from 76 healthcare providers (HPs) from 24 states across the US (physicians = 7%), to identify HP knowledge and training regarding available prevention, treatment, and recovery (PTR) programs in treating OUD, assessment and management skills, and networking and collaboration capacity among the RNACs they serve. The HP completed the Opioid Survey for Health Care Providers online. A majority of HPs reported a need for knowledge and training regarding OUD treatments (92%). Less than half of the HPs provide intensive outpatient treatment; 40% contracted out for medication assisted treatment/medications for opioid use disorder (MAT/MOUD) services. Recovery support was low at 33% for adults and 38% for youth. HPs reported use of Narcan to be effective in reversing overdose (87%). Qualitative responses supported survey findings and described barriers, including lack of resources, inadequate staffing, insufficient funding, lack of training and OUD knowledge, stigma, and lack of tribal involvement and support. The study findings indicate HPs' need for information and training about OUD and networking and collaboration of healthcare settings to meet the needs of the RNAC they serve. Efforts are needed to improve on recovery programs with an emphasis on the youth. Culturally adapted MAT/MOUD approaches are needed to sustain long-term recovery care.