Bakgrund: Opioidmissbruk är ett fenomen som är vanligt världen över. Sjuksköterskor oavsett arbetsplats kommer att möta patienter med missbruksproblematik. Opioider används inom vården som smärtlindring och kan vara mycket beroendeframkallande då tolerans snabbt utvecklas. Smärta är något som alla har erfarenhet av och patienter med opioidmissbruk ställs inför unika problem då tolerans tillsammans med beroende skapar problem vid smärtbehandling. Relationen till vården kan också vara svår då rädsla för stigman och förutfattade meningar förekommer.  Syfte: Att beskriva sjuksköterskors erfarenheter av att ge smärtbehandling till patienter med opioidmissbruk.   Metod: En litteraturstudie har genomförts på befintlig forskning. Åtta kvalitativa artiklar har granskats, dess innehåll analyserats och sammanställts. Resultat: Litteraturstudien genererade tre kategorier och två respektive tre subkategorier i resultatet. Kategorin bristande kunskap med subkategorierna; att känna osäkerhet, avsaknad av utbildning och rädsla för att göra fel. Förhålla sig till egna attityder med subkategorierna; misstänksamhet och bristande tillit samt förutfattade meningar och stigma. Och till sist kommunikation har betydelse med subkategorierna; förhållandet mellan sjuksköterska och patient samt gemensam förståelse inom vårdteamet.  Slutsats: Att arbeta med patienter lidande av smärta med ett opioidmissbruk kan vara en utmaning. Det finns ett stort behov av förbättrad utbildning, förändrade attityder samt tydlig kommunikation. Detta för att patienterna ska få en jämlik vård och ökat välmående. Mer forskning krävs för att upptäcka ytterligare kunskapsluckor och behov. / Background: Opioid abuse is a common phenomenon all around the globe. Nurses will encounter this regardless of their workplace. Opioids are used within the healthcare setting as pain relief and can be highly addictive due to the quick development of tolerance. Pain is something that everyone experiences and patients with opioid abuse syndrome encounter unique problems when tolerance combined with addiction create issues regarding pain treatment. The relationship towards the healthcare system can also be difficult due to patients fear that stigmatization and preconceived notions will occur.  Aim: To describe nurses experiences to give pain management to patients with opioid abuse.  Method: A literature study was performed. Eight qualitative articles were reviewed, and the content was analysed and compiled.  Results: The result generated three categories with two and three subcategories each. The category lack of knowledge with the subcategories; to feel insecure, lack of education and fear of doing wrong. To consider own attitudes with the subcategories, suspicion, and lack of trust as well as preconceived notions and stigma. And at last communication carries importance with the subcategories; the relationship between nurse and patient as well as shared understanding within the healthcare team. Conclusion: Working with patients suffering from pain whilst having an opioid abuse, can be a challenge. Improved education and changed attitudes as well as clarity in communication is highly needed. This in order to make sure that patients get equal care as well as improved wellbeing. Further research is needed to discover additional gaps of knowledge and needs.

This dissertation explores the potential of documentary films to impact the discourse around a public health issue and in particular the current opioid epidemic. In addition to reviewing the history of drug policy and drug epidemics, this dissertation analyzed an HBO documentary about the opioid epidemic as a means of contextualizing the current crisis and understanding whether documentary can change the narrative around a public health matter. A systematic review of the literature was conducted to evaluate the existing published evaluation studies relating to the potential role of documentary films to influence the levers of discourse related to the opioid epidemic and related substance use and mental health disorders and found the existing research was limited to fifty-four citations. Documentaries can have a potential impact on public discourse most notably through raising public awareness but the impact is limited as drug use epidemics are complex and multifactorial. Further study is needed to fully understand the role that documentary films can play in shaping public discourse.

The dissertation is intended to guide the selection and implementation of health department-led interventions with a long-term goal of reducing opioid overdose deaths. This dissertation is comprised of three aims. First, a narrative review describes models of buprenorphine treatment, summarizes retention in buprenorphine treatment, and includes descriptions of how each study defined and measured retention in treatment to aid cross-study comparisons. Trends in buprenorphine retention, as well as heterogeneity in trends, are described, and sub-analyses examine the role clinician experience in inducting patients on buprenorphine treatment may play in promoting retention. Lastly, the effect of a specific intervention—academic detailing—aimed at reducing the prescribing of opioid analgesics is measured using methods aimed at isolating the impact of a policy intervention that occurred at the same time as the detailing campaign. Overall, this dissertation finds a lack of consistency in how retention in buprenorphine treatment is measured, which precludes easy identification of the most effective models and interventions for retention in buprenorphine treatment. Additionally, significant variation in buprenorphine treatment retention and trends in buprenorphine treatment was observed, suggesting opportunities for improvement. From 2015 to 2019, retention in buprenorphine increased among New York City residents; however, in 2019, the predicted prevalence of retention for three months was 52.7% and 34.6% for six months, below rates observed in other studies. Lastly, this dissertation should prompt public health officials to reconsider using academic detailing campaigns to decrease opioid analgesic prescribing, given that decreases in prescribing practices were only observed following one detailing campaign, which coincided with a policy change, and did not occur following another campaign, which took place two years after the policy change.

Opium, the dried resin obtained from the unripe seedpods of the poppy flower, has been used for medicinal and euphoric purposes since ancient times. Morphine, the main active ingredient of opium, and other clinically useful opioid analgesics all mediate their effects through activating the mu opioid receptor. Studies involving the mu opioid receptor knockout mice showed that the interaction with the mu opioid receptor is also responsible for many notorious side effects associated with these drugs including dependence and addiction. Therefore, selective antagonists for the mu opioid receptor are needed to study its function in drug abuse and addiction. Previously, based on molecular modeling studies and the “message-address” concept, a series of 14-O-substituted naltrexone derivatives were designed and synthesized. These compounds carried an ester-linked heteroaromatic substitution at the 14-position of naltrexone which was designed to interact with the putative “address” site, that was identified in the mu opioid receptor through molecular modeling studies. The lead compound of this series was determined to have a high affinity and selectivity for the mu opioid receptor. Because the 14-O-substituted naltrexone derivatives were not very stable, the ester linkage in these compounds was replaced by an amide one and a series of 14-N-substituted naltrexone derivatives were synthesized. The affinity and selectivity of these novel naltrexone derivatives were determined in a competitive radioligand binding assay. Interestingly, the 14-N-substituted naltrexone derivatives did not maintain the high selectivity of the 14-O-substituted series. It was hypothesized that the conformational constraint introduced by the amide linker was detrimental to the mu opioid receptor selectivity. Therefore, three 14-N-substituted naltrexone derivatives which carried more flexible linkages were synthesized and evaluated. The mu opioid receptor selectivity was not recovered by introducing rotational freedom into the linker. Some of these 14-N-substitued naltrexone derivatives were determined to be mu-kappa opioid receptor dual selective antagonists. Since the mu opioid receptor antagonists are effective at treating drug addiction, while growing evidence suggests that the kappa opioid receptor antagonists may be beneficial in lowering drug cravings, these novel mu-kappa opioid receptor dual selective antagonists may find unique clinical utility in the treatment of opioid dependence.

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Rates of prescription drug misuse in Texas are alarmingly high. One in five Texas high school students have taken prescription drugs without a doctor’s prescription. In 2015, Texas had the second highest total healthcare costs from opioid abuse in the nation ($1.96 billion), and Texas is home to four of the top 25 cities in the U.S. for opioid abuse. Meanwhile, only one in three prescribers is using the statewide Prescription Drug Monitoring Program (PDMP), leading to a massive loss of data. There is substantial need for increased infrastructure and prevention measures in Texas, especially related to the emergence of prescription drug misuse. This panel will describe the current landscape of prescription drug misuse and its consequences, discuss strategies to turn down misuse, and explain the proactive approach Texas is taking to enhance misuse prevention and data infrastructure across the state.

The rise in America’s drug poisoning rates has been described as a public health crisis and has long been attributed to the rapid rise in opioid supply due to increased volumes of medical prescribing in the United States that began in the mid-1990s and peaked in 2012. In 2016, the introduction of the “deaths of despair” hypothesis provided a more nuanced explanation for the rising rates of drug poisoning deaths: increasing income inequality and stagnation of middle-class worker wages, driven by long-term shifts in the labor market, reduced employment opportunities and overall life prospects for persons with a high school degree or less, driving increases in “deaths of despair” (i.e., deaths from suicide, cirrhosis of the liver, and drug poisonings). This focus on economic and social conditions as capable of shaping geospatial differences in drug demand and attendant drug-related harms (e.g., drug poisonings) provides a larger context to factors potentially underlying the heterogeneous distribution of prescription opioid supply across the United States. However, despite the likelihood that economic and social conditions may be important demand-side factors that also interact with supply-side factors to produce the rates of fatal drug poisonings, little information exists about the effect of area-level socioeconomic conditions on fatal drug poisoning rates, and no study has investigated whether socioeconomic conditions interact with prescription opioid supply to affect area-level rates of fatal drug poisonings. The overarching goal of this dissertation was to test the independent and joint effects of supply- and demand-side factors, operationalized as prescription opioid supply and socioeconomic conditions, on fatal drug poisoning in the U.S. First, a systematic review of the literature was conducted to critically evaluate the evidence on the ecological relationship of prescription opioid supply and socioeconomic conditions on rates of drug poisoning deaths. The systematic review provides robust evidence of the independent effect of each prescription opioid supply and socioeconomic conditions on rates of drug poisoning deaths. The gap in the literature on the joint effects of prescription opioid supply and socioeconomic conditions was clear, with no study examining the interaction between supply- and demand-side factors on rates of fatal drug poisonings. Moreover, although greater prescription opioid supply was associated with higher rates of fatal drug poisonings in most of the studies, two studies presented contradictory findings, with one study showing no effect of supply on drug poisoning deaths and the other showing locations with higher levels of prescription opioid supply were associated with fewer drug-related deaths. Three limitations were also identified in the reviewed studies that could partially explain the observed associations. First, although studies aggregated data on drug poisoning deaths to a range of administrative spatial levels, including census tract, 5-digit ZIP code, county, 3-digit ZIP code, and state, no study investigated the sensitivity of findings to the level of geographic aggregation. Second, spatial modeling requires the assessment of spatial autocorrelation in both the unadjusted and adjusted data, but few studies even assessed spatial autocorrelation in the data, and fewer still incorporated spatial dependencies in the model. This is important because when spatial autocorrelation is present, the independence assumption in standard statistical regression models is violated, potentially causing bias and loss of efficiency. Third, studies operationalized prescription opioid supply and socioeconomic conditions using a variety of different measures, and no study assessed the sensitivity of findings to the different measures of supply and socioeconomic conditions. Second, the ecological relationship between prescription opioid supply and fatal drug poisonings was examined. For this, pooled cross-sectional time series data from 3,109 U.S. counties in 49 states (2006-2016) were used in Bayesian Poisson conditional autoregressive models to estimate the effect of county prescription opioid supply on four types of drug poisoning deaths: any drug (drug-related death), any opioid (opioid-related death), any prescription opioid but not heroin (prescription opioid-related death), and heroin (heroin-related death), adjusting for compositional and contextual differences across counties. Comparisons were made by type of drug poisoning (any drug, any opioid, prescription opioids only, heroin), level of geographic aggregation (county versus state), and measure of prescription opioid supply (rate of opioid-prescribing per 100 persons and morphine milligram equivalents per-capita). Results indicated a positive association between prescription opioid supply and rates of fatal drug poisonings consistent across changes in type of drug poisoning, level of aggregation, and measure of prescription opioid supply. However, removing confounders from the model caused the direction of the effect estimate to reverse for drug poisoning deaths from any drug, any opioid, and heroin. These results suggested that differences in adjustment for confounding could explain most of the inconsistent findings in the literature. Finally, a rigorous test of the hypothesis that worse socioeconomic conditions increase risk of fatal drug poisonings at the county level, and interact with prescription opioid supply was conducted. This analysis used the same pooled cross-sectional time series data from 3,109 U.S. counties in 49 states (2006-2016). The analysis modeled the effect of five key socioeconomic variables, including three single socioeconomic variables (unemployment, poverty rate, income inequality) and two index variables (Rey index, American Human Development Index [HDI]) on four types of drug poisoning deaths: any drug (drug-related death), any opioid (opioid-related death), any prescription opioid but not heroin (prescription opioid-related death), and heroin (heroin-related death). Using a hierarchical Bayesian modeling approach to account for spatial dependence and the variability of fatal drug poisoning rates due to the small number of events, the independent effect of socioeconomic conditions on rates of drug poisoning deaths and their joint multiplicative and additive effect with prescription opioid supply were estimated. Results showed that rates of fatal drug poisonings were higher in more economically and socially disadvantaged counties; the five key indicator variables were differentially associated with drug poisoning rates; and the American Human Development Index (HDI) and income inequality were most strongly associated with fatal drug poisoning rates. Finally, the results indicate that both HDI and income inequality interact with county-level prescription opioid supply to affect drug poisoning rates. Specifically, the effect of higher prescription opioid supply on rates of fatal drug poisonings was greater in counties with higher HDI and more equal income distributions than counties with lower HDI and less equal income distributions. Overall, this dissertation increased knowledge about the separate and conjoint roles of supply- and demand-side factors in the geospatial distribution of fatal drug poisonings in the U.S. The idea that area-level prescription opioid supply are key drivers of prescription drug use, misuse, and addiction and the attendant consequences, including nonfatal and fatal drug poisonings, has been in the literature for well over a decade. However, no study to date has shown that area-level socioeconomic conditions modify the effect of prescription opioid supply on fatal drug poisonings. By identifying important contextual factors capable of modifying the effect of prescription opioid supply reductions on mortality, high-risk geographic areas can be prioritized for interventions to counter any unintended effects of reducing the prescription opioid supply in an area. As federal and state policies continue to target the rising rates of fatal drug poisonings, these findings show that area-level socioeconomic conditions may represent an important target for policy intervention during the current drug poisoning crisis and a critical piece of information necessary for predicting any future drug-related crises.

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