Faculty Bibliography

BACKGROUND:The opioid overdose crisis in the United States continues to worsen. Opioid overdose mortality is entirely preventable with timely administration of naloxone. Since 2001, many states have passed laws to create an enabling environment for the implementation of overdose education and naloxone distribution (OEND) programs. We assessed whether state-level naloxone laws and their provisions stimulated the implementation of OEND programs in the United States. METHODS:Covering the period from 2000 to 2014, we utilized five data sources including the Westlaw legal database, the Prescription Drug Abuse Policy System, the Harm Reduction Coalition's OEND database, National Center of Health Statistics and the United States Census. Random effects logistic regression models with robust variances were used to examine the association of naloxone access laws and their provisions with OEND program implementation as of 2014. RESULTS:At the end of 2014, 8% of counties had OEND programs implemented within them. Counties within states that had a naloxone law (aOR = 28.98; p < 0.001) or a law with any one of the six provisions - third party (aOR = 12.86; p = 0.001), standing order (aOR = 11.45; p < 0.001), possession (aOR = 45.97; p < 0.001), prescriber immunity (aOR = 5.19; p = 0.007), dispenser immunity (aOR = 3.50; p = 0.028) or layperson dispensing (aOR = 12.91; p = 0.001) - had increased odds of an OEND program implemented within them, compared to counties within states without a law or specific provision, respectively. CONCLUSION:Our findings suggest that naloxone laws facilitated the implementation of OEND programs. With only 8% of counties having an OEND program within them, future studies should investigate strategies to improve the implementation of OEND programs.

Among polar bears (Ursus maritimus), fitness is dependent on body size through males' abilities to win mates, females' abilities to provide for their young and all bears' abilities to survive increasingly longer fasting periods caused by climate change. In the Western Hudson Bay subpopulation (near Churchill, Manitoba, Canada), polar bears have declined in body size and condition, but nothing is known about the genetic underpinnings of body size variation, which may be subject to natural selection. Here, we combine a 4449-individual pedigree and an array of 5,433 single nucleotide polymorphisms (SNPs) to provide the first quantitative genetic study of polar bears. We used animal models to estimate heritability (h² ) among polar bears handled between 1966 and 2011, obtaining h² estimates of 0.34-0.48 for strictly skeletal traits and 0.18 for axillary girth (which is also dependent on fatness). We genotyped 859 individuals with the SNP array to test for marker-trait association and combined p-values over genetic pathways using gene-set analysis. Variation in all traits appeared to be polygenic, but we detected one region of moderately large effect size in body length near a putative noncoding RNA in an unannotated region of the genome. Gene-set analysis suggested that variation in body length was associated with genes in the regulatory cascade of cyclin expression, which has previously been associated with body size in mice. A greater understanding of the genetic architecture of body size variation will be valuable in understanding the potential for adaptation in polar bear populations challenged by climate change.

Distribution of the opioid overdose reversal drug naloxone has been central to efforts to combat the ongoing opioid epidemic in the United States. This report presents data from Prevention Point Pittsburgh (PPP), a public health advocacy and direct service organization that has operated an overdose prevention program (OPP) with naloxone distribution since 2005. The program initially provided naloxone training and distribution only to people who use opioids (PWUO). In 2015, a change to state law enabled PPP to provide naloxone to anyone in a position to respond to an opioid-related overdose. This report examines the characteristics and naloxone-related experiences of 1330 PWUO trained in overdose prevention and naloxone administration by PPP between January 1, 2006, and December 31, 2015, and compares rates of return for a naloxone refill by PWUO and the 619 non-users trained between January 1, 2015, and December 31, 2015. While larger numbers of individuals obtained naloxone after state law changed, PWUO-especially heroin users-were significantly more likely to reverse an overdose and return to PPP for a naloxone refill. Based on these findings, we recommend that resource-limited, community-based organizations prioritize the distribution of naloxone to PWUO.

BACKGROUND:Opioid-related overdose deaths are a major public health challenge. Forty-nine states have implemented Prescription Drug Monitoring Programs (PDMPs) that collect information about individuals' prescription medications. Little is known about state governments' implementation of PDMPs. We conducted semi-structured interviews with PDMP staff, law enforcement officials, and administrative agency employees to learn about their attitudes and experiences with PDMPs. METHODS:From May 2015 to June 2016, we conducted 37 semi-structured interviews with state actors in four states. Questions focused on interviewees' perceptions about PDMP goals, home agency characteristics, and future PDMP initiatives. States were selected purposively. Interviewees were identified through purposive and snowball sampling. RESULTS:Interviewees identified key PDMP goals as: improve patient treatment decisions; influence prescribing practices; assist in the identification of "doctor shoppers"; and serve as a tool for law enforcement. Interviewees identified the following characteristics as key for a PDMP's home agency: regulatory and enforcement authority; intra- and inter-agency collaboration; and commitment to data quality and protection. Interviewees identified three promising areas for future PDMP efforts: data sharing and analysis; integration of PDMP data with electronic medical records; and training for current and potential PDMP users. CONCLUSIONS:Our findings reveal areas that states may want to prioritize, including improving prescribers' knowledge and use of the PDMP as well as fostering inter-agency collaborations that include PDMP staff. By capitalizing on these opportunities, state governments may improve the effectiveness of their PDMPs, potentially making them more useful tools to curb the morbidity and mortality associated with opioid use disorders.

More than a decade in the making, America's opioid crisis has morphed from being driven by prescription drugs to one fuelled by heroin and, increasingly, fentanyl. Drawing on historical lessons of the era of National Alcohol Prohibition highlights the unintended, but predictable impact of supply-side interventions on the dynamics of illicit drug markets. Under the Iron Law of Prohibition, efforts to interrupt and suppress the illicit drug supply produce economic and logistical pressures favouring ever-more compact substitutes. This iatrogenic progression towards increasingly potent illicit drugs can be curtailed only through evidence-based harm reduction and demand reduction policies that acknowledge the structural determinants of health.

BACKGROUND:A relatively large number of "pill mills," in which physicians prescribed and sometimes dispensed controlled substances without medical justification, operated in Florida beginning in the mid-2000s. Investigations into these operations have resulted in the arrest and conviction of dozens of physicians for activities related to illegal trafficking in controlled substances. METHODS:Using information from the federal Drug Enforcement Administration, the Florida Department of Health, and court records, we constructed a database of Florida-licensed medical doctors who had been indicted or convicted of crimes related to illegal prescribing of controlled substances in Florida during 2010-2015. We then determined whether and when physicians in this data set were temporarily or permanently barred from practicing medicine in the state. RESULTS:We identified 43 physicians who faced criminal action for prescribing-related crimes during the study period. Twenty-eight of these physicians had been convicted or pled guilty as of September 30, 2016, of which 25 (89%) had been permanently barred from practicing medicine in the state. Only 1 of the 25 physicians permanently lost their license before they had been convicted or pled guilty. On average, physicians did not lose their license to practice for more than 9 months (291 days) after being convicted and 587 days after being indicted of a crime directly related to illegal prescribing of controlled substances. Seventeen physicians (68%) maintained their licenses for at least 1 year after being indicted. CONCLUSIONS:This review suggests that the adoption of a more proactive and streamlined process may reduce the time from when physicians are indicted or convicted of illegally prescribing or dispensing controlled substances to board investigation and potential sanction, potentially reducing opioid-related adverse events in the state.

BACKGROUND:Overdose from opioids is a serious public health and clinical concern. Veterans are at increased risk for opioid overdose compared with the civilian population, suggesting the need for enhanced efforts to address overdose prevention in Department of Veterans Affairs (VA) health care settings, such as primary care clinics. METHODS:Prescribing providers (N = 45) completed surveys on baseline knowledge and concerns about the VA Overdose Education and Naloxone Distribution (OEND) initiative prior to attending an OEND educational training. RESULTS:Survey items were grouped into 4 OEND-related categories, reflecting (1) lack of knowledge/familiarity/comfort; (2) concerns about iatrogenic effects; (3) concerns about impressions of unsafe opioid prescribing; and (4) concerns about risks of naloxone prescribing. Although certain OEND-related categories were associated with each other, concerns related to iatrogenic effects of OEND (e.g., patients will use more opioids and/or be less likely to see treatment) and lack of knowledge/familiarity/comfort with OEND were endorsed more than concerns related to giving impressions of unsafe opioid prescribing. The majority of providers endorsed the belief that those prescribing opioids to patients should be responsible for providing overdose education to those patients. System-wide naloxone prescription rates and sources increased over 320% following initiation of OEND expansion efforts, although these increases cannot be viewed as a direct result of the in-service trainings. CONCLUSIONS:Findings demonstrate that some providers believe they lack knowledge of opioid overdose prevention techniques and hold concerns about OEND implementation. More training of medical providers outside substance use treatment settings is needed, with particular attention to concerns about harmful consequences resulting from the receipt of naloxone.

Despite shifts in rhetoric and some positive movement, Americans with the disease of addiction are still often stigmatized, criminalized, and denied access to evidencebased care. Dramatically reducing the number of lives unnecessarily lost to overdose requires an evidence-based, equity-focused, well-funded, and coordinated response. We present in this brief article evidence-based and promising practices for improving and refocusing the response to this simmering public health crisis. Topics covered include improving clinical decision-making, improving access to non-judgmental evidence-based treatment, investing in comprehensive public health approaches to problematic drug use, and changing the way law enforcement actors interact with people who use drugs.