Illicit Prescription Opioid Use Among U.S. Firefighters
, Sara A. Jahnke 2,*,†, Natinee Jitnarin 2,†, Christopher Kaipust 2,†, Christopher K. Haddock 2,†and Walker S. C. Poston II 2,†
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsInteresting topic. However, no test for normal distribution mentioned. Such a test must be performed, its results declared and the statistical analysis adjusted accordingly.
SPECIFIC ITEMS
line 15: No comma after “Yet” please.
line 20: please indicate that Vicodin(R) etc are trade names and give the respective international proprietary names (INN) as well.
lines 20 and 21 and followin: “14.0%” and “59.8%”, ie, giving percentages to one digit behind the decimal point is spurious accuracy. Please give integers (ie whole numbers) for percentages please.
lines 20 and 21: For easier comparison, give the respective percentages for comparable general population samples in the abstract as well (you had given this number in line 46).
line 25: Please give the abbreviation, ie, “PTSD”, too.
line 95: Did you guarantee the interviewees confidentiality? If so, how? Please state that explicitly.
line 155: Were the data normally distributed? If not, you must not give means and SDs. Please perform a test for normal distribution and adjust the manuscript accordingly.
lines 170f: Again, indicate that Vicodin(R) etc are trade names and give the respective international proprietary names (INN) as well.
Author Response
Responses to reviewer 1
Comment 1: no test for normal distribution mentioned. Such a test must be performed, its results declared and the statistical analysis adjusted accordingly.
Response: We examined the distributions for our independent continuous variables. In all cases, the distributions were normal (e.g., Kurtosis statistics <1). We have indicated this in the revised manuscript in the statistical analysis section.
Comment 2: line 15: No comma after “Yet” please.
Response: Removed comma
Comment 3: line 20: please indicate that Vicodin(R) etc are trade names and give the respective international proprietary names (INN) as well.
Response: We now provide the INN or generic names and trade names for all drugs e.g., “The most commonly misused opioids were the hydrocodones with trade names Vicodin, Lortab, and Lorcet”
Comment 4: lines 20 and 21 and following: “14.0%” and “59.8%”, ie, giving percentages to one digit behind the decimal point is spurious accuracy. Please give integers (ie whole numbers) for percentages please.
Response: Percentages given as whole numbers
Comment 5: lines 20 and 21: For easier comparison, give the respective percentages for comparable general population samples in the abstract as well (you had given this number in line 46).
Response: We now include lifetime prevalence in abstract “was 14% compared to 13% in the general U.S. population”
Comment 6: line 25: Please give the abbreviation, ie, “PTSD”, too.
Response: Included PTSD
Comment 7: line 95: Did you guarantee the interviewees confidentiality? If so, how? Please state that explicitly.
Response: We provided all participating firefighters confidentiality, but the study was questionnaire based. Confidentiality was guaranteed during the consent process. For instance, in the informed consent document we stated:
“Precautions will be taken to prevent unauthorized acquisition of data and promote safety during the validation study.” And
“This study will be conducted under the protection of a federal certificate of confidentiality (CoC), which prevents data from being subpoenaed and used in any court of law. The CoC protects the researcher from being compelled by legal authorities to provide research material or testify about responses to project assessments.” And
“After survey responses are collected, names will be removed from the dataset and id numbers assigned. ID numbers will be connected to names and contact information in a separate document to protect confidentiality.”
Reviewer 2 Report
Comments and Suggestions for AuthorsThis is a very well-written manuscript. The background and value of the study are clear and the methodology was clearly discussed. The study design is rigorous and the results presented were clear. The discussion is very thorough and conclusion is supported by the results. A few minor questions/comments for the authors:
1. Maybe it would be helpful to also include demographic distribution of the sample. The discussion mentioned the limitation of the demographic diversity, but the distribution was not very clear in the result section (Table 2).
2. For all the table used, what are the statistics showed in the "No illicit use" and "illicit Use" sections? Are they the average of the survey result or percentages?
Author Response
Responses to reviewer 2
Comment 1: This is a very well-written manuscript. The background and value of the study are clear and the methodology was clearly discussed. The study design is rigorous and the results presented were clear. The discussion is very thorough and conclusion is supported by the results.
Response: Thank you
Comment 2: Maybe it would be helpful to also include demographic distribution of the sample. The discussion mentioned the limitation of the demographic diversity, but the distribution was not very clear in the result section (Table 2).
Response: We added demographics for the overall sample to the results. The revised manuscript now includes the following: “Overall, participants were 21 to 77 years of age (M = 38.3, SD = 9.1 years) and had one to 44 years of employment in the fire service (M = 13.8, SD = 8.7 years). Participants were mostly White (74.3%), married or cohabitating (89.8%), and educated with 90.9% having some college or a college degree. In addition, 56.1% of the participants were firefighters/paramedics and 67.6% earned $75,000 or more per year.”
Comment 3: For all the table used, what are the statistics showed in the "No illicit use" and "illicit Use" sections? Are they the average of the survey result or percentages?
Response: We clarify that there are percentages and means in the tables. We added (%) to all variables expressed as a percent and Mean +/- SD to continuous variables.
Reviewer 3 Report
Comments and Suggestions for AuthorsDear Authors,
Many thanks for submitting this paper for review.The manuscript reads well and is clear with lots of unique and relevant information.
Some specific comments:
The introduction clearly sets out the rational and reasoning for the paper.
Page 3 2.2.2 Mental and Physical Health: there seems to be some results in this section relating to ranges of reports e.g. line 125, 132, 136 etc. These should in my opinion be in results section and not the Materials and Methods.
Line 174 - typo - spelling of "methadone"
From an interest point I know you have looked at illicit use but I would be interested if some of the illicit use was the incorrect use of analgesics prescribed (e.g. I would be keen to know if it was illicit use of the individuals own medication or is they were having to obtain the medication from other sources.)
Table 2 and 3 are these percentages?
Table 2 - interesting to see the rate if higher in more senior staff - is this previous experiences or stresses related to managing a service etc?
Table 3 could be a bit clearer.
The manuscript is very interesting and gives insight to the issue
Many thanks
Author Response
Responses to reviewer 3
Comment 1: Many thanks for submitting this paper for review. The manuscript reads well and is clear with lots of unique and relevant information.
Response: Thank you
Comment 1: Page 3 2.2.2 Mental and Physical Health: there seems to be some results in this section relating to ranges of reports e.g. line 125, 132, 136 etc. These should in my opinion be in results section and not the Materials and Methods.
Response: We moved the ranges to the results section. They are associated with Table 4.
Comment 2: Line 174 - typo - spelling of "methadone"
Response: Fixed
Comment 3: From an interest point I know you have looked at illicit use but I would be interested if some of the illicit use was the incorrect use of analgesics prescribed (e.g. I would be keen to know if it was illicit use of the individuals own medication or is they were having to obtain the medication from other sources.)
Comment 4: Table 2 and 3 are these percentages?
Response: We clarify that there are percentages and means in the tables. We added (%) to all variables expressed as a percent and Mean +/- SD to continuous variables.
Comment 5: Table 2 - interesting to see the rate if higher in more senior staff - is this previous experiences or stresses related to managing a service etc?
Comment 6: Table 3 could be a bit clearer.
Response: Better describe the columns and changed the title to improve clarity of Table 3.
“Table 3: Differences in the misuse of other drugs between participants not illicitly using prescription opioids and those illicitly using prescription opioids. “
Reviewer 4 Report
Comments and Suggestions for AuthorsThank you for the opportunity to review this manuscript describing opioid misuse among trauma-exposed firefighters. There are several strengths of this manuscript, including the recognition of the overlap of trauma and substance misuse among first responders as well as the specific focus on opioid use.
Major:
-Yet another strength of this manuscript is the consideration of pain in the context of illicit substance use. Authors should be commended for considering this aspect of functioning and risk among firefighters.
Author Response
Responses to reviewer 4
Comment 1: There are several strengths of this manuscript, including the recognition of the overlap of trauma and substance misuse among first responders as well as the specific focus on opioid use. Yet another strength of this manuscript is the consideration of pain in the context of illicit substance use. Authors should be commended for considering this aspect of functioning and risk among firefighters.
Response: Thank you
Reviewer 5 Report
Comments and Suggestions for AuthorsUpon Review, the Author’s submitted work appears to address an issue both timely and societally relevant. As Authors saliently observe, “ …[I]n the United States (U.S.), the prevalence of self-reported lifetime illicit prescription opioids use is around 13.0% — and as likewise noted “Due to the nature of their profession, firefighters face a higher risk of physical injuries and mental health disorders compared to other occupations”. Reviewer finds additional concordance in Authors statement that “…Given the widespread opioid crisis in the U.S. and the numerous risk factors for opioid abuse noted among firefighters, there is a critical need to fill this gap in the literature.”
From a Methods standpoint, Reviewer also finds genuine utility in the noted line item data set — yet with a most important omission — that being the utter absence of each timeline from which the reported data were derived (!)
In the past five years, with confluent, traumatic exacerbations linked, for example, to COVID 19 and George Floyd, this information ought be considered highly relevant — particularly given the overall theme of Authors’ submission. Moreover, Reviewer suggests that a time-dependent analysis of the noted ‘self-medicating tactics’ employed by workers might reflect marked differences ‘prior to’ and ‘after’ these noted societal crises.
As the data presented in Authors’ present submitted iteration were likely derived from time-stamped reporting, the incorporation of such factual detail should not cause Authors an inordinate degree of ‘starting over’ level effort. Moreover, ‘baking in’ these variables would likely imbue Authors’ submission with contextual gravitas — to the greater benefit of Authors and interested readers / investigators alike.
It is particularly noteworthy that in the Conclusion section (lines 312-313) Authors observe that “Further research focusing on firefighters is essential, particularly to validate self-reported instances of illicit opioid use and to explore causal associations.” Reviewer cannot but wholeheartedly agree.
Author Response
Responses to reviewer 5
Comment 1: Upon Review, the Author’s submitted work appears to address an issue both timely and societally relevant.
Response: Thank you
Comment 2: From a Methods standpoint, Reviewer also finds genuine utility in the noted line item data set — yet with a most important omission — that being the utter absence of each timeline from which the reported data were derived (!)
Response: Could you be more specific about what “timeline” means? We included the dates that data were collected
Comment 3: In the past five years, with confluent, traumatic exacerbations linked, for example, to COVID 19 and George Floyd, this information ought be considered highly relevant — particularly given the overall theme of Authors’ submission. Moreover, Reviewer suggests that a time-dependent analysis of the noted ‘self-medicating tactics’ employed by workers might reflect marked differences ‘prior to’ and ‘after’ these noted societal crises.
Response: While this is an interesting suggestion and one that seems to have important undertones, it is beyond the scope of the current manuscript. Perhaps this is a question we can pursue in a future study.
Comment 4: As the data presented in Authors’ present submitted iteration were likely derived from time-stamped reporting, the incorporation of such factual detail should not cause Authors an inordinate degree of ‘starting over’ level effort. Moreover, ‘baking in’ these variables would likely imbue Authors’ submission with contextual gravitas — to the greater benefit of Authors and interested readers / investigators alike.
Response: We are not sure what is being referred to here, but we have included the dates data were collected in the revised manuscript.
Round 2
Reviewer 1 Report
Comments and Suggestions for Authorsacceptable
Reviewer 5 Report
Comments and Suggestions for AuthorsI appreciate the effort Authors have invested to address Reviewer's initial commments.
