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Lynch D, Chitty L, Johnson B, Hoefnagel AL. Suspected Buprenorphine-Precipitated Opioid Withdrawal following Intercourse: A Case Report. J Pain Palliat Care Pharmacother 2023; 37:314-316. [PMID: 37640398 DOI: 10.1080/15360288.2023.2250344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/21/2023] [Accepted: 08/06/2023] [Indexed: 08/31/2023]
Abstract
Buprenorphine, a partial mu-opioid receptor agonist, is a commonly prescribed medication for opioid use disorder (OUD). There is evidence that drugs may enter the male genitourinary tract by an ion-trapping process, based on the lipid solubility and degree of ionization (1). While little is known about the pharmacokinetics of drugs in seminal fluid, pH is thought to play an integral role. Limited evidence exists surrounding cervical absorption of drugs via seminal fluid transmission. This also prompts survey of the frequency of this event and the influence on treatment within this population.
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Affiliation(s)
- Davene Lynch
- Department of Anesthesia UF Health Jacksonville, University of Florida-Jacksonville, Jacksonville, FL, USA
| | - Lyndsey Chitty
- Department of Anesthesia UF Health Jacksonville, University of Florida-Jacksonville, Jacksonville, FL, USA
| | - Brittany Johnson
- Department of Pharmacy UF Health Jacksonville, University of Florida-Jacksonville, Jacksonville, FL, USA
| | - Amie L Hoefnagel
- Department of Anesthesia UF Health Jacksonville, University of Florida-Jacksonville, Jacksonville, FL, USA
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102
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Opheim A, Benth JŠ, Solli KK, Kloster PS, Fadnes LT, Kunøe N, Gaulen Z, Tanum L. Risk of relapse to non-opioid addictive substances among opioid dependent patients treated with an opioid receptor antagonist or a partial agonist: A randomized clinical trial. Contemp Clin Trials 2023; 135:107360. [PMID: 37865138 DOI: 10.1016/j.cct.2023.107360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/24/2023] [Accepted: 10/15/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND AND OBJECTIVE First study to assess any compensatory increase in use of non-opioid illicit substances and alcohol in opioid dependent patients randomized to treatment with extended-release naltrexone (XR-NTX) or buprenorphine-naloxone (BP-NLX) and in longer term treatment with extended-release naltrexone. METHOD A multicenter, outpatient, open-label randomized clinical trial where patients received intramuscular extended-release naltrexone hydrochloride, 380 mg/month, or daily sublingual buprenorphine-naloxone 8-24/2-6 mg for 12 weeks, and an option to continue with extended-release naltrexone for an additional 36 week follow-up. The study was conducted at five urban addiction clinics and detoxification units in Norway between November 2012, and July 2016. RESULTS Among the 143 patients, 106 men and 37 women, there were no significant differences between those randomized to XR-NTX or BP-NLX in the risk of first relapse to alcohol (HR 1.31; 0.68-2.53), amphetamines (HR 0.88; 0.43-1.80), benzodiazepines (HR 1.24; 0.74-2.09) or cannabis (HR 1.55; 0.83-2.89). Also in the 36-week (12-48 weeks) follow-up period we found no significant differences between patients continuing with XR-NTX compared to those switching to XR-NTX after the randomized period in risk of first relapse to any non-opioid substance. In both study periods, the mean time in the study were longer among those relapsing to non-opioid addictive substances than those who did not. There was no significant association between first relapse to illicit opioids and first relapse to non-opioid addictive substances. CONCLUSION There was no increase in the risk of relapse to non-opioid addictive substances neither in short term nor longer-term treatment with extended-release naltrexone. Trial registrationclinicaltrials.gov Identifier: NCT01717963.
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Affiliation(s)
- Arild Opheim
- Department of Addiction Medicine, Haukeland University Hospital, Norway; Institute of Global Public Health and Primary Care, University of Bergen, Norway.
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, P.O.Box 1171, 0318 Blindern, Norway; Health Services Research Unit, Akershus University Hospital, P.O. Box 1000, 1478 Lorenskog, Norway
| | - Kristin Klemmetsby Solli
- Norwegian Centre for Addiction Research, University of Oslo, 0315 Oslo, Norway,; Department of Research and Development in Mental Health Services, Akershus University Hospital, 1478 Lorenskog, Norway; Vestfold Hospital Trust, 3116 Tonsberg, Norway
| | - Pia S Kloster
- Department of Addiction Medicine, Haukeland University Hospital, Norway
| | - Lars Thore Fadnes
- Department of Addiction Medicine, Haukeland University Hospital, Norway; Institute of Global Public Health and Primary Care, University of Bergen, Norway
| | - Nikolaj Kunøe
- Lovisenberg Diaconal Hospital, P.O. Box 4970, 0440 Oslo, Norway
| | - Zhanna Gaulen
- Department of Addiction Medicine, Haukeland University Hospital, Norway; Department of Clinical Dentistry, University of Bergen, Norway
| | - Lars Tanum
- Department of Research and Development in Mental Health Services, Akershus University Hospital, 1478 Lorenskog, Norway; Faculty for Health Science, Oslo Metropolitan University, Pilestredet 32, 0167 Oslo, Norway
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103
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Robinson HL, Moerke MJ, Banks ML, Negus SS. Effects of naltrexone on amphetamine choice in rhesus monkeys and rats. Exp Clin Psychopharmacol 2023; 31:1080-1091. [PMID: 37184942 PMCID: PMC10788965 DOI: 10.1037/pha0000655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Clinical amphetamine use is constrained by high abuse potential, and amphetamine use disorder is a persistent clinical problem with no approved medications for its treatment. The opioid antagonist naltrexone has been reported to reduce some abuse-related effects of amphetamine. This study used an amphetamine-versus-food choice procedure in rhesus monkeys and rats to test the hypothesis that naltrexone might serve as either (a) a maintenance medication for amphetamine use disorder treatment or (b) an "abuse-deterrent" adjunct to clinical amphetamine formulations. Male rhesus monkeys and male and female rats were trained to choose between increasing unit doses of intravenous amphetamine and an alternative food reinforcer during daily behavioral sessions. Experiment 1 evaluated effectiveness of continuous naltrexone maintenance to reduce amphetamine-versus-food choice in both monkeys and rats. Experiment 2 combined naltrexone with amphetamine in fixed-proportion amphetamine + naltrexone mixtures to evaluate the effectiveness of naltrexone in both species to reduce mixture choice relative to amphetamine-alone choice. Amphetamine maintained a dose-dependent increase in amphetamine choice in both monkeys and rats. Naltrexone maintenance did not significantly decrease amphetamine choice in either species. Addition of naltrexone to amphetamine reduced amphetamine choices per session in monkeys, but behavior was not reallocated to food choice, and in rats, the addition of naltrexone only decreased food choice without significantly affecting amphetamine choice. These results argue against the use of naltrexone as either (a) a maintenance medication for treatment of amphetamine use disorder or (b) an "abuse-deterrent" adjunct to amphetamine for clinical applications. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
| | | | - Matthew L. Banks
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA 23298
| | - S. Stevens Negus
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA 23298
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Komboz F, Mehsein Z, Kobaïter-Maarrawi S, Chehade HD, Maarrawi J. Epidural Posterior Insular Stimulation Alleviates Neuropathic Pain Manifestations in Rats With Spared Nerve Injury Through Endogenous Opioid System. Neuromodulation 2023; 26:1602-1611. [PMID: 35219569 DOI: 10.1016/j.neurom.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/05/2022] [Accepted: 01/09/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Neuropathic pain (NP) is defined as constant disabling pain secondary to a lesion or disease of the somatosensory nervous system. This condition is particularly difficult to treat because it often remains resistant to most treatment strategies. Despite the recent diversification of neurostimulation methods, some patients still suffer from refractory pain syndromes. The central role of the posterior insular cortex (PI) in the modulation of pain signaling and perception has been repeatedly suggested. The objective of this study is to assess whether epidural insular stimulation (IS) could reverse NP behavior. MATERIALS AND METHODS A total of 53 adult Sprague-Dawley rats received left-sided spared nerve injury (SNI) or Sham-SNI to induce NP symptoms. Afterward, epidural electrodes were implanted over the right PI. After two weeks of postoperative recovery, three groups of SNI-operated rats each received a different stimulation modality: Sham-IS, low-frequency-IS (LF-IS), or high-frequency-IS (HF-IS). Behavioral and functional tests were conducted before and after IS. They comprised the acetone test, pinprick test, von Frey test, and sciatic functional index. An additional LF-IS group received a dose of opioid antagonist naloxone before IS. Intergroup means were compared through independent-samples t-tests, and pre- and post-IS means in the same group were compared through paired t-tests. RESULTS We found a significant reduction of cold allodynia (p = 0.019), mechanical hyperalgesia (p = 0.040), and functional disability (p = 0.005) after LF-IS but not HF-IS. Mechanical allodynia only showed a tendency to decrease after LF-IS. The observed analgesic effects were reversed by opioid antagonist administration. CONCLUSION These results suggest a significant reversal of NP symptoms after LF-IS and offer additional evidence that IS might be beneficial in the treatment of resistant NP syndromes through endogenous opioid secretion. Relying on our novel epidural IS model, further fine tuning of stimulation parameters might be necessary to achieve optimal therapeutic effects.
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Affiliation(s)
- Fares Komboz
- Laboratory of Research in Neuroscience, Pôle Technologie Santé, Faculty of Medicine, Saint Joseph University of Beirut, Beirut, Lebanon
| | - Zeinab Mehsein
- Laboratory of Research in Neuroscience, Pôle Technologie Santé, Faculty of Medicine, Saint Joseph University of Beirut, Beirut, Lebanon
| | - Sandra Kobaïter-Maarrawi
- Laboratory of Research in Neuroscience, Pôle Technologie Santé, Faculty of Medicine, Saint Joseph University of Beirut, Beirut, Lebanon.
| | - Hiba-Douja Chehade
- Laboratory of Research in Neuroscience, Pôle Technologie Santé, Faculty of Medicine, Saint Joseph University of Beirut, Beirut, Lebanon
| | - Joseph Maarrawi
- Laboratory of Research in Neuroscience, Pôle Technologie Santé, Faculty of Medicine, Saint Joseph University of Beirut, Beirut, Lebanon; Department of Neurosurgery, Hôtel-Dieu de France Hospital, Beirut, Lebanon
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105
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Dowd WN. The effect of untargeted naloxone distribution on opioid overdose outcomes. Health Econ 2023; 32:2801-2818. [PMID: 37670413 DOI: 10.1002/hec.4755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 06/06/2023] [Accepted: 08/23/2023] [Indexed: 09/07/2023]
Abstract
Opioid overdose has claimed the lives of over 340,000 Americans in the last decade. Over that same period, policymakers have taken steps to increase the availability of naloxone-an opioid antagonist used to rescue overdose victims-to people in the community. Previous studies, most of which have examined the effects of state laws designed to facilitate access to naloxone, have reached mixed conclusions about the effects of naloxone access on fatal and non-fatal overdoses. This paper exploits a unique policy experiment provided by two naloxone giveaways intended to increase naloxone possession among the general public in Pennsylvania to estimate the causal impact of naloxone distribution on fatal overdoses and opioid-related emergency department (ED) visits. Using a difference-in-differences design, I find evidence that opioid overdose deaths fell immediately following the first giveaway but increased following the second giveaway and discuss these apparently contradictory findings in the context of the changing composition of the opioid supply. I also find some evidence of a decline in opioid overdose-related ED visits following the giveaways. This study is the first to examine the effects of untargeted naloxone distribution and has implications for other novel, naloxone distribution efforts currently underway.
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Affiliation(s)
- William N Dowd
- Public Health Division, RTI International, Research Triangle Park, North Carolina, USA
- Division of Health Research, Lancaster University, Lancaster, UK
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106
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Miller JC, Brooks MA, Wurzel KE, Cox EJ, Wurzel JF. A Guide to Expanding the Use of Buprenorphine Beyond Standard Initiations for Opioid Use Disorder. Drugs R D 2023; 23:339-362. [PMID: 37938531 PMCID: PMC10676346 DOI: 10.1007/s40268-023-00443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 11/09/2023] Open
Abstract
Buprenorphine has become an important medication in the context of the ongoing opioid epidemic. However, complex pharmacologic properties and varying government regulations create barriers to its use. This narrative review is intended to facilitate buprenorphine use-including non-traditional initiation methods-by providers ranging from primary care providers to addiction specialists. This article briefly discusses the opioid epidemic and the diagnosis and treatment of opioid use disorder (OUD). We then describe the basic and complex pharmacologic properties of buprenorphine, linking these properties to their clinical implications. We guide readers through the process of initiating buprenorphine in patients using full agonist opioids. As there is no single recommended approach for buprenorphine initiation, we discuss the details, advantages, and disadvantages of the standard, low-dose, bridging-strategy, and naloxone-facilitated initiation techniques. We consider the pharmacology of, and evidence base for, buprenorphine in the treatment of pain, in both OUD and non-OUD patients. Throughout, we address the use of buprenorphine in children and adolescent patients, and we finish with considerations related to the settings of pregnancy and breastfeeding.
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Affiliation(s)
- James C Miller
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Michael A Brooks
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Kelly E Wurzel
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Emily J Cox
- Providence Research Network, Renton, WA, USA
| | - John F Wurzel
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA.
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D’Onofrio G, Perrone J, Hawk KF, Cowan E, McCormack R, Coupet E, Owens PH, Martel SH, Huntley K, Walsh SL, Lofwall MR, Herring A. Early emergency department experience with 7-day extended-release injectable buprenorphine for opioid use disorder. Acad Emerg Med 2023; 30:1264-1271. [PMID: 37501652 PMCID: PMC10822018 DOI: 10.1111/acem.14782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/17/2023] [Accepted: 07/25/2023] [Indexed: 07/29/2023]
Abstract
As the opioid overdose epidemic escalates, there is an urgent need for treatment innovations to address both patient and clinician barriers when initiating buprenorphine in the emergency department (ED). These include insurance status, logistical challenges such as the ability to fill a prescription and transportation, concerns regarding diversion, and availability of urgent referral sites. Extended-release buprenorphine (XR-BUP) preparations such as a new 7-day injectable could potentially solve some of these issues. We describe the pharmacokinetics of a new 7-day XR-BUP formulation and the feasibility of its use in the ED setting. We report our early experiences with this medication (investigational drug CAM2038), in the context of an ongoing clinical trial entitled Emergency Department-Initiated BUP VAlidaTION (ED INNOVATION), to inform emergency clinicians as they consider incorporating this medication into their practice. The medication was approved by the European Medicines Agency in 2018 and the U.S. Food and Drug Administration in 2023 for those 18 years or older for the treatment of moderate to severe opioid use disorder (OUD). We report our experience with approximately 800 ED patients with OUD who received the 7-day XR-BUP preparation in the ED between June 2020 and July 2023.
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Affiliation(s)
- Gail D’Onofrio
- Department of Emergency Medicine, Yale School of Medicine,
New Haven, Connecticut
- Yale School of Public Health New Haven, Connecticut
| | - Jeanmarie Perrone
- Department of Emergency Medicine Perelman School of
Medicine at the University of Pennsylvania. Philadelphia, Pennsylvania
| | - Kathryn F. Hawk
- Department of Emergency Medicine, Yale School of Medicine,
New Haven, Connecticut
- Yale School of Public Health New Haven, Connecticut
| | - Ethan Cowan
- Department of Emergency Medicine, Yale School of Medicine,
New Haven, Connecticut
- Department of Emergency Medicine Icahn School of Medicine
at Mount Sinai New York, New York
| | - Ryan McCormack
- Department of Emergency Medicine NYU Langone Medical Center
New York, New York
| | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine,
New Haven, Connecticut
| | - Patricia H. Owens
- Department of Emergency Medicine, Yale School of Medicine,
New Haven, Connecticut
| | - Shara H. Martel
- Department of Emergency Medicine, Yale School of Medicine,
New Haven, Connecticut
| | | | - Sharon L. Walsh
- University of Kentucky College of Medicine Center on Drug
and Alcohol Research, Lexington, Kentucky
| | - Michelle R. Lofwall
- University of Kentucky College of Medicine Center on Drug
and Alcohol Research, Lexington, Kentucky
| | - Andrew Herring
- Department of Emergency Medicine Highland Hospital Oakland,
California
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108
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Ware OD, Dunn KE. Clinically meaningful individual differences in opioid withdrawal expression. Exp Clin Psychopharmacol 2023; 31:1005-1009. [PMID: 37166910 PMCID: PMC10638457 DOI: 10.1037/pha0000654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Opioid use disorder (OUD) is a significant public health concern. An individual with an OUD may experience withdrawal after stopping opioid use. There has been limited exploration of the individual differences in withdrawal expression. This study expands understanding of this issue by examining the presence and frequency at which persons who have ever had opioid withdrawal have experienced different opioid withdrawal symptoms. Using cross-sectional data captured online from Amazon Mechanical Turk, 124 adults with a lifetime experience of opioid withdrawal were included. Respondents were able to indicate ever experiencing 31 individual opioid withdrawal symptoms. If a symptom was ever experienced, respondents would indicate if it was common and whether it bothered them. A cluster analysis was used to explore variability between the withdrawal symptoms. The sample was primarily men (n = 76, 61.3%) with an average age of 34.7 (SD = 11.6). The typical withdrawal syndrome lasted 6.5 days (SD = 4.9) and was most severe at 5.7 (SD = 4.9) days. Lifetime endorsement of individual symptoms ranged from a high of 73.4% (anxious) to a low of 43.5% (nausea). The cluster analysis was significant, F(1, 122) = 215.6, p < .001, with good Bayesian information criteria (0.7). The two clusters are conceptualized here as HIGH (N = 73; 59%) and LOW (N = 51; 41%) endorsing, with a mean of 21.9 and 8.5 items endorsed. These data add to prior studies by suggesting high variability in the individual expression of opioid withdrawal symptoms. It may be time for the field to develop a consensus regarding opioid withdrawal symptom expression and measurement to enhance clinical care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Orrin D. Ware
- Orrin D. Ware., PhD., MPH., MSW. Academic Rank: Assistant Professor, School of Social Work, University of North Carolina at Chapel Hill, 325 Pittsboro Street, Chapel Hill, NC 27599
- Kelly E. Dunn, PhD., MBA, Academic Rank: Professor, Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224
| | - Kelly E. Dunn
- Kelly E. Dunn, PhD., MBA, Academic Rank: Professor, Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224
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Knudsen HK, Freeman PR, Oyler DR, Oser CB, Walsh SL. Scaling up overdose education and naloxone distribution in Kentucky: adoption and reach achieved through a "hub with many spokes" model. Addict Sci Clin Pract 2023; 18:72. [PMID: 38031180 PMCID: PMC10688494 DOI: 10.1186/s13722-023-00426-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/17/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Scaling up overdose education and naloxone distribution (OEND), an evidence-based practice for reducing opioid overdose mortality, in communities remains a challenge. Novel models and intentional implementation strategies are needed. Drawing upon the EPIS model's phases of Exploration, Preparation, Implementation, and Sustainment (Aarons et al. in Adm Policy Ment Health 38:4-23, 2011), this paper describes the development of the University of Kentucky's unique centralized "Naloxone Hub with Many Spokes" approach to implementing OEND as part of the HEALing Communities Study (HCS-KY). METHODS To scale up OEND in eight Kentucky counties, implementation strategies were utilized at two levels: a centralized university-based naloxone dispensing unit ("Naloxone Hub") and adopting organizations ("Many Spokes"). Implementation strategies varied across the EPIS phases, but heavily emphasized implementation facilitation. The Naloxone Hub provided technical assistance, overdose education resources, and no-cost naloxone to partner organizations. Implementation outcomes across the EPIS phases were measured using data from internal study management trackers and naloxone distribution data submitted by partner organizations. RESULTS Of 209 organizations identified as potential partners, 84.7% (n = 177) engaged in the Exploration/Preparation phase by participating in an initial meeting with an Implementation Facilitator about the HCS-KY OEND program. Adoption of the HCS-KY OEND program, defined as receipt of at least one shipment of naloxone, was achieved with 69.4% (n = 145) of all organizations contacted. During the Implementation phase, partner organizations distributed 40,822 units of naloxone, with partner organizations distributing a mean of 281.5 units of naloxone (SD = 806.2). The mean number of units distributed per county was 5102.8 (SD = 3653.3; range = 1057 - 11,053) and the mean county level distribution rate was 8396.5 units per 100,000 residents (SD = 8103.1; range = 1709.5-25,296.3). Of the partner organizations that adopted the HCS-KY OEND program, 87.6% (n = 127) attended a sustainability meeting with an Implementation Facilitator and agreed to transition to the state-funded naloxone program. CONCLUSIONS These data demonstrate the feasibility of this "Hub with Many Spokes" model for scaling up OEND in communities highly affected by the opioid epidemic. Trial registration ClinicalTrials.gov, NCT04111939. Registered 30 September 2019, https://clinicaltrials.gov/ct2/show/NCT04111939 .
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Affiliation(s)
- Hannah K Knudsen
- Department of Behavioral Science and Center on Drug & Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 204, Lexington, KY, 40508, USA.
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science and Center for the Advancement of Pharmacy Practice, College of Pharmacy, University of Kentucky, Lexington, KY, 40536, USA
| | - Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, 40536, USA
| | - Carrie B Oser
- Department of Sociology, Center on Drug & Alcohol Research, and Center for Health Equity Transformation, University of Kentucky, Lexington, KY, 40536, USA
| | - Sharon L Walsh
- Department of Behavioral Science and Center on Drug & Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 204, Lexington, KY, 40508, USA
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Marks KR, Oyler DR, Strickland JC, Jaggers J, Roberts MF, Miracle DK, Barnes C, Lei F, Smith A, Mackin E, Martin MC, Freeman PR. Bystander preference for naloxone products: a field experiment. Harm Reduct J 2023; 20:171. [PMID: 38017424 PMCID: PMC10685501 DOI: 10.1186/s12954-023-00904-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 11/17/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Bystander administration of naloxone is a critical strategy to mitigate opioid overdose mortality. To ensure bystanders' willingness to carry and administer naloxone in response to a suspected overdose, it is critical to select products for community distribution with the highest likelihood of being utilized. This study examines bystanders' preference for and willingness to administer three naloxone products approved by the FDA for bystander use and identify product features driving preference. METHODS The population was a convenience sample of individuals who attended the Kentucky State Fair, August 18-28, 2022, in Louisville, Kentucky. Participants (n = 503) watched a standardized overdose education and naloxone training video, rated their willingness to administer each of three products (i.e., higher-dose nasal spray, lower-dose nasal spray, intramuscular injection), selected a product to take home, and rated factors affecting choice. RESULTS After training, 44.4% chose the higher-dose nasal spray, 30.1% chose the intramuscular injection, and 25.5% chose the lower-dose nasal spray. Factors most influencing choice on a 10-point Likert scale were ease of use (9 [7-10]), naloxone dose (8 [5-10]), and product familiarity (5 [5-9]). CONCLUSIONS Bystanders expressed high willingness to administer all studied formulations of naloxone products. Product choice preference varied as a function of product features. As the number and variety of available products continue to increase, continuous evaluation of formulation acceptability, in addition to including individuals with lived experience who are receiving and administering overdose reversal agents, is critical to support adoption and save lives.
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Affiliation(s)
- Katherine R Marks
- Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, KY, USA.
- Department for Behavioral Health, Developmental and Intellectual Disabilities, Cabinet for Health and Family Services, 275 E. Main Street, Frankfort, KY, 40621, USA.
| | - Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Justin C Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jody Jaggers
- Kentucky Pharmacy Education and Research Foundation, Frankfort, KY, USA
| | - Monica F Roberts
- Substance Use Priority Research Area, University of Kentucky, Lexington, KY, USA
| | - Dustin K Miracle
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Chase Barnes
- Kentucky Department for Public, Health Division of Public Health Protection & Safety, Frankfort, KY, USA
| | - Feitong Lei
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Amanda Smith
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Eric Mackin
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Martika C Martin
- Kentucky Pharmacy Education and Research Foundation, Frankfort, KY, USA
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
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Essmat N, Karádi DÁ, Zádor F, Király K, Fürst S, Al-Khrasani M. Insights into the Current and Possible Future Use of Opioid Antagonists in Relation to Opioid-Induced Constipation and Dysbiosis. Molecules 2023; 28:7766. [PMID: 38067494 PMCID: PMC10708112 DOI: 10.3390/molecules28237766] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
Opioid receptor agonists, particularly those that activate µ-opioid receptors (MORs), are essential analgesic agents for acute or chronic mild to severe pain treatment. However, their use has raised concerns including, among others, intestinal dysbiosis. In addition, growing data on constipation-evoked intestinal dysbiosis have been reported. Opioid-induced constipation (OIC) creates an obstacle to continuing treatment with opioid analgesics. When non-opioid therapies fail to overcome the OIC, opioid antagonists with peripheral, fast first-pass metabolism, and gastrointestinal localized effects remain the drug of choice for OIC, which are discussed here. At first glance, their use seems to only be restricted to constipation, however, recent data on OIC-related dysbiosis and its contribution to the appearance of several opioid side effects has garnered a great of attention from researchers. Peripheral MORs have also been considered as a future target for opioid analgesics with limited central side effects. The properties of MOR antagonists counteracting OIC, and with limited influence on central and possibly peripheral MOR-mediated antinociception, will be highlighted. A new concept is also proposed for developing gut-selective MOR antagonists to treat or restore OIC while keeping peripheral antinociception unaffected. The impact of opioid antagonists on OIC in relation to changes in the gut microbiome is included.
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Affiliation(s)
- Nariman Essmat
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig 44519, Egypt
| | - Dávid Árpád Karádi
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
| | - Ferenc Zádor
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
| | - Kornél Király
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
| | - Susanna Fürst
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
| | - Mahmoud Al-Khrasani
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
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112
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Zhang W, Wang D, Ostertag-Hill CA, Han Y, Li X, Zheng Y, Lu B, Kohane DS. On-Demand Opioid Effect Reversal with an Injectable Light-Triggered Polymer-Naloxone Conjugate. Nano Lett 2023; 23:10545-10553. [PMID: 37937844 PMCID: PMC10949359 DOI: 10.1021/acs.nanolett.3c03426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Misuse of opioids can lead to a potential lethal overdose. Timely administration of naloxone is critical for survival. Here, we designed a polymer-naloxone conjugate that can provide on-demand phototriggered opioid reversal. Naloxone was attached to the polymer poly(lactic-co-glycolic acid) via a photocleavable coumarin linkage and formulated as injectable nanoparticles. In the absence of irradiation, the formulation did not release naloxone. Upon irradiation with blue (400 nm) light, the nanoparticles released free naloxone, reversing the effect of morphine in mice. Such triggered events could be performed days and weeks after the initial administration of the nanoparticles and could be performed repeatedly.
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Affiliation(s)
- Wei Zhang
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Dali Wang
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Claire A. Ostertag-Hill
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Yiyuan Han
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Xiyu Li
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Yueqin Zheng
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Berwyn Lu
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Daniel S. Kohane
- Laboratory for Biomaterials and Drug Delivery, The Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
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113
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Yao H, Hu D, Wang J, Wu W, Zhao HH, Wang L, Gleeson J, Haddad GG. Buprenorphine and methadone differentially alter early brain development in human cortical organoids. Neuropharmacology 2023; 239:109683. [PMID: 37543137 DOI: 10.1016/j.neuropharm.2023.109683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/12/2023] [Accepted: 08/01/2023] [Indexed: 08/07/2023]
Abstract
Buprenorphine (BUP) and methadone (MTD) are used for medication-assisted treatment (MAT) in opioid use disorder. Although both medications show improved maternal and neonatal outcomes compared with illicit opioid use during pregnancy, BUP has exhibited more favorable outcomes to newborns than MTD. The underlying cellular and molecular mechanisms for the difference between BUP and MTD are largely unknown. Here, we examined the growth and neuronal activity in human cortical organoids (hCOs) exposed to BUP or MTD. We found that the growth of hCOs was significantly restricted in the MTD-treated but not in the BUP-treated hCOs and BUP attenuated the growth-restriction effect of MTD in hCOs. Furthermore, a κ-receptor agonist restricted while an antagonist alleviated the growth-restriction effect of MTD in hCOs. Since BUP is not only a μ-agonist but a κ-antagonist, the prevention of this growth-restriction by BUP is likely due to its κ-receptor-antagonism. In addition, using multielectrode array (MEA) technique, we discovered that both BUP and MTD inhibited neuronal activity in hCOs but BUP showed suppressive effects only at higher concentrations. Furthermore, κ-receptor antagonist nBNI did not prevent the MTD-induced suppression of neuronal activity in hCOs but the NMDA-antagonism of MTD (that BUP lacks) plays a role in the inhibition of neuronal activity. We conclude that, although both MTD and BUP are μ-opioid agonists, a) the additional κ-receptor antagonism of BUP mitigates the MTD-induced growth restriction during neurodevelopment and b) the lack of NMDA antagonism of BUP (in contrast to MTD) induces much less suppressive effect on neural network communications.
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Affiliation(s)
- Hang Yao
- Department of Pediatrics, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Daisy Hu
- Department of Pediatrics, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Juan Wang
- Department of Pediatrics, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Wei Wu
- Department of Pediatrics, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Helen H Zhao
- Department of Pediatrics, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Lu Wang
- Department of Neurosciences, University of California, San Diego, La Jolla, CA, 92093, USA; Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Joe Gleeson
- Department of Neurosciences, University of California, San Diego, La Jolla, CA, 92093, USA; Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Gabriel G Haddad
- Department of Pediatrics, University of California, San Diego, La Jolla, CA, 92093, USA; Department of Neurosciences, University of California, San Diego, La Jolla, CA, 92093, USA; Rady Children's Hospital, San Diego, CA, 92123, USA
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114
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Bowie AR, Gibson-Corley KN, Yu ENZ. Pharmacokinetics of Extended-release Buprenorphine in Mongolian Gerbils ( Meriones unguiculatus). J Am Assoc Lab Anim Sci 2023; 62:538-544. [PMID: 37813575 PMCID: PMC10772909 DOI: 10.30802/aalas-jaalas-23-000048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/26/2023] [Accepted: 08/09/2023] [Indexed: 10/11/2023]
Abstract
Both the Guide for the Care and Use of Laboratory Animals and the Animal Welfare Act and Regulations require animals in research to receive adequate analgesia unless an exception can be scientifically justified and IACUC approved. Extended- release buprenorphine (BUP-XR) is a pharmaceutical-grade formulation that is FDA-indexed for use in mice and rats. However, this new formulation has not been evaluated in adult Mongolian gerbils (Meriones unguiculatus). Our goal was to determine whether the extrapolated dose (1 mg/kg SC) would achieve plasma buprenorphine concentrations above the murine therapeutic threshold (> 1.0 ng/mL) in male and female gerbils. We hypothesized that BUP-XR administered at 1 mg/kg would achieve the murine therapeutic threshold in both male and female gerbils until at least 48 h after injection. Gerbils received one injection of BUP-XR (1 mg/kg SC) and underwent 4 serial blood collections (0.5, 1, 2, and 4, or 0.5, 24, 48, and 72 h after injection). The average plasma buprenorphine concentrations were above 1 ng/mL within 30 min of administration for both males and females. Plasma buprenorphine concentrations remained above 1.0 ng/mL for 48 h after administration. In males, plasma buprenorphine concentrations were significantly higher at 1 h after injection as compared with females; no other significant differences were observed between sexes. Mild to moderate injection-site granulomas were observed in five of nine gerbils, presumably due to the lipid matrix of the BUP-XR formulation. Our findings demonstrate that a single BUP-XR dose (1 mg/kg SC) achieves plasma buprenorphine levels that remain above the murine therapeutic threshold of 1.0 ng/mL for up to 48 h in both sexes.
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Affiliation(s)
- Aleaya R Bowie
- Division of Animal Care, Deptartment of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katherine N Gibson-Corley
- Division of Animal Care, Deptartment of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erin NZ Yu
- Division of Animal Care, Deptartment of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
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115
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Lopez-Echeverria G, Alamaw E, Gorman G, Jampachaisri K, Huss MK, Pacharinsak C. Comparing Three Formulations of Buprenorphine in an Incisional Pain Model in Mice. J Am Assoc Lab Anim Sci 2023; 62:531-537. [PMID: 38030144 PMCID: PMC10772916 DOI: 10.30802/aalas-jaalas-23-000011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/08/2023] [Accepted: 04/10/2023] [Indexed: 12/01/2023]
Abstract
This study compared the therapeutic effects in mice of 3 different formulations of buprenorphine. These formulations were standard buprenorphine hydrochloride (Bup-HCL) and 2 different extended-release buprenorphine formulations (Bup-ER and Ethiqa-XR [Bup-XR]). Drugs were evaluated based on their ability to attenuate thermal hypersensitivity in a mouse plantar incisional pain model. We hypothesized that Bup-HCL would attenuate postoperative thermal hypersensitivity at 20 min after administration, and that Bup-ER and Bup-XR would attenuate thermal hypersensitivity at 40 min after administration. Male C57BL6/J mice were randomly assigned to 1 of 4 treatment groups: 1) saline, 5 mL/kg SC, once; 2) Bup-HCL, 0.1 mg/kg SC, once; 3) Bup-ER, 1 mg/kg, SC, once; and 4) Bup-XR, 3.25 mg/kg, SC, once. Thermal hypersensitivity was assessed on the day before surgery and again on the day of surgery at 20, 40, 60, 90, and 120 min after drug administration. Thermal hypersensitivity after surgery was not different among the Bup-HCL, Bup-ER and Bup-XR groups at any timepoint. In addition, all buprenorphine treatment groups showed significantly less thermal hypersensitivity after surgery than did the saline group. Subjective observations suggested that mice that received Bup-ER or Bup-XR became hyperactive after drug administration (83 and 75% of mice tested, respectively). Our results indicate that Bup-HCL, Bup-ER, or Bup-XR attenuate thermal hyper- sensitivity related to foot incision by 20 min after administration.
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Affiliation(s)
| | - Eden Alamaw
- Department of Comparative Medicine, Stanford University, Stanford, California
| | - Gregory Gorman
- Pharmaceutical Sciences Research Institute, McWhorter School of Pharmacy, Samford University, Birmingham, Alabama
| | | | - Monika K Huss
- Department of Comparative Medicine, Stanford University, Stanford, California
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116
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Kesich Z, Ibragimov U, Komro K, Lane K, Livingston M, Young A, Cooper HLF. "I'm not going to lay back and watch somebody die": a qualitative study of how people who use drugs' naloxone experiences are shaped by rural risk environment and overdose education/naloxone distribution intervention. Harm Reduct J 2023; 20:166. [PMID: 37946233 PMCID: PMC10636969 DOI: 10.1186/s12954-023-00900-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/04/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Overdoses have surged in rural areas in the U.S. and globally for years, but harm reduction interventions have lagged. Overdose education and naloxone distribution (OEND) programs reduce overdose mortality, but little is known about people who use drugs' (PWUD) experience with these interventions in rural areas. Here, we analyze qualitative data with rural PWUD to learn about participants' experiences with an OEND intervention, and about how participants' perceptions of their rural risk environments influenced the interventions' effects. METHODS Twenty-nine one-on-one, semi-structured qualitative interviews were conducted with rural PWUD engaged in the CARE2HOPE OEND intervention in Appalachian Kentucky. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. Thematic analysis was conducted, guided by the Rural Risk Environment Framework. RESULTS Participants' naloxone experiences were shaped by all domains of their rural risk environments. The OEND intervention transformed participants' roles locally, so they became an essential component of the local rural healthcare environment. The intervention provided access to naloxone and information, thereby increasing PWUDs' confidence in naloxone administration. Through the intervention, over half of participants gained knowledge on naloxone (access points, administration technique) and on the criminal-legal environment as it pertained to naloxone. Most participants opted to accept and carry naloxone, citing factors related to the social environment (responsibility to their community) and physical/healthcare environments (overdose prevalence, suboptimal emergency response systems). Over half of participants described recent experiences administering intervention-provided naloxone. These experiences were shaped by features of the local rural social environment (anticipated negative reaction from recipients, prior naloxone conversations). CONCLUSIONS By providing naloxone paired with non-stigmatizing health and policy information, the OEND intervention offered support that allowed participants to become a part of the healthcare environment. Findings highlight need for more OEND interventions; outreach to rural PWUD on local policy that impacts them; tailored strategies to help rural PWUD engage in productive dialogue with peers about naloxone and navigate interpersonal conflict associated with overdose reversal; and opportunities for rural PWUD to formally participate in emergency response systems as peer overdose responders. Trial registration The ClinicalTrials.gov ID for the CARE2HOPE intervention is NCT04134767. The registration date was October 19th, 2019.
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Affiliation(s)
- Zora Kesich
- Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA.
| | - Umedjon Ibragimov
- Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Kelli Komro
- Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Kenneth Lane
- College of Public Health, University of Kentucky, Lexington, KY, 40536, USA
| | - Melvin Livingston
- Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - April Young
- College of Public Health, University of Kentucky, Lexington, KY, 40536, USA
| | - Hannah L F Cooper
- Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
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117
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Locke T, Salisbury-Afshar E, Coyle DT. Treatment Updates for Pain Management and Opioid Use Disorder. Med Clin North Am 2023; 107:1035-1046. [PMID: 37806723 DOI: 10.1016/j.mcna.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
The medical community has proposed several clinical recommendations to promote patient safety and health amid the opioid overdose public health crisis. For a frontline practicing physician, distilling the evidence and implementing the latest guidelines may prove challenging. This article aims to highlight pertinent updates and clinical care pearls as they relate to primary care management of chronic pain and opioid use disorder.
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Affiliation(s)
- Thomas Locke
- University of Colorado School of Medicine, 13001 East 17th Place, Aurora, CO 80045, USA.
| | - Elizabeth Salisbury-Afshar
- University of Wisconsin School of Medicine and Public Health, 610 North Whitney Way, Suite 200, Madison, WI 53705, USA
| | - David Tyler Coyle
- University of Colorado School of Medicine, 13001 East 17th Place, Aurora, CO 80045, USA
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118
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Suzuki N, Okuyama M, Kamiya K. Effects and Limitations of Naldemedine for Opioid-Induced Urinary Retention: A Case Report. J Palliat Med 2023; 26:1593-1595. [PMID: 37347929 DOI: 10.1089/jpm.2023.0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
A 78-year-old man with postoperative recurrence of esophageal cancer was admitted to the hospital due to chest pain and dyspnea. Oral short-acting opioids provided some relief, but chest pain persisted and worsened, leading to the initiation of a transdermal fentanyl patch. However, the patient developed opioid-induced urinary retention, which was treated with a naldemedine, a medication used for opioid-induced constipation and urinary retention. Opioid switching led to recurrent urinary retention, requiring placement of a urinary catheter. The patient ultimately required continuous deep sedation for refractory symptoms and died several days later.
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Affiliation(s)
- Naoki Suzuki
- Department of Palliative Medicine, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Megumi Okuyama
- Department of Palliative Medicine, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Kohei Kamiya
- MY Wells Community Care Workshop, Inc., Yamagata, Japan
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119
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Gao E, Melnick ER, Paek H, Nath B, Taylor RA, Loza AJ. Adoption of Emergency Department-Initiated Buprenorphine for Patients With Opioid Use Disorder: Secondary Analysis of a Cluster Randomized Trial. JAMA Netw Open 2023; 6:e2342786. [PMID: 37948075 PMCID: PMC10638655 DOI: 10.1001/jamanetworkopen.2023.42786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/02/2023] [Indexed: 11/12/2023] Open
Abstract
Importance Emergency department (ED) initiation of buprenorphine is safe and effective but underutilized in practice. Understanding the factors affecting adoption of this practice could inform more effective interventions. Objective To quantify the factors, including social contagion, associated with the adoption of the practice of ED initiation of buprenorphine for patients with opioid use disorder. Design, Setting, and Participants This is a secondary analysis of the EMBED (Emergency Department-Initiated Buprenorphine For Opioid Use Disorder) trial, a multicentered, cluster randomized trial of a clinical decision support intervention targeting ED initiation of buprenorphine. The trial occurred from November 2019 to May 2021. The study was conducted at ED clusters across health care systems from the northeast, southeast, and western regions of the US and included attending physicians, resident physicians, and advanced practice practitioners. Data analysis was performed from August 2022 to June 2023. Exposures This analysis included both the intervention and nonintervention groups of the EMBED trial. Graph methods were used to construct the network of clinicians who shared in the care of patients for whom buprenorphine was initiated during the trial before initiating the practice themselves, termed exposure. Main Outcomes and Measures Cox proportional hazard modeling with time-dependent covariates was performed to assess the association of the number of these exposures with self-adoption of the practice of ED initiation of buprenorphine while adjusting for clinician role, health care system, and intervention site status. Results A total of 1026 unique clinicians in 18 ED clusters across 5 health care systems were included. Analysis showed associations of the cumulative number of exposures to others initiating buprenorphine with the self-practice of buprenorphine initiation. This increased in a dose-dependent manner (1 exposure: hazard ratio [HR], 1.31; 95% CI, 1.16-1.48; 5 exposures: HR, 2.85; 95% CI, 1.66-4.89; 10 exposures: HR, 3.55; 95% CI, 1.47-8.58). Intervention site status was associated with practice adoption (HR, 1.50; 95% CI, 1.04-2.18). Health care system and clinician role were also associated with practice adoption. Conclusions and Relevance In this secondary analysis of a multicenter, cluster randomized trial of a clinical decision support tool for buprenorphine initiation, the number of exposures to ED initiation of buprenorphine and the trial intervention were associated with uptake of ED initiation of buprenorphine. Although systems-level approaches are necessary to increase the rate of buprenorphine initiation, individual clinicians may change practice of those around them. Trial Registration ClinicalTrials.gov Identifier: NCT03658642.
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Affiliation(s)
- Evangeline Gao
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
| | - Hyung Paek
- Information Technology Services, Yale New Haven Health, Stratford, Connecticut
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - R. Andrew Taylor
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew J. Loza
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
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120
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Rawal S, Osae SP, Tackett RL, MacKinnon NJ, Soiro FD, Young HN. Community pharmacists' naloxone counseling: A theory-informed qualitative study. J Am Pharm Assoc (2003) 2023; 63:1743-1752.e2. [PMID: 37633453 DOI: 10.1016/j.japh.2023.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Opioid-related overdose (ORO) deaths have reached a record high in the United States. Naloxone is an opioid antagonist that can rapidly reverse an opioid overdose. Pharmacists are in an ideal position to provide naloxone and related counseling, given their accessibility and expertise. However, minimal research is available on community pharmacists' naloxone counseling. OBJECTIVES The aim of this study was to investigate Georgia community pharmacists' naloxone counseling as well as explore their attitudes, subjective norms, and perceived behavioral control toward counseling. METHODS Semi-structured telephone interviews were conducted to elicit pharmacists' beliefs and practices regarding naloxone counseling. The interviews were guided by open-ended questions based on the theory of planned behavior (TPB). Thematic analysis was performed to identify the modal salient beliefs expressed by the pharmacists. The Consolidated Criteria for Reporting Qualitative Research was used to report the study findings. RESULTS A total of 12 community pharmacists participated. Pharmacists held mixed attitudes toward naloxone counseling. While they recognized it as a vital part of their profession to prevent ORO deaths, they also expressed concerns about offending patients. Regarding normative beliefs, pharmacists identified several groups, including regulatory agencies (e.g., Board of Pharmacy, CDC), managers, news/media, patients, and doctors, influencing their provision of naloxone counseling. Facilitators to counseling included receiving naloxone training and having access to counseling guidelines and resources. Reimbursement issues, high costs of naloxone, and lack of patient awareness were the most commonly cited barriers. Pharmacists reported participating in counseling and providing information on identifying signs of opioid overdose and administering naloxone. CONCLUSIONS The TPB is a useful framework for understanding community pharmacists' beliefs and practices regarding naloxone counseling. Capitalizing on facilitators and targeting barriers related to pharmacists' reimbursement issues, high costs of naloxone, and increasing patients' awareness of naloxone use and benefits may enhance pharmacists' naloxone counseling.
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121
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Galati BM, Wenzinger M, Rogers CE, Cooke E, Kelly JC. Buprenorphine Extended-Release Treatment for Opioid Use Disorder in the Postpartum Period. Obstet Gynecol 2023; 142:1148-1152. [PMID: 37856853 DOI: 10.1097/aog.0000000000005319] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/15/2023] [Indexed: 10/21/2023]
Abstract
Buprenorphine extended-release (XR) is an extended-release monthly injection to treat opioid use disorder (OUD). This retrospective case series includes 15 postpartum patients who were treated with buprenorphine-XR at a single center and reports on their outcomes. The average total daily sublingual buprenorphine dose before initiation of buprenorphine-XR was 16.25 mg (SD±7.76, range 2-32 mg). Overall, 137 total doses of buprenorphine-XR were administered between May 17, 2021, and April 11, 2023. Urine toxicology test results were negative for opioids other than buprenorphine in the majority (80.0%) of patients once appropriate maintenance doses were achieved. Euphoria and intoxication were not reported. A minority of patients (20.0%) discontinued buprenorphine-XR. Although more extensive research is needed before widespread use, buprenorphine-XR may be a favorable treatment for OUD in this high-risk population.
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Affiliation(s)
- Bridget M Galati
- Department of Psychiatry and the Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, and the Department of Pharmacy, Barnes Jewish Hospital, St. Louis, Missouri
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Ou H, Chen CY. Naltrexone May Attenuate the Effect of Acamprosate in Patients With Alcohol Use Disorder and Major Depressive Disorder. Am J Ther 2023; 30:e579-e580. [PMID: 35551131 DOI: 10.1097/mjt.0000000000001517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Hsun Ou
- Department of Psychiatry, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan, ROC
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Mezaache S, Turlure F, Fredon N, Le Brun Gadelius M, Micallef J, Frauger E. [Opioid overdose prevention and naloxone diffusion (POP program): Results of an overview conducted among addiction specialized centres]. Therapie 2023; 78:605-614. [PMID: 37012152 DOI: 10.1016/j.therap.2023.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/20/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023]
Abstract
INTRODUCTION In France, opioids are responsible for the majority of overdose deaths in France. The antidote naloxone is available in France in take home formulations since 2016. Addiction specialized centres are in front-line for naloxone diffusion. The objective was to provide an overview of professional practices, difficulties and needs regarding overdose prevention and naloxone diffusion in these centres of the Provence-Alpes-Côte d'Azur (PACA) region. METHODS The POP programme "Prevention and harm reduction of opioid overdoses in PACA region" aims to improve the care of patients at risk of overdose and facilitate naloxone diffusion. The 75 addiction specialized centres of the PACA region were invited to respond to a semi-structured interview or a telephone questionnaire. Data collected included 2020 centres' activity and professionals' perceptions of overdose risk in their active file, their practices, difficulties and needs. RESULTS Overall, 33 centres answered. Among them, 22 were dispensing naloxone with a mean of 20 kits dispensed in 2020 (min-max: 1-100). Two strategies were pointed out: systematically offering of naloxone to all opioids users or targeting people considered at risk. Several difficulties limiting naloxone diffusion were expressed: a lack of knowledge from opioids users, refusal from people not feeling concerned or refusing the injectable formulation, a lack of training of some professionals to be comfortable with the tool or reglementary or time constraints. CONCLUSION Naloxone diffusion is incrementally getting into common practices. However barriers are persisting. On the basis of expressed difficulties and needs, information and training materials were co-designed and diffused.
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Affiliation(s)
- Salim Mezaache
- Centre d'évaluation et d'information sur la pharmacodépendance-addictovigilance (CEIP-A) PACA Corse, service de pharmacologie clinique et pharmacovigilance, AP-HM-Timone, AMU, INS, Inserm UMR1106, 13000 Marseille, France.
| | - Franck Turlure
- Centre d'évaluation et d'information sur la pharmacodépendance-addictovigilance (CEIP-A) PACA Corse, service de pharmacologie clinique et pharmacovigilance, AP-HM-Timone, AMU, INS, Inserm UMR1106, 13000 Marseille, France
| | - Nathalie Fredon
- Centre d'évaluation et d'information sur la pharmacodépendance-addictovigilance (CEIP-A) PACA Corse, service de pharmacologie clinique et pharmacovigilance, AP-HM-Timone, AMU, INS, Inserm UMR1106, 13000 Marseille, France
| | | | - Joëlle Micallef
- Centre d'évaluation et d'information sur la pharmacodépendance-addictovigilance (CEIP-A) PACA Corse, service de pharmacologie clinique et pharmacovigilance, AP-HM-Timone, AMU, INS, Inserm UMR1106, 13000 Marseille, France
| | - Elisabeth Frauger
- Centre d'évaluation et d'information sur la pharmacodépendance-addictovigilance (CEIP-A) PACA Corse, service de pharmacologie clinique et pharmacovigilance, AP-HM-Timone, AMU, INS, Inserm UMR1106, 13000 Marseille, France
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Hernandez SE, Gilson AM, Gassman M, Ford JH. Piloting an opioid callback program in community pharmacies. J Am Pharm Assoc (2003) 2023; 63:1796-1802. [PMID: 37574197 DOI: 10.1016/j.japh.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Although opioid prescribing has recently trended downward, opioid-related overdoses and deaths have drastically increased. Community pharmacists are accessible health care providers who are well positioned to disseminate information on opioid safety and to educate and counsel on medication use, managing adverse events, and proper medication disposal. Patient callbacks facilitate appropriate medication usage. We developed an opioid callback program that provides a framework for pharmacists to follow up with patients with an opioid prescription. OBJECTIVES This study aimed to (1) describe the development of the opioid callback initiative and (2) report results from a pilot test in 2 community pharmacies. METHODS The opioid callback process and data collection forms were collaboratively developed with community pharmacists at each site. Data recorded on the opioid callback forms were descriptively analyzed and chi-square test of independence explored differences by pain durations related to opioid disposal, security, and safety. Participating pharmacy staff were interviewed to identify facilitators and barriers to implementation, as well as opportunities for improvement. RESULTS Forty-one opioid callbacks were attempted and 36 were completed (87.8%). Pharmacists were statistically significantly more likely to discuss naloxone with patients with chronic pain (89.5%) than those with acute pain (46.2%). Pharmacists reported that the program successfully raised awareness of opioid disposal opportunities and safe opioid practices, including storage and naloxone ownership. They expressed patients' willingness to answer questions and appreciation for the extra attention and care. CONCLUSION Community pharmacists are well positioned to address the opioid crisis as access points for medication questions, opioid safety education, opioid disposal, naloxone, and medications for people with an opioid use disorder. This study presents a proof of concept for a pharmacist-led opioid callback program. Expansion could help inform patients about how to use opioids safely, how to treat an opioid overdose, and where to dispose of unused medications.
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Suen LW, Wenger LD, Morris T, Majano V, Davidson PJ, Browne EN, Ray B, Megerian CE, Lambdin BH, Kral AH. Evaluating oxygen monitoring and administration during overdose responses at a sanctioned overdose prevention site in San Francisco, California: A mixed-methods study. Int J Drug Policy 2023; 121:104165. [PMID: 37652815 DOI: 10.1016/j.drugpo.2023.104165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Overdose prevention sites (OPSs) are spaces where individuals can use pre-obtained drugs and trained staff can immediately intervene in the event of an overdose. While some OPSs use a combination of naloxone and oxygen to reverse overdoses, little is known about oxygen as a complementary tool to naloxone in OPS settings. We conducted a mixed methods study to assess the role of oxygen provision at a locally sanctioned OPS in San Francisco, California. METHODS We used descriptive statistics to quantify number and type of overdose interventions delivered in 46 weeks of OPS operation in 2022. We used qualitative data from OPS staff interviews to evaluate experiences using oxygen during overdose responses. Interviews were coded and thematically analyzed to identify themes related to oxygen impact on overdose response. RESULTS OPS staff were successful in reversing 100% of overdoses (n = 333) during 46 weeks of operation. Oxygen became available 18 weeks after opening. After oxygen became available (n = 248 overdose incidents), nearly all involved oxygen (91.5%), with more than half involving both oxygen and naloxone (59.3%). Overdoses involving naloxone decreased from 98% to 66%, though average number of overdoses concomitantly increased from 5 to 9 per week. Interviews revealed that oxygen improved overdose response experiences for OPS participants and staff. OPS EMTs were leaders of delivering and refining the overdose response protocol and trained other staff. Challenges included strained relationships with city emergency response systems due to protocol requiring 911 calls after all naloxone administrations, inconsistent supplies, and lack of sufficient staffing causing people to work long shifts. CONCLUSIONS Although the OPS operated temporarily, it offered important insights. Ensuring consistent oxygen supplies, staffing, and removing 911 call requirements after every naloxone administration could improve resource management. These recommendations may enable success for future OPS in San Francisco and elsewhere.
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Affiliation(s)
- Leslie W Suen
- Division of General Internal Medicine at San Francisco General Hospital, Department of Medicine, University of California San Francisco, Box 1364, San Francisco, CA, United States.
| | | | | | | | | | | | - Bradley Ray
- RTI International, Berkeley, CA, United States
| | | | | | - Alex H Kral
- RTI International, Berkeley, CA, United States
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Stolbach AI, Mazer-Amirshahi ME, Nelson LS, Cole JB. American College of Medical Toxicology and the American Academy of Clinical Toxicology position statement: nalmefene should not replace naloxone as the primary opioid antidote at this time. Clin Toxicol (Phila) 2023; 61:952-955. [PMID: 38039052 DOI: 10.1080/15563650.2023.2283391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/09/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Nalmefene is a potent opioid antagonist that has recently been reintroduced in the United States to treat known or suspected opioid overdose. NALMEFENE CLINICAL TRIAL DATA The injection formulation, which had been withdrawn in 2008, was reintroduced in 2022, and in 2023 the United States Food and Drug Administration approved a new intranasal formulation of nalmefene. Because nalmefene had been previously approved for use in 1995 via injection, the new intranasal formulation did not require new clinical data as it was approved under an Abbreviated New Drug Application. Inherent to this abbreviated approval process, intranasal nalmefene was not studied in patients currently suffering opioid overdose. NALOXONE AND NALMEFENE Nalmefene also has unique characteristics compared with naloxone, the current standard opioid antidote. Nalmefene has a higher affinity for opioid receptors and a longer duration of action than naloxone. Comparative effectiveness data regarding naloxone and nalmefene are sparse, and it is unclear if the inherent properties of nalmefene are beneficial in opioid overdose. We have decades of experience using naloxone safely and effectively as the primary opioid antidote, even in cases of fentanyl and fentanyl analog overdoses. There is, however, evidence to suggest nalmefene may result in more prolonged and severe opioid withdrawal than naloxone, which could be harmful to patients. POSITION As nalmefene is untested in the current clinical environment of synthetic opioid overdoses and has the potential to cause harm via prolonged withdrawal, it is the opinion of the American College of Medical Toxicology and the American Academy of Clinical Toxicology that nalmefene should not replace naloxone as the primary opioid antidote at this time. RECOMMENDATIONS We recommend additional clinical studies of nalmefene, administered via all approved routes, be conducted in a comparative fashion with naloxone, and that safety and effectiveness outcomes be evaluated before nalmefene is recommended as a primary opioid antidote.
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Affiliation(s)
| | | | | | - Jon B Cole
- Minnesota Poison Control System, Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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Orme S, Zarkin GA, Dunlap LJ, Monico LB, Gryczynski J, Fishman MJ, Schwartz RP, O'Grady KE, Mitchell SG. Health care use and cost of treatment for adolescents and young adults with opioid use disorder. J Subst Use Addict Treat 2023; 154:209137. [PMID: 37558183 PMCID: PMC10687977 DOI: 10.1016/j.josat.2023.209137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 06/09/2023] [Accepted: 07/18/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Few studies have examined the cost of medication for opioid use disorder (MOUD) with counseling for the adolescent and young adult population. This study calculated the health care utilization and cost of MOUD treatment, other substance use disorder treatment, and general health care for adolescents and young adults receiving treatment for opioid use disorder. METHODS The study randomized youth ages 15 to 21 (N = 288) equally into the two study conditions: extended-release naltrexone (XR-NTX) or treatment as usual (TAU). While participants committed to treatment based on randomization the study observed considerable nonadherence to both randomized conditions. Instead of using the randomly assigned study conditions, we present descriptive costs by the type of MOUD treatment received: XR-NTX only, buprenorphine only, any other combination of MOUD treatments, and no MOUD. Health care use was aggregated over the 6-month period for each participant, and we calculated average/participant utilization for each treatment group. To determine participant costs, we multiplied the unit costs of health care services obtained from the literature by the reported amount of health care utilization for each participant. We then calculated the mean, standard error, median and IQR for MOUD costs, other substance use disorder treatment costs and general healthcare cost from the health care sector perspective. RESULTS On average, participants in the XR-NTX only group received 2.6 doses of XR-NTX (equivalent to approximately 78 days of treatment). The buprenorphine only group had an average of 97 days of buprenorphine treatment. The XR-NTX only group had higher/patient costs compared to participants in the buprenorphine only group ($10,491 vs. $8765) and higher XR-NTX utilization would further increase costs. Participants in the any other MOUD combination group had the highest total costs ($14,627) while participants in the no MOUD group at the lowest ($3453). DISCUSSION Our cost analysis calculates the real-world cost of MOUD treatment and, while not generalizable, provides policy makers an estimate of costs for adolescents and young adults. We found that participants in the XR-NTX only group received fewer days of medication compared to the buprenorphine only group, but their medication costs were higher due to the cost of XR-NTX injections. While the buprenorphine only group had the highest number of days of medication utilization of all the groups, the average number of days of medication utilization was considerably shorter than the six-month treatment period.
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Affiliation(s)
- Stephen Orme
- RTI International, 3040 Cornwallis Drive, Research Triangle Park, NC, USA.
| | - Gary A Zarkin
- RTI International, 3040 Cornwallis Drive, Research Triangle Park, NC, USA
| | - Laura J Dunlap
- RTI International, 3040 Cornwallis Drive, Research Triangle Park, NC, USA
| | - Laura B Monico
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, USA
| | - Jan Gryczynski
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, USA
| | - Marc J Fishman
- Mountain Manor Treatment Center, 3800 Frederick Avenue, Baltimore 21229, MD, USA
| | - Robert P Schwartz
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, USA
| | - Kevin E O'Grady
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
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Skains RM, Reynolds L, Carlisle N, Heath S, Covington W, Hornbuckle K, Walter L. Impact of Emergency Department-Initiated Buprenorphine on Repeat Emergency Department Utilization. West J Emerg Med 2023; 24:1010-1017. [PMID: 38165181 PMCID: PMC10754187 DOI: 10.5811/westjem.60511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Recent studies have demonstrated the promise of emergency department (ED)-initiated buprenorphine/naloxone (bup/nx) for improving 30-day retention in outpatient addiction care programs for patients with opioid use disorder (OUD). We investigated whether ED-initiated bup/nx for OUD also impacts repeat ED utilization. Methods We performed a retrospective chart review of ED patients discharged with a primary diagnosis of OUD from July 2019-December 2020. Characteristics considered included age, gender, race, insurance status, domicile status, presence of comorbid Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, presenting chief complaint, and provision of a bup/nx prescription and/or naloxone kit. Primary outcomes included repeat ED visit (opioid or non-opioid related) within 30 days, 90 days, and one year. Statistical analyses included bivariate comparison and Poisson regression. Results Of 169 participants, the majority were male (67.5%), White (82.8%), uninsured (72.2%), and in opioid withdrawal and/or requesting "detox" (75.7%). Ninety-one (53.8%) received ED-initiated bup/nx, which was independent of age, gender, race, insurance status, presence of comorbid DSM-5 diagnosis, or domicile status. Naloxone was more likely to be provided to patients who received bup/nx (97.8% vs 26.9%; P < 0.001), and bup/nx was more likely to be given to patients who presented with opioid withdrawal and/or requested "detox" (63.3% vs 36.7%; P < 0.001). Bup/nx provision was associated with decreased ED utilization for opioid-related visits at 30 days (P = 0.04). Homelessness and lack of insurance were associated with increased ED utilization for non-opioid-related visits at 90 days (P = 0.008 and P = 0.005, respectively), and again at one year for homelessness (P < 0.001). When controlling for age and domicile status, the adjusted incidence rate ratio for overall ED visits was 0.56 (95% confidence interval [CI] 0.33-0.96) at 30 days, 0.43 (95% CI 0.27-0.69) at 90 days, and 0.60 (95% CI 0.39-0.92) at one year, favoring bup/nx provision. Conclusion Initiation of bup/nx in the ED setting was associated with decreased subsequent ED utilization. Socioeconomic factors, specifically health insurance and domicile status, significantly impacted non-opioid-related ED reuse. These findings demonstrate the ED's potential as an initiation point for bup/nx and highlight the importance of considering the social risk and social need for OUD patients.
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Affiliation(s)
- Rachel M Skains
- University of Alabama at Birmingham, Heersink School of Medicine, Department of Emergency Medicine, Birmingham, Alabama
- Birmingham VA Medical Center, Department of Emergency Medicine, Birmingham, Alabama
| | - Lindy Reynolds
- University of Alabama at Birmingham, Heersink School of Medicine, Department of Emergency Medicine, Birmingham, Alabama
| | - Nicholas Carlisle
- University of Alabama at Birmingham, School of Public Health, Department of Health Behavior, Birmingham, Alabama
| | - Sonya Heath
- University of Alabama at Birmingham, Heersink School of Medicine, Department of Internal Medicine, Birmingham, Alabama
| | - Whitney Covington
- University of Alabama at Birmingham, Heersink School of Medicine, Department of Emergency Medicine, Birmingham, Alabama
| | - Kyle Hornbuckle
- University of Alabama at Birmingham, Heersink School of Medicine, Birmingham, Alabama
| | - Lauren Walter
- University of Alabama at Birmingham, Heersink School of Medicine, Department of Emergency Medicine, Birmingham, Alabama
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Seo DC, Satterfield N, Alba-Lopez L, Lee SH, Crabtree C, Cochran N. "That's why we're speaking up today": exploring barriers to overdose fatality prevention in Indianapolis' Black community with semi-structured interviews. Harm Reduct J 2023; 20:159. [PMID: 37891632 PMCID: PMC10612233 DOI: 10.1186/s12954-023-00894-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Opioid overdose deaths are of great concern to public health, with over one million lives lost since 1999. While many efforts have been made to mitigate these, Black communities continue to experience a greater burden of fatalities than their white counterparts. This study aims to explore why by working with Black community members in Indianapolis through semi-structured interviews. METHODS Semi-structured one-on-one in-depth interviews were conducted in spring and summer of 2023 with Black residents (N = 23) of zip codes 46202, 46205, 46208, and 46218 in Indianapolis. Ten interview questions were used to facilitate conversations about opioid overdoses, recovery, fatality prevention tools such as calling 911 and naloxone, law enforcement, and racism. Data were analyzed using grounded theory and thematic analysis. RESULTS Interviews revealed access barriers and intervention opportunities. Racism was present in both. Mental access barriers such as stigma, fear, and mistrust contributed to practical barriers such as knowledge of how to administer naloxone. Racism exacerbated mental barriers by adding the risk of race-based mistreatment to consequences related to association with substance use. Participants discussed the double stigma of substance use and being Black, fear of being searched in law enforcement encounters and what would happen if law enforcement found naloxone on them, and mistrust of law enforcement and institutions that provide medical intervention. Participants had favorable views of interventions that incorporated mutual aid and discussed ideas for future interventions that included this framework. CONCLUSIONS Racism exacerbates Blacks' mental access barriers (i.e., help-seeking barriers), which, in turn, contribute to practical barriers, such as calling 911 and administering naloxone. Information and resources coming from people within marginalized communities tend to be trusted. Leveraging inter-community relationships may increase engagement in opioid overdose fatality prevention. Interventions and resources directed toward addressing opioid overdose fatalities in Black communities should use mutual aid frameworks to increase the utilization of the tools they provide.
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Affiliation(s)
- Dong-Chul Seo
- School of Public Health, Indiana University Bloomington, IN, 1025 E 7th St., Bloomington, IN, 47405, USA.
| | - Naomi Satterfield
- School of Public Health, Indiana University Bloomington, IN, 1025 E 7th St., Bloomington, IN, 47405, USA
| | - Leonardo Alba-Lopez
- School of Education, Indiana University Bloomington, IN, 201 N Rose Ave., Bloomington, IN, 47405, USA
| | - Shin Hyung Lee
- School of Public Health, Indiana University Bloomington, IN, 1025 E 7th St., Bloomington, IN, 47405, USA
| | - Charlotte Crabtree
- Overdose Lifeline, Inc., Indianapolis, IN, 1100 W 42Nd St., Suite 385, Indianapolis, IN, 46208, USA
| | - Nicki Cochran
- Overdose Lifeline, Inc., Indianapolis, IN, 1100 W 42Nd St., Suite 385, Indianapolis, IN, 46208, USA
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Laubenthal CE, Escalona R, Welch JE. Rapid Treatment of Anhedonia With Pramipexole as Adjunct to Buprenorphine in Opioid Use Disorder. Prim Care Companion CNS Disord 2023; 25:22cr03535. [PMID: 37923547 DOI: 10.4088/pcc.22cr03535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Affiliation(s)
- Clare E Laubenthal
- New Mexico VA Health Care System, Albuquerque, New Mexico
- Corresponding Author: Clare E. Laubenthal, PA-C, Department of Psychiatry, Mayo Clinic Health System, 1025 Marsh St, Mankato, MN 56001-4752
| | - Rodrigo Escalona
- New Mexico VA Health Care System, Albuquerque, New Mexico
- University of New Mexico School of Medicine, Department of Psychiatry and Behavioral Sciences, Albuquerque, New Mexico (Escalona)
| | - Jaclyn E Welch
- New Mexico VA Health Care System, Albuquerque, New Mexico
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Escamilla I, Juan N, Peñalva C, Sánchez-Llorens M, Renau J, Benito A, Haro G. Treatment of dissociative symptoms with opioid antagonists: a systematic review. Eur J Psychotraumatol 2023; 14:2265184. [PMID: 37860852 PMCID: PMC10591526 DOI: 10.1080/20008066.2023.2265184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 08/10/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND The clinical guidelines for the treatment of dissociation focus primarily on psychotherapy. However, different psychoactive drugs are used in clinical practice. The use of opioid antagonists has been proposed as a therapeutic option based on the theory that dissociation might be a phenomenon mediated by dysregulation of the endogenous opioid system. OBJECTIVE To review and meta-analyse the available evidence on the efficacy of the opioid antagonists naltrexone, naloxone, and nalmefene as treatments for dissociative symptoms and disorders. METHOD The PRISMA guidelines were followed, and this review was registered in Prospero with reference number CRD42021280976. The search was performed in the PubMed, Scopus, Web of Science, EMBASE, PsycINFO, and PubPsych databases. RESULTS 1,798 citations were obtained. After removing duplicates and applying inclusion and exclusion criteria, we included 5 comparative studies with 9 dissociation measures that had included a total of 154 participants, of whom 134 had been treated with an opioid antagonist. The results of the meta-analysis showed a treatment effect for dissociation when using opioid antagonists [pooled d = 1.46 (95% CI: 0.62-2.31)]. However, the studies we included were very heterogeneous [Q = 66.89 (p < .001)] and there may have been publication bias. CONCLUSIONS Although more research is needed and the results must be interpreted with caution because of the limited amount of data and heterogeneity in the studies and their methodological qualities, opioid antagonists (particularly naltrexone) are promising candidates for the treatment of dissociative symptoms and showed a moderate - large effect size in reducing these symptoms.
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Affiliation(s)
- Irene Escamilla
- TXP Research Group. Department of Medicine and Surgery, Universidad Cardenal Herrera-CEU, CEU Universities, Castellón de la Plana, Spain
- Consorcio Hospitalario Provincial Castellón, Castellón de la Plana, Spain
| | - Nerea Juan
- TXP Research Group. Department of Medicine and Surgery, Universidad Cardenal Herrera-CEU, CEU Universities, Castellón de la Plana, Spain
- Consorcio Hospitalario Provincial Castellón, Castellón de la Plana, Spain
| | - Celeste Peñalva
- TXP Research Group. Department of Medicine and Surgery, Universidad Cardenal Herrera-CEU, CEU Universities, Castellón de la Plana, Spain
- Consorcio Hospitalario Provincial Castellón, Castellón de la Plana, Spain
| | | | - Jorge Renau
- TXP Research Group. Department of Medicine and Surgery, Universidad Cardenal Herrera-CEU, CEU Universities, Castellón de la Plana, Spain
- Consorcio Hospitalario Provincial Castellón, Castellón de la Plana, Spain
| | - Ana Benito
- TXP Research Group. Department of Medicine and Surgery, Universidad Cardenal Herrera-CEU, CEU Universities, Castellón de la Plana, Spain
- Torrent Mental Health Unit, Hospital General Universitario Valencia, Valencia, Spain
| | - Gonzalo Haro
- TXP Research Group. Department of Medicine and Surgery, Universidad Cardenal Herrera-CEU, CEU Universities, Castellón de la Plana, Spain
- Dual Disorder Program, Consorcio Hospitalario Provincial Castellón, Castellón de la Plana, Spain
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Sugarman OK, Hulsey EG, Heller D. Achieving the Potential of Naloxone Saturation by Measuring Distribution. JAMA Health Forum 2023; 4:e233338. [PMID: 37889482 DOI: 10.1001/jamahealthforum.2023.3338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
This Viewpoint advocates for improved strategies to measure naloxone distribution and evaluate how effectively naloxone reaches people most likely to experience or witness an opioid overdose.
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Affiliation(s)
- Olivia K Sugarman
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Sze J, Chan T, Dalpoas S, Kiruthi C, Harris CM, Gundareddy V, Parker MS, Jacob E. Implementation of a Pharmacist-Led, Multidisciplinary Naloxone Patient Education Program at an Academic Medical Center. J Pharm Pract 2023; 36:1201-1210. [PMID: 35484711 DOI: 10.1177/08971900221094268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Opioid related overdoses are a leading cause of death in the United States (U.S). National, state and local initiatives have been implemented to combat the opioid crisis. However, there is a paucity of initiatives that examine the role of comprehensive naloxone education interventions for hospitalized patients. Objective: The aim of this study was to design a multidisciplinary, pharmacist-driven, standardized, patient and product tailored, inpatient naloxone education program (NEP) at a U.S. academic medical center, targeting patients at high risk of opioid overdose, and to examine patients' retention of education. Methods: This prospective pilot study targeted hospitalized patients who were considered at high-risk for opioid overdose once discharged. Using daily screening methods and established inclusion criteria, we evaluated the impact of implementing a patient-tailored NEP. The primary outcome measures were patient knowledge and awareness of naloxone use. A paired t-test analysis was conducted to assess for improvement in patient naloxone awareness and knowledge. Results: Of ninety-five patients screened, forty-four patients met inclusion criteria and nineteen patients completed naloxone education along with pre- and post-assessments. Patients more accurately completed the assessment, indicating enhanced knowledge about naloxone use and administration, following the naloxone education (4.68 ± .13 vs 3.42 ± .31 out of 5 questions, mean ± SEM; P = .0016). Conclusion: This study found a positive impact on patient knowledge of naloxone use and administration following implementation of a robust and comprehensive NEP.
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Affiliation(s)
- Jennifer Sze
- OptumRx, Customer Service, United Health Group, Overland Park, KS, USA
| | - Tsz Chan
- OptumRx, Customer Service, United Health Group, Overland Park, KS, USA
| | - Stacy Dalpoas
- Department of Pharmacy, Novant Health, Winston-Salem, NC
| | - Catherine Kiruthi
- Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Che Matthew Harris
- Department of General Internal Medicine, Division of Hospital Medicine, Johns Hopkins School of Medicine, and Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Venkat Gundareddy
- Department of General Internal Medicine, Division of Hospital Medicine, Johns Hopkins School of Medicine, and Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Marlena S Parker
- Department of Pharmacy, University of Pittsburgh Medical Center, Harrisburg, PA, USA
| | - Elsen Jacob
- College of Pharmacy & Health Sciences, St. John's University, Queens, NY, USA
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Hecht ML, Jayawardene W, Henderson C, Pezalla A, Flood-Grady E, Krieger JL, Frederick A, Parker M, Ables E. Developing the Opioid Rapid Response System™ for Lay Citizen Response to the Opioid Overdose Crisis: a Randomized Controlled Trial. Prev Sci 2023; 24:1386-1397. [PMID: 37737966 DOI: 10.1007/s11121-023-01588-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 09/23/2023]
Abstract
Emergency responders face challenges in arriving timely to administer naloxone in opioid overdoses. Therefore, interest in having lay citizens administer naloxone nasal spray has emerged. These citizens, however, must be recruited and trained, and be in proximity to the overdose. This study aimed to develop the Opioid Rapid Response System (ORRS)tm to meet this need by developing a system to recruit and train citizen responders and evaluate outcomes in a randomized clinical trial. ORRS recruitment messages and training platform were developed iteratively and then outcomes for each were evaluated in a randomized, unblinded two-arm waitlist-controlled trial. ORRS was field tested in 5 Indiana counties, recruiting adult citizen responders (age 18 or older) who did not self-identity as a certified first responder. Participants were recruited using either personal or communal messages and then randomly assigned to online naloxone training and waitlisted-control conditions. Pre- and post-surveys were administered online to measure the exposure to recruitment messages and training effects on knowledge of opioid overdose, confidence responding, concerns about responding, and intent to respond. Of the 220 randomized participants (114 training, 106 waitlisted-control), 140 were analyzed (59 training, 81 waitlisted-control). Recruited participants more frequently identified with communal appeal than with the personal appeal (chi-square = 53.5; p < 0.0001). Between-group differences for intervention effects were significant for knowledge of overdose signs (Cohen's d = 1.17), knowledge of overdose management (d = 1.72), self-efficacy (d = 1.39), and concerns (d = 1.31), but not for intent (d = 0.17), which suffered from a ceiling effect. ORRS provides stronger support for efficacy than that reported for other training interventions and the digital modality eases rapid dissemination.Trial Registration: NCT04589676.
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Affiliation(s)
| | - Wasantha Jayawardene
- School of Human Sciences, Southern Illinois University Carbondale, Carbondale, IL, USA.
| | - Cris Henderson
- Prevention Insights, School of Public Health, Indiana University Bloomington, Bloomington, IN, USA
| | | | - Elizabeth Flood-Grady
- STEM Translational Communication Center, University of Florida, Gainesville, FL, USA
| | - Janice L Krieger
- STEM Translational Communication Center, University of Florida, Gainesville, FL, USA
| | - Amy Frederick
- Prevention Insights, School of Public Health, Indiana University Bloomington, Bloomington, IN, USA
| | - Maria Parker
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University Bloomington, Bloomington, IN, USA
| | - Erin Ables
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University Bloomington, Bloomington, IN, USA
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Chatterjee A, Yan S, Lambert A, Morgan JR, Green TC, Jeng PJ, Jalali A, Xuan Z, Krieger M, Marshall BDL, Walley AY, Murphy SM. Comparison of a national commercial pharmacy naloxone data source to state and city pharmacy naloxone data sources-Rhode Island, Massachusetts, and New York City, 2013-2019. Health Serv Res 2023; 58:1141-1150. [PMID: 37408299 PMCID: PMC10480090 DOI: 10.1111/1475-6773.14200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVE Accurate naloxone distribution data are critical for planning and prevention purposes, yet sources of naloxone dispensing data vary by location, and completeness of local datasets is unknown. We sought to compare available datasets in Massachusetts, Rhode Island, and New York City (NYC) to a commercially available pharmacy national claims dataset (Symphony Health Solutions). DATA SOURCES AND STUDY SETTING We utilized retail pharmacy naloxone dispensing data from NYC (2018-2019), Rhode Island (2013-2019), and Massachusetts (2014-2018), and pharmaceutical claims data from Symphony Health Solutions (2013-2019). STUDY DESIGN We conducted a descriptive, retrospective, and secondary analysis comparing naloxone dispensing events (NDEs) captured via Symphony to NDEs captured by local datasets from the three jurisdictions between 2013 and 2019, when data were available from both sources, using descriptive statistics, regressions, and heat maps. DATA COLLECTION/EXTRACTION METHODS We defined an NDE as a dispensing event documented by the pharmacy and assumed that each dispensing event represented one naloxone kit (i.e., two doses). We extracted NDEs from local datasets and the Symphony claims dataset. The unit of analysis was the ZIP Code annual quarter. PRINCIPAL FINDINGS NDEs captured by Symphony exceeded those in local datasets for each time period and location, except in RI following legislation requiring NDEs to be reported to the PDMP. In regression analysis, absolute differences in NDEs between datasets increased substantially over time, except in RI before the PDMP. Heat maps of NDEs by ZIP code quarter showed important variations reflecting where pharmacies may not be reporting NDEs to Symphony or local datasets. CONCLUSIONS Policymakers must be able to monitor the quantity and location of NDEs in order to combat the opioid crisis. In regions where NDEs are not required to be reported to PDMPs, proprietary pharmaceutical claims datasets may be useful alternatives, with a need for local expertise to assess dataset-specific variability.
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Affiliation(s)
- Avik Chatterjee
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal MedicineBoston Medical Center/Boston University School of MedicineBostonMassachusettsUSA
| | - Shapei Yan
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal MedicineBoston Medical Center/Boston University School of MedicineBostonMassachusettsUSA
| | - Audrey Lambert
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal MedicineBoston Medical Center/Boston University School of MedicineBostonMassachusettsUSA
| | - Jake R. Morgan
- Boston University School of Public HealthBostonMassachusettsUSA
| | - Traci C. Green
- The Heller School for Social Policy and ManagementBrandeis UniversityWalthamMassachusettsUSA
| | - Philip J. Jeng
- Department of Population Health SciencesWeill Cornell Medical CollegeNew York CityNew YorkUSA
| | - Ali Jalali
- Department of Population Health SciencesWeill Cornell Medical CollegeNew York CityNew YorkUSA
| | - Ziming Xuan
- Boston University School of Public HealthBostonMassachusettsUSA
| | - Maxwell Krieger
- Department of EpidemiologyBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Brandon D. L. Marshall
- Department of EpidemiologyBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Alexander Y. Walley
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal MedicineBoston Medical Center/Boston University School of MedicineBostonMassachusettsUSA
| | - Sean M. Murphy
- Department of Population Health SciencesWeill Cornell Medical CollegeNew York CityNew YorkUSA
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Harris D, Kalir D, Chevalier C, Dobbie K, Fielding F, Lagman R, Makhoul A, McInnes S, Najafi S, Neale K, Rybicki L, Robbins-Ong M, Neuendorf K. Response Rates to Methylnaltrexone in Hospitalized Cancer Patients. Am J Hosp Palliat Care 2023; 40:1093-1097. [PMID: 36565253 DOI: 10.1177/10499091221147903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Context: Methylnaltrexone is a peripherally-acting mu-opioid receptor antagonist studied in both cancer and non-cancer patients with opioid-induced constipation (OIC), but mostly in the outpatient setting. For adult hospitalized cancer patients with OIC, its effectiveness is unknown. Objectives: Describe the efficacy of methylnaltrexone for OIC in the inpatient setting, defined as bowel movement (BM) within 24 hours of methylnaltrexone administration. Methods: We performed a single-center, retrospective chart review of all hospitalized, adult patients with a cancer diagnosis who received methylnaltrexone from the palliative care team between January 1st, 2012 and July 1st, 2019. Results: We identified 194 patients. The mean age was 59, 50.5% were male and 88% were white. 192 patients (98%) received the 8 mg dose subcutaneously. The median oral morphine equivalent (OME) was 135 mg (IQR 70-354 mg). 45% (95% confidence interval, 38-53%) had a BM within 24 hours. Higher OME was correlated with successful BM, with a response in 93% (86/92) of patients receiving ≥150 OME and 2% (2/102) of patients receiving <150 OME (P < .0001). Prior laxative use did not predict response at 24 hours whether these were osmotic laxatives (40.7% vs 47.1%, P = .52), stimulant laxatives (45.7% vs 45.2%, P > .99), or stool softeners (44.7% vs 46.1%, P = .89). Conclusion: Methylnaltrexone has a high response rate when used as treatment for OIC in hospitalized adult cancer patients, especially for patients taking ≥150 OME.
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Affiliation(s)
- David Harris
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Kalir
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cory Chevalier
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Krista Dobbie
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Flannery Fielding
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ruth Lagman
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahed Makhoul
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Susan McInnes
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sina Najafi
- Department of Supportive and Palliative Care, Baylor Scott and White Health, Dallas, TX, USA
| | - Kyle Neale
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lisa Rybicki
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Melanie Robbins-Ong
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kathleen Neuendorf
- Department of Palliative and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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Sato R, Ishida M, Uchida N, Sakimoto T, Yamaguchi T, Ooya Y, Takahashi T, Onishi H. Naldemedine-induced opioid withdrawal with restlessness as the predominant symptom in a palliative care setting. Palliat Support Care 2023; 21:957-959. [PMID: 37350233 DOI: 10.1017/s1478951523000858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
OBJECTIVES Opioid analgesics play a central role in cancer pain treatment; however, it has been reported that opioid-induced constipation (OIC) develops in 80% of patients using opioid analgesics and leads to a decrease in quality of life. Naldemedine improves constipation without affecting the analgesic action of opioid analgesics via peripheral μ-opioid receptors. METHODS We report a terminally ill cancer patient who was diagnosed with opioid withdrawal syndrome (OWS) based on symptoms centered around restlessness and sweating that developed 43 days after administration of naldemedine for OIC. RESULTS The patient was a 78-year-old woman who was diagnosed with stage IVB uterine sarcoma in October, 1 year prior to her visit to our clinic, and underwent chemotherapy after surgery, but the disease became progressive. Thereafter, metastasis to the fourth thoracic vertebrae (Th4) was identified, and loxoprofen and acetaminophen were started for pain at the metastatic site. Oxycodone hydrochloride hydrate 10 mg/day was additionally administered on postoperative day 11, followed by naldemedine 0.2 mg/day for OIC. On the 43rd day after administration, the patient began to wander the hospital ward in a wheelchair and became noticeably restless. OWS due to naldemedine administration was suspected, and naldemedine was discontinued. The symptoms improved 7 days later, and no similar symptoms were observed thereafter. SIGNIFICANCE OF RESULTS Patients receiving palliative care often exhibit psychiatric symptoms such as anxiety and depression, but OWS due to naldemedine should also be considered as a potential cause.
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Affiliation(s)
- Ryota Sato
- Department of Pharmacy, Maruki Memorial Medical and Social Welfare Center, Saitama, Japan
| | - Mayumi Ishida
- Department of Psycho-oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Nozomu Uchida
- Department of Supportive Oncology and Palliative Medicine, Saitama Medical University International Medical Center, Saitama, Japan
- Department of General Medicine, Ogano Town Central Hospital, Saitama, Japan
| | - Takehiko Sakimoto
- Department of Palliative Medicine, Asahi General Hospital, Chiba, Japan
| | - Takefumi Yamaguchi
- Department of Palliative Care, Maruki Memorial Medical and Social Welfare Center, Saitama, Japan
| | - Yoshitaka Ooya
- Department of Trauma and Emergency Acute Medicine, Saitama Medical University International Medical Center, Saitama, Japan
| | - Takao Takahashi
- Department of Supportive Oncology and Palliative Medicine, Saitama Medical University International Medical Center, Saitama, Japan
| | - Hideki Onishi
- Department of Psycho-oncology, Saitama Medical University International Medical Center, Saitama, Japan
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Duncan K, Scheuermeyer F, Lane D, Ahamad K, Moe J, Dong K, Nolan S, Buxton J, Miles I, Johnson C, Christenson J, Whyte M, Daoust R, Garrod E, Badke K, Kestler A. Patient opinion and acceptance of emergency department buprenorphine/naloxone to-go home initiation packs. CAN J EMERG MED 2023; 25:802-807. [PMID: 37606738 DOI: 10.1007/s43678-023-00568-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 07/26/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVES Many emergency department (ED) patients with opioid use disorder are candidates for home buprenorphine/naloxone initiation with to-go packs. We studied patient opinions and acceptance of buprenorphine/naloxone to-go packs, and factors associated with their acceptance. METHODS We identified patients at two urban EDs in British Columbia who met opioid use disorder criteria, were not presently on opioid agonist therapy and not in active withdrawal. We offered patients buprenorphine/naloxone to-go as standard of care and then administered a survey to record buprenorphine/naloxone to-go acceptance, the primary outcome. Survey domains included current substance use, prior experience with opioid agonist therapy, and buprenorphine/naloxone related opinions. Patient factors were examined for association with buprenorphine/naloxone to-go acceptance. RESULTS Of the 89 patients enrolled, median age was 33 years, 27% were female, 67.4% had previously taken buprenorphine/naloxone, and 19.1% had never taken opioid agonist therapy. Overall, 78.7% believed that EDs should dispense buprenorphine/naloxone to-go packs. Thirty-eight (42.7%) patients accepted buprenorphine/naloxone to-go. Buprenorphine/naloxone to-go acceptance was associated with lack of prior opioid agonist therapy, less than 10 years of opioid use and no injection drug use. Reasons to accept included initiating treatment while in withdrawal; reasons to reject included prior unsatisfactory buprenorphine/naloxone experience and interest in other treatments. CONCLUSION Although less than half of our study population accepted buprenorphine/naloxone to-go when offered, most thought this intervention was beneficial. In isolation, ED buprenorphine/naloxone to-go will not meet the needs of all patients with opioid use disorder. Clinicians and policy makers should consider buprenorphine/naloxone to-go as a low-barrier option for opioid use disorder treatment from the ED when integrated with robust addiction care services.
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Affiliation(s)
- Kevin Duncan
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- St. Paul's Hospital, Vancouver, BC, Canada
- Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Daniel Lane
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Keith Ahamad
- St. Paul's Hospital, Vancouver, BC, Canada
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Jessica Moe
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health, Vancouver, BC, Canada
- Provincial Health Services Authority, Vancouver, BC, Canada
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Kathryn Dong
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Seonaid Nolan
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Jane Buxton
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Isabelle Miles
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- St. Paul's Hospital, Vancouver, BC, Canada
- Division of Addiction Medicine, St Paul's Hospital, Vancouver, BC, Canada
| | - Cheyenne Johnson
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
- Providence Health Care Research Institute, Vancouver, BC, Canada
| | | | - Raoul Daoust
- Emergency Medicine, Hôpital Sacré-Coeur de Montréal, Montreal, QC, Canada
- Département Médecine de Famille et Médecine d'Urgence, Université de Montréal, Montreal, QC, Canada
| | - Emma Garrod
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | | | - Andrew Kestler
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- St. Paul's Hospital, Vancouver, BC, Canada
- Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
- Vancouver Coastal Health, Vancouver, BC, Canada
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
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Mariani JJ, Basaraba C, Pavlicova M, Alschuler DM, Brooks DJ, Mahony AL, Brezing C, Naqvi NH, Levin FR. Open label trial of lofexidine-assisted non-opioid induction onto naltrexone extended-release injection for opioid use disorder. Am J Drug Alcohol Abuse 2023; 49:618-629. [PMID: 37791817 DOI: 10.1080/00952990.2023.2241981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 07/25/2023] [Indexed: 10/05/2023]
Abstract
Background: Opioid use disorder (OUD) continues to be major public health problem in the US and innovative medication strategies are needed. The extended-release injectable formulation of naltrexone (ER-NTX), an opioid receptor antagonist, is an effective treatment for OUD, but the need for an opioid-free period during the induction phase of treatment is a barrier to treatment success, particularly in the outpatient setting. Lofexidine, an alpha-2-adrenergic agonist, is an effective treatment for opioid withdrawal.Objectives: To evaluate the feasibility, safety, and tolerability of lofexidine for facilitating induction onto ER-NTX in the management of OUD.Methods: In an open-label, uncontrolled, 10-week outpatient clinical trial, 20 adults (four women) with OUD were treated with a fixed-flexible dosing strategy (maximum 0.54 mg 4×/daily) of lofexidine for up to 10 days to manage opioid withdrawal prior to receiving ER-NTX. The COVID-19 pandemic resulted in a modification of the study methods after enrolling 10 participants who attended all visits in person. The second group of 10 participants attended most induction period visits remotely.Results: Overall, 10 of the 20 participants (50%) achieved the primary outcome by receiving the first ER-NTX injection. Rates of induction success did not differ by the presence of fentanyl or remote visit attendance, although the small sample size provided limited statistical power. Six out of 20 participants (30%) initiated on lofexidine required dose adjustments. There were no study-related serious adverse events.Conclusions: This study provides preliminary evidence supporting the feasibility of inducting individuals with OUD onto ER-NTX using lofexidine.
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Affiliation(s)
- John J Mariani
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | - Cale Basaraba
- Mental Health Data Science, New York State Psychiatric Institute, New York, NY, USA
| | - Martina Pavlicova
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Daniel M Alschuler
- Mental Health Data Science, New York State Psychiatric Institute, New York, NY, USA
| | - Daniel J Brooks
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York, NY, USA
| | - Amy L Mahony
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York, NY, USA
| | - Christina Brezing
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | - Nasir H Naqvi
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | - Frances R Levin
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
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Ipsarides J. Education Intervention to Increase Naltrexone Use Among Adult Inpatients With Alcohol Use Disorder. J Psychosoc Nurs Ment Health Serv 2023; 61:10-14. [PMID: 37134282 DOI: 10.3928/02793695-20230424-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Alcohol use disorder (AUD) accounts for high rates of global deaths, disability, and health care spending. Naltrexone is an opioid antagonist used to reduce alcohol cravings. Despite demonstrated safety and efficacy, naltrexone is highly underutilized in a variety of health care settings. The current quality improvement (QI) project aimed to increase knowledge and prescribing behaviors of naltrexone. A chart review of a purposive convenience sample was performed to determine the impact of the intervention. Staff participants completed a pre/posttest and a post-module survey. The primary objectives of the QI project were to increase the number of patients with AUD discharged with a prescription for naltrexone by 5% and achieve 50% staff participation in the online module, pre/posttest, and post-module survey. [Journal of Psychosocial Nursing and Mental Health Services, 61(9), 10-14.].
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Malhotra A, Drexler K, Hsu M, Tang YL. Medication treatment for alcohol use disorder in special populations. Am J Addict 2023; 32:433-441. [PMID: 37551638 DOI: 10.1111/ajad.13455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/28/2023] [Accepted: 07/26/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Alcohol use disorder (AUD) is a significant public health concern, with underutilized effective treatments, particularly in special populations. This article summarizes the current evidence and guidelines for treating AUD in special populations. METHODS This article is a literature review that synthesizes the latest research on AUD treatment for special populations. We screened 242 articles and included 57 in our final review. RESULTS There are four food and Drug Administration-approved medications for AUD (MAUD): disulfiram, oral naltrexone, extended-release injectable naltrexone (XR-NTX), and acamprosate. Naltrexone and disulfiram have the potential to cause liver toxicity, and acamprosate should be avoided in patients with severe kidney disease. Psychosocial treatments should be considered first-line for pregnant and nursing patients. Naltrexone is contraindicated in patients on opioids, as it may precipitate acute withdrawal. For patients experiencing homelessness, nonabstinent treatment goals may be more practical, and XR-NTX should be considered to improve adherence. Limited evidence suggests medication can improve AUD treatment outcomes in adolescents and young adults. For patients with poor treatment response despite adequate medication adherence, switching to a different medication and augmentation with psychosocial treatments should be considered. DISCUSSION AND CONCLUSIONS Understanding the unique considerations for special populations with AUD is crucial, and addressing their special needs may improve their treatment outcomes. SCIENTIFIC SIGNIFICANCE Our study significantly contributes to the existing literature by summarizing crucial information for the treatment of AUD in special populations, highlighting distinct challenges, and emphasizing tailored approaches to improve overall health and well-being.
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Affiliation(s)
- Aniket Malhotra
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | - Karen Drexler
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | - Michael Hsu
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
- Substance Abuse Treatment Program, Joseph Maxwell Cleland Atlanta VA Medical Center, Decatur, Georgia, USA
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Kaski SW, Hull I, Roy PJ. A Response to the Feasibility of the IPPAS Protocol for Low-dose Buprenorphine Induction. J Addict Med 2023; 17:625-626. [PMID: 37788626 DOI: 10.1097/adm.0000000000001175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Grande LA, Cundiff D, Greenwald MK, Murray M, Wright TE, Martin SA. Evidence on Buprenorphine Dose Limits: A Review. J Addict Med 2023; 17:509-516. [PMID: 37788601 PMCID: PMC10547105 DOI: 10.1097/adm.0000000000001189] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/03/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES As overdose deaths from fentanyl continue to increase, optimizing use of medications for opioid use disorder has become increasingly important. Buprenorphine is a highly effective medication for reducing the risk of overdose death, but only if a patient remains in treatment. Shared decision making between prescribers and patients is important to establish a dose that meets each patient's treatment needs. However, patients frequently face a dose limit of 16 or 24 mg/d based on dosing guidelines on the Food and Drug Administration's package label. METHODS This review discusses patient-centered goals and clinical criteria for determining dose adequacy, reviews the history of buprenorphine dose regulation in the United States, examines pharmacological and clinical research results with buprenorphine doses up to 32 mg/d, and evaluates whether diversion concerns justify maintaining a low buprenorphine dose limit. RESULTS Pharmacological and clinical research results consistently demonstrate buprenorphine's dose-dependent benefits up to at least 32 mg/d, including reductions in withdrawal symptoms, craving, opioid reward, and illicit use while improving retention in care. Diverted buprenorphine is most often used to treat withdrawal symptoms and reduce illicit opioid use when legal access to it is limited. CONCLUSIONS In light of established research and profound harms from fentanyl, the Food and Drug Administration's current recommendations on target dose and dose limit are outdated and causing harm. An update to the buprenorphine package label with recommended dosing up to 32 mg/d and elimination of the 16 mg/d target dose would improve treatment effectiveness and save lives.
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Hosea K, Mashburn P, Kennelty K, Westrick SC, Look K, Evon D, Carpenter DM. Naloxone analogy and opioid overdose terminology preferences among rural caregivers: Differences by race. J Am Pharm Assoc (2003) 2023; 63:1521-1529.e3. [PMID: 37149142 PMCID: PMC10660692 DOI: 10.1016/j.japh.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/30/2023] [Accepted: 05/01/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Despite national and state policies aimed at increasing naloxone access via pharmacies, opioid overdose death rates rose during the COVID-19 pandemic, particularly among Blacks and American Indians (AIs) in rural areas. Caregivers, or third parties who can administer naloxone during an overdose event, are important individuals in the naloxone administration cascade, yet no studies have explored rural caregivers' opioid overdose terminology and naloxone analogy preferences or whether these preferences differ by race. OBJECTIVES To identify rural caregivers' overdose terminology and naloxone analogy preferences and determine whether preferences differ by race. METHODS A sample of 40 caregivers who lived with someone at high risk of overdose and used pharmacies in 4 largely rural states was recruited. Each caregiver completed a demographic survey and a 20- to 45-minute audio-recorded semi-structured interview that was transcribed, de-identified, and imported into a qualitative software package for thematic analysis by 2 independent coders using a codebook. Overdose terminology and naloxone analogy preferences were analyzed for differences by race. RESULTS The sample was 57.5% white, 35% Black, and 7.5% AIs. Many participants (43%) preferred that pharmacists use the term "bad reaction" to refer to overdose events over the terms "accidental overdose" (37%) and "overdose" (20%). The majority of white and Black participants preferred "bad reaction" while AI participants preferred "accidental overdose." For naloxone analogies, "EpiPen" was most preferred (64%), regardless of race. "Fire extinguisher" (17%), "lifesaver" (9.5%), and other analogies (9.5%) were preferred by some white and Black participants but not AI participants. CONCLUSION Our findings suggest that pharmacists should use the "bad reaction" term and "EpiPen" analogy when counseling rural caregivers about overdose and naloxone, respectively. Caregivers' preferences varied by race, suggesting that pharmacists may want to tailor the terminology and analogy they use when discussing naloxone with caregivers.
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145
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Fleißner S, Stöver H, Schäffer D. [Take-home naloxone: a building block of drug emergency prophylaxis in Germany]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66:1035-1041. [PMID: 37233811 PMCID: PMC10465660 DOI: 10.1007/s00103-023-03705-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/19/2023] [Indexed: 05/27/2023]
Abstract
Naloxone is an opioid antagonist that reverses the (respiratory-paralyzing) effects of opioids in the body within minutes. Naloxone can therefore reduce opioid overdose deaths. Take-home naloxone (THN) is an intervention recommended by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the World Health Organization (WHO). It involves training opioid users and their relatives or friends in the use of naloxone and providing them with the drug in case of emergency.So far, THN has been implemented in Germany mainly by individual addiction support facilities. In order to fully exploit the potential of THN, it is necessary to establish the measure nationwide. In particular, THN can be included in the services offered in (low-threshold) addiction support facilities, in psychiatric facilities, in the context of opioid substitution treatment, and in the correctional system.This discussion article reviews the development of THN in Germany since 1998, highlights the difficulties and obstacles to its widespread implementation, and outlines how THN can succeed as an effective public health intervention in Germany. This is particularly relevant in view of the increasing number of drug-related deaths over the past 10 years.
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Affiliation(s)
- Simon Fleißner
- Institut für Suchtforschung Frankfurt (ISFF), University of Applied Sciences Frankfurt, Nibelungenplatz 1, 60318, Frankfurt am Main, Deutschland.
| | - Heino Stöver
- Institut für Suchtforschung Frankfurt (ISFF), University of Applied Sciences Frankfurt, Nibelungenplatz 1, 60318, Frankfurt am Main, Deutschland
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146
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McCormack RP, Rotrosen J, Gauthier P, D'Onofrio G, Fiellin DA, Marsch LA, Novo P, Liu D, Edelman EJ, Farkas S, Matthews AG, Mulatya C, Salazar D, Wolff J, Knight R, Goodman W, Williams J, Hawk K. Implementing Programs to Initiate Buprenorphine for Opioid Use Disorder Treatment in High-Need, Low-Resource Emergency Departments: A Nonrandomized Controlled Trial. Ann Emerg Med 2023; 82:272-287. [PMID: 37140493 PMCID: PMC10524047 DOI: 10.1016/j.annemergmed.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 05/05/2023]
Abstract
STUDY OBJECTIVE We hypothesized that implementation facilitation would enable us to rapidly and effectively implement emergency department (ED)-initiated buprenorphine programs in rural and urban settings with high-need, limited resources and dissimilar staffing structures. METHODS This multicenter implementation study employed implementation facilitation using a participatory action research approach to develop, introduce, and refine site-specific clinical protocols for ED-initiated buprenorphine and referral in 3 EDs not previously initiating buprenorphine. We assessed feasibility, acceptability, and effectiveness by triangulating mixed-methods formative evaluation data (focus groups/interviews and pre/post surveys involving staff, patients, and stakeholders), patients' medical records, and 30-day outcomes from a purposive sample of 40 buprenorphine-receiving patient-participants who met research eligibility criteria (English-speaking, medically stable, locator information, nonprisoners). We estimated the primary implementation outcome (proportion receiving ED-initiated buprenorphine among candidates) and the main secondary outcome (30-day treatment engagement) using Bayesian methods. RESULTS Within 3 months of initiating the implementation facilitation activities, each site implemented buprenorphine programs. During the 6-month programmatic evaluation, there were 134 ED-buprenorphine candidates among 2,522 encounters involving opioid use. A total of 52 (41.6%) practitioners initiated buprenorphine administration to 112 (85.1%; 95% confidence interval [CI] 79.7% to 90.4%) unique patients. Among 40 enrolled patient-participants, 49.0% (35.6% to 62.5%) were engaged in addiction treatment 30 days later (confirmed); 26 (68.4%) reported attending one or more treatment visits; there was a 4-fold decrease in self-reported overdose events (odds ratio [OR] 4.03; 95% CI 1.27 to 12.75). The ED clinician readiness increased by a median of 5.02 (95% CI: 3.56 to 6.47) from 1.92/10 to 6.95/10 (n(pre)=80, n(post)=83). CONCLUSIONS The implementation facilitation enabled us to effectively implement ED-based buprenorphine programs across heterogeneous ED settings rapidly, which was associated with promising implementation and exploratory patient-level outcomes.
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Affiliation(s)
| | - John Rotrosen
- New York University Grossman School of Medicine, New York, NY
| | | | - Gail D'Onofrio
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; Yale School of Medicine, Department of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
| | - David A Fiellin
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; Yale School of Medicine, Department of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
| | - Lisa A Marsch
- Geisel School of Medicine at Dartmouth College, Hanover, NH
| | - Patricia Novo
- New York University Grossman School of Medicine, New York, NY
| | - David Liu
- National Institute on Drug Abuse, Rockville, MD
| | - E Jennifer Edelman
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; Yale School of Medicine, Department of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
| | - Sarah Farkas
- New York University Grossman School of Medicine, New York, NY
| | | | | | | | | | | | | | | | - Kathryn Hawk
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
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147
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van Lemmen M, Florian J, Li Z, van Velzen M, van Dorp E, Niesters M, Sarton E, Olofsen E, van der Schrier R, Strauss DG, Dahan A. Opioid Overdose: Limitations in Naloxone Reversal of Respiratory Depression and Prevention of Cardiac Arrest. Anesthesiology 2023; 139:342-353. [PMID: 37402248 DOI: 10.1097/aln.0000000000004622] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Opioids are effective analgesics, but they can have harmful adverse effects, such as addiction and potentially fatal respiratory depression. Naloxone is currently the only available treatment for reversing the negative effects of opioids, including respiratory depression. However, the effectiveness of naloxone, particularly after an opioid overdose, varies depending on the pharmacokinetics and the pharmacodynamics of the opioid that was overdosed. Long-acting opioids, and those with a high affinity at the µ-opioid receptor and/or slow receptor dissociation kinetics, are particularly resistant to the effects of naloxone. In this review, the authors examine the pharmacology of naloxone and its safety and limitations in reversing opioid-induced respiratory depression under different circumstances, including its ability to prevent cardiac arrest.
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Affiliation(s)
- Maarten van Lemmen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeffrey Florian
- Division of Applied Regulatory Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Zhihua Li
- Division of Applied Regulatory Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eveline van Dorp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elise Sarton
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - David G Strauss
- Division of Applied Regulatory Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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148
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Bobb R, Malayala SV, Papudesi BN, Potluri D. A Case of Acute Opioid Withdrawal after Liposuction Surgery in a Patient on Extended-release Buprenorphine. J Addict Med 2023; 17:621-623. [PMID: 37788623 DOI: 10.1097/adm.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND The US Food and Drug Administration approved the once-monthly injectable extended-release buprenorphine product to treat moderate-to-severe opioid use disorders. The patient in our case report had a liposuction procedure and immediately started having opioid withdrawal symptoms after the procedure. CASE DESCRIPTION The patient is a 27-year-old African-American woman who injects drugs and has morbid obesity. She enrolled in a medications for addiction treatment program and opted to get treated with extended-release buprenorphine monthly injections. She tolerated them well for a span of 6 months. In one clinic visit, she reported opioid withdrawal symptoms and started purchasing and using sublingual buprenorphine from her acquaintances. On review of history, she underwent liposuction surgery and this triggered the opioid withdrawal symptoms. Examining her abdomen revealed surgical scars at the site of the buprenorphine injection and the residual buprenorphine depot was not palpable.A subcutaneous injection of 300-mg extended release buprenorphine was administered in the right periumbilical area in this clinic visit. The following week, she was doing well and denied any withdrawal symptoms. DISCUSSION This is a unique case of "iatrogenic opioid withdrawal" after a fairly common surgical procedure. The extended-release buprenorphine formulation solidifies when it comes into contact with bodily fluids forming a depot. The depot and surrounding adipose tissue may have been removed during the patient's liposuction procedure, causing an immediate drop in buprenorphine levels leading to acute opioid withdrawal.This case report highlights the precautions that need to be taken before patients go for a surgical procedure like liposuction.
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Affiliation(s)
- Raymond Bobb
- From the Merakey Parkside Recovery, Philadelphia, PA (RB, SVM); Mercy Suburban Hospital, Philadelphia, PA (BNP); Reading Hospital, Reading, PA (DP)
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149
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Cowan E, Perrone J, Bernstein SL, Coupet E, Fiellin DA, Hawk K, Herring A, Huntley K, McCormack R, Venkatesh A, D'Onofrio G. National Institute on Drug Abuse Clinical Trials Network Meeting Report: Advancing Emergency Department Initiation of Buprenorphine for Opioid Use Disorder. Ann Emerg Med 2023; 82:326-335. [PMID: 37178101 PMCID: PMC10524880 DOI: 10.1016/j.annemergmed.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 05/15/2023]
Abstract
Opioid use disorder and opioid overdose deaths are a major public health crisis, yet highly effective evidence-based treatments are available that reduce morbidity and mortality. One such treatment, buprenorphine, can be initiated in the emergency department (ED). Despite evidence of efficacy and effectiveness for ED-initiated buprenorphine, universal uptake remains elusive. On November 15 and 16, 2021, the National Institute on Drug Abuse Clinical Trials Network convened a meeting of partners, experts, and federal officers to identify research priorities and knowledge gaps for ED-initiated buprenorphine. Meeting participants identified research and knowledge gaps in 8 categories, including ED staff and peer-based interventions; out-of-hospital buprenorphine initiation; buprenorphine dosing and formulations; linkage to care; strategies for scaling ED-initiated buprenorphine; the effect of ancillary technology-based interventions; quality measures; and economic considerations. Additional research and implementation strategies are needed to enhance adoption into standard emergency care and improve patient outcomes.
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Affiliation(s)
- Ethan Cowan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - David A Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kathryn Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Andrew Herring
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, University of California, San Francisco, CA
| | | | - Ryan McCormack
- Department of Emergency Medicine, New York University School of Medicine, New York, NY
| | - Arjun Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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150
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Friedmann PD, Jawa R, Wilson D, Ramsey S, Hoskinson R, McKenzie M, Walley AY, Green TC, Bratberg J, Rich JD. Prescribe to Save Lives: An Intervention to Increase Naloxone Prescribing Among HIV Clinicians. J Addict Med 2023; 17:598-603. [PMID: 37788616 PMCID: PMC10593983 DOI: 10.1097/adm.0000000000001190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Overdose is a major cause of preventable death among persons living with HIV. This study aimed to increase HIV clinicians' naloxone prescribing, which can reduce overdose mortality. METHODS We enrolled 22 Ryan White-funded HIV practices and implemented onsite, peer-to-peer training, posttraining academic detailing, and pharmacy peer-to-peer contact around naloxone prescribing in a nonrandomized stepped wedge design. Human immunodeficiency virus clinicians completed surveys to assess attitudes toward prescribing naloxone at preintervention and 6 and 12 months postintervention. Aggregated electronic health record data measured the number of patients with HIV prescribed and the number of HIV clinicians prescribing naloxone by site over the study period. Models controlled for calendar time and clustering of repeated measures among individuals and sites. RESULTS Of 122 clinicians, 119 (98%) completed a baseline survey, 111 (91%) a 6-month survey, and 93 (76%) a 12-month survey. The intervention was associated with increases in self-reported "high likelihood" to prescribe naloxone (odds ratio [OR], 4.1 [1.7-9.4]; P = 0.001). Of 22 sites, 18 (82%) provided usable electronic health record data that demonstrated a postintervention increase in the total number of clinicians who prescribed naloxone (incidence rate ratio, 2.9 [1.1-7.6]; P = 0.03) and no significant effects on sites having at least one clinician who prescribed naloxone (OR, 4.1 [0.7-23.8]; P = 0.11). The overall proportion of all HIV patients prescribed naloxone modestly increased from 0.97% to 1.6% (OR, 2.2 [0.7-6.8]; P = 0.16). CONCLUSION On-site, practice-based, peer-to-peer training with posttraining academic detailing was a modestly effective strategy to increase HIV clinicians' prescribing of naloxone.
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Affiliation(s)
- Peter D. Friedmann
- University of Massachusetts Chan Medical School - Baystate, Springfield, MA
| | - Raagini Jawa
- Center for Research on Healthcare, Section of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Donna Wilson
- University of Massachusetts Chan Medical School - Baystate, Springfield, MA
| | - Susan Ramsey
- The Center for Health and Justice Transformation, The Miriam Hospital, Providence, RI
- The COBRE on Opioids and Overdose at Rhode Island Hospital, Providence, RI
- The Warren Alpert Medical School of Brown University
| | - Randall Hoskinson
- University of Massachusetts Chan Medical School - Baystate, Springfield, MA
| | - Michelle McKenzie
- The Center for Health and Justice Transformation, The Miriam Hospital, Providence, RI
- The COBRE on Opioids and Overdose at Rhode Island Hospital, Providence, RI
| | - Alexander Y. Walley
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA
| | - Traci C Green
- The COBRE on Opioids and Overdose at Rhode Island Hospital, Providence, RI
- Opioid Policy Research Collaborative, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | | | - Josiah D. Rich
- The Center for Health and Justice Transformation, The Miriam Hospital, Providence, RI
- The COBRE on Opioids and Overdose at Rhode Island Hospital, Providence, RI
- The Warren Alpert Medical School of Brown University
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