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Faccio E, Aquili L, Anonymous, Rocelli M. When the non-sharing of therapeutic goals becomes the problem: The story of a consumer and his addiction to methadone. J Psychiatr Ment Health Nurs 2022; 29:174-180. [PMID: 34379854 PMCID: PMC9291105 DOI: 10.1111/jpm.12793] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/10/2021] [Accepted: 06/16/2021] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: It is well known that psychotropic drugs, besides having beneficial effects, may become a source of addiction. Drug therapy involving methadone is traditionally considered an essential medicine in the treatment for heroin dependence since it significantly reduces drug injecting and death rates associated with opioid dependence. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper investigates a paradoxical situation: the use of methadone therapy to maintain a condition of addiction rather than to overcome it. The story is told jointly by the head of a rehab centre and a young man who has developed a methadone addiction and kept it hidden for years from the operators of the addiction centre, who supplied him with the substance. WHAT ARE THE IMPLICATIONS FOR MENTAL-HEALTH NURSING?: The young man's story offers a key example which can be of interest not only for addiction centres but also for all mental-health services that supply drugs as therapy. This study examines what happens when a person taken over by a service pursues goals that are in contrast to the service mission. Specific communication strategies have to be implemented to update and negotiate goals in continuity with the personal live project of the service user. This story is a warning to not rely on consolidated operational practices, ignoring the investigation of personal meanings and aims of those who experience them. ABSTRACT: Introduction Mental health services typically follow standardized intervention protocols and systematic operating practices. Aim/Question This paper explores what happens when a service relies exclusively on fixed practices rather than on the negotiation of objectives and the differentiation of procedures according to the needs of the user. Method The analysis of the narratives produced in first person by Oliver, a former substance user, emphasizes the need of constructing a therapeutic plan in close cooperation, promoting an user active role and strengthening his affiliation in the change process. Results and Discussion In this specific case, the involvement of the user meant the identification of the peculiar meanings he attributed to the "substance of use," which paradoxically coincided with the "therapeutic substance" (methadone). Implications for Practice Oliver's story is an effective mirror for rethinking staff conduct when it assumes that the drug is therapeutic in itself, regardless of the way the person experiences and means it, it also offers a description of the interactive ways in which the relationship between a young person and service staff proved to be effectively therapeutic.
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Affiliation(s)
- Elena Faccio
- Department of Philosophy, Sociology, Education and Applied Psychology, University of Padua, Padua, Italy
| | - Ludovica Aquili
- Department of Philosophy, Sociology, Education and Applied Psychology, University of Padua, Padua, Italy
| | - Anonymous
- Community for Drug Addicts Arcobaleno, Fermo, Italy
| | - Michele Rocelli
- Department of Philosophy, Sociology, Education and Applied Psychology, University of Padua, Padua, Italy
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202
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Stalund IV, Grønseth H, Reinholt FP, Svarstad E, Marti HP, Leh S. Chronic Kidney Disease from Polyvinylpyrrolidone Deposition in Persons with Intravenous Drug Use. Clin J Am Soc Nephrol 2022; 17:518-526. [PMID: 35296512 PMCID: PMC8993479 DOI: 10.2215/cjn.13681021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/17/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Persons with intravenous drug use have a higher risk of developing CKD compared with the general population. In Norway, deposits of polyvinylpyrrolidone have been observed in kidney biopsies taken from persons with opioid addiction and intravenous drug use since 2009. Polyvinylpyrrolidone is an excipient commonly used in pharmaceuticals, and the polyvinylpyrrolidone deposits observed in these patients were caused by intravenous injection of a specific oral methadone syrup containing very high molecular weight polyvinylpyrrolidone. Here, we present the clinicopathologic findings from 28 patients with CKD associated with polyvinylpyrrolidone deposition in the kidney. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The 28 patients and their kidney biopsies were included when polyvinylpyrrolidone deposition was recognized, either retrospectively or at the time of diagnostic evaluation. Biopsies were taken between 2009 and 2016. We collected laboratory parameters and clinical data from digital patient charts. For each kidney biopsy, the glomerular volume, extent of polyvinylpyrrolidone deposition, and tubulointerstitial area with tubular atrophy were assessed quantitatively. RESULTS All patients (mean age: 37 years) had CKD (mean eGFR: 33 ml/min per 1.73 m2) and normal urine protein or non-nephrotic-range proteinuria. Biopsies showed moderate to severe tubular atrophy (mean extent: 65%) and interstitial infiltrates of vacuolated macrophages containing polyvinylpyrrolidone (mean share of biopsy area: 1.5%). Underperfused and ischemic glomeruli were common findings. In 22 samples, ultrastructural investigation revealed polyvinylpyrrolidone-containing vacuoles in the mesangial or endothelial cells of glomeruli. At the last follow-up, most patients had stable or improved eGFR. Two patients had developed kidney failure and underwent hemodialysis. CONCLUSIONS Intravenous injection of a specific oral methadone syrup caused polyvinylpyrrolidone deposition in the kidney in persons with opioid addiction and intravenous drug use. Kidney biopsy findings suggested an association between polyvinylpyrrolidone deposition and tubular atrophy.
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Affiliation(s)
- Ida V Stalund
- Department of Pathology, Haukeland University Hospital, Bergen, Norway .,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Heidi Grønseth
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Finn P Reinholt
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Einar Svarstad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hans-Peter Marti
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Sabine Leh
- Department of Pathology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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203
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Lintzeris N, Mankabady B, Rojas-Fernandez C, Amick H. Strategies for Transfer From Methadone to Buprenorphine for Treatment of Opioid Use Disorders and Associated Outcomes: A Systematic Review. J Addict Med 2022; 16:143-151. [PMID: 33900228 PMCID: PMC8920020 DOI: 10.1097/adm.0000000000000855] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/06/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To review the currently available evidence on transfer strategies from methadone to sublingual buprenorphine used in clinical trials and observational studies of medication for opioid use disorder treatment, and to consider whether any strategies yield better clinical outcomes than others. METHODS Six medical and public health databases were searched for articles and conference abstracts. The Cochrane Central Register of Controlled Trials and the World Health Organization International Clinical Trials Registry Platform were used to identify unpublished trial results. Records were dually screened, and data were extracted and checked independently. Results were summarized qualitatively and, when possible, analyzed quantitatively. RESULTS Eighteen studies described transfer from methadone to buprenorphine. Transfer protocols were extremely varied. Most studies reported successful rates of transfer, even among studies involving transfer from high methadone doses, although lower pretransfer methadone dose was significantly associated with higher rate of successful transfer. Precipitated withdrawal was not reported frequently. A range of innovative approaches to transfer from methadone to buprenorphine remains untested. CONCLUSIONS Few studies have used designs that enable comparison of different approaches to transfer patients from methadone to buprenorphine. Most international clinical guidelines provide recommendations consistent with the available evidence. However, clinical guidelines should be perceived as providing "guidance" rather than "protocols," and clinicians and patients need to exercise judgment when attempting transfers.
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Affiliation(s)
- Nicholas Lintzeris
- Division Addiction Medicine, University Sydney; and South East Sydney Local Health District, NSW Health, New South Wales, Australia (NL); Indivior Inc., North Chesterfield, VA (BM); Venebio Group, LLC; Novartis Pharma Canada Inc., Cardiovascular, Renal and Metabolic Business Franchise, Dorval, Québec, Canada (CR-F); Venebio Group, LLC, Richmond, VA (HA)
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204
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Grecco GG, Haggerty DL, Reeves KC, Gao Y, Maulucci D, Atwood BK. Prenatal opioid exposure reprograms the behavioural response to future alcohol reward. Addict Biol 2022; 27:e13136. [PMID: 35229956 PMCID: PMC8896285 DOI: 10.1111/adb.13136] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/10/2021] [Accepted: 12/17/2021] [Indexed: 12/20/2022]
Abstract
As the opioid crisis has continued to grow, so has the number of infants exposed to opioids during the prenatal period. A growing concern is that prenatal exposure to opioids may induce persistent neurological changes that increase the propensity for future addictions. Although alcohol represents the most likely addictive substance that the growing population of prenatal opioid exposed will encounter as they mature, no studies to date have examined the effect of prenatal opioid exposure on future sensitivity to alcohol reward. Using a recently developed mouse model of prenatal methadone exposure (PME), we investigated the rewarding properties of alcohol and alcohol consumption in male and female adolescent PME and prenatal saline exposed (PSE) control animals. Conditioned place preference to alcohol was disrupted in PME offspring in a sex-dependent manner with PME males exhibiting resistance to the rewarding properties of alcohol. Repeated injections of alcohol revealed enhanced sensitivity to the locomotor-stimulating effects of alcohol specific to PME females. PME males consumed significantly more alcohol over 4 weeks of alcohol access relative to PSE males and exhibited increased resistance to quinine-adulterated alcohol. Further, a novel machine learning model was developed to employ measured differences in alcohol consumption and drinking microstructure to reliably predict prenatal exposure. These findings indicate that PME alters the sensitivity to alcohol reward in adolescent mice in a sex-specific manner and suggests prenatal opioid exposure may induce persistent effects on reward neurocircuitry that can reprogram offspring behavioural response to alcohol later in life.
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Affiliation(s)
- Gregory G. Grecco
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.,Indiana University School of Medicine, Medical Scientist Training Program, Indianapolis, IN 46202
| | - David L. Haggerty
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Kaitlin C. Reeves
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Yong Gao
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Danielle Maulucci
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Brady K. Atwood
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.,Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.,Corresponding Author: Brady K. Atwood, Ph.D. Department of Pharmacology and Toxicology, Contact: 320 W. 15th St, Indianapolis, IN 46202, NB 400-C. phone: 317-274-8917.
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205
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Jasmine Silva M, Coffee Z, Goza J, Rumrill K. Microinduction to Buprenorphine from Methadone for Chronic Pain: Outpatient Protocol with Case Examples. J Pain Palliat Care Pharmacother 2022; 36:40-48. [PMID: 35290161 DOI: 10.1080/15360288.2022.2049422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The negative sequelae of full mu agonist chronic opioid analgesic therapy (COAT) are numerous and well documented. One safer alternative to COAT use in chronic, non-cancer pain (CNCP) is a transition to buprenorphine. However, transitioning patients from methadone COAT regimens can be challenging due to the pharmacodynamics of buprenorphine, as well as to the limited commercial formulations of buprenorphine available, and their restrictive instructions for use. Presented here are clinical cases transitioned to buprenorphine from methadone via a novel microinduction protocol during enrollment in an outpatient, group, integrative, multidisciplinary program. The protocol was successful to promote satisfactory and sustained COAT cessation for patients with CNCP and is arguably safer than current conventional practices.
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206
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Kelley-Quon LI, Zamora AK, Ourshalimian S, Kim E, Leventhal AM, Kaplan C, Lakshmanan A. Iatrogenic opioid withdrawal in hospitalized infants. J Perinatol 2022; 42:399-400. [PMID: 35169229 DOI: 10.1038/s41372-022-01332-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 12/29/2021] [Accepted: 01/27/2022] [Indexed: 02/08/2023]
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207
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Hill D, Hayes V, Demirkol A, Lintzeris N. Clinical Case Conference: Strategies for Transferring From Methadone to Buprenorphine. J Addict Med 2022; 16:152-156. [PMID: 33870954 PMCID: PMC8919996 DOI: 10.1097/adm.0000000000000854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/01/2021] [Indexed: 11/26/2022]
Abstract
The mainstay of treatment for opioid use disorder are medications, methadone (a full opioid agonist), or buprenorphine (a partial opioid agonist), in conjunction with psychosocial interventions. Both treatments are effective but safety, efficacy, and patient preference can lead to a decision to change from one treatment to the other. Transfer from buprenorphine to methadone is not clinically challenging; however, changing from methadone to buprenorphine is more complex. Published reports describe varied approaches to manage this transfer to both minimize patient symptoms associated with withdrawal from methadone and reduce risk of precipitating withdrawal symptoms with introduction of the partial agonist buprenorphine [Lintzeris et al. J Addict Med. 2020; in press]. There is no single approach for methadone to buprenorphine that is superior to others and no approach that is suitable for all case presentations. This case conference describes three different approaches to achieve a successful methadone to buprenorphine transfer and provides commentary on how the case may be managed based on published transfer "strategies."
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Affiliation(s)
- Duncan Hill
- NHS Lanarkshire, Motherwell, UK (DH); The Langton Centre, South East Sydney Local Health District, NSW Health, Surry Hills, New South Wales, Australia (VH, AD, NL); School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (VH, AD); University Sydney, Division Addiction Medicine, Sydney, Australia (NL)
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208
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DiMeola KA, Haynes J, Barone M, Beitel M, Madden LM, Cutter CJ, Raso A, Gaeta M, Zheng X, Barry DT. A Pilot Investigation of Nonpharmacological Pain Management Intervention Groups in Methadone Maintenance Treatment. J Addict Med 2022; 16:229-234. [PMID: 34145187 PMCID: PMC8678387 DOI: 10.1097/adm.0000000000000877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 01/03/2023]
Abstract
OBJECTIVES We examined the feasibility (i.e., single-session attendance) of conducting 3 counselor-delivered nonpharmacological pain management intervention (NPMI) groups in methadone maintenance treatment (MMT): (1) Coping with Pain, an intervention based on cognitive-behavioral therapy, (2) Wii-Covery, an exergame intervention to facilitate exercise, and (3) Juggling Group, an intervention to promote social inclusion and reduce stress. We examined pre-post session changes in pain and mood associated with group attendance. METHODS Over 1 month at an MMT clinic with 1800 patients, each NPMI group was offered daily Monday-Friday and 1 was offered on Saturdays. A standardized but unvalidated measure was administered before and after sessions to assess acute changes in current pain intensity and mood states. Paired t-tests with Bonferroni corrections were performed for each NPMI group (P < 0.0007 [.05/7]). RESULTS About 452 patients (67% male, 84% White, mean age, 40) attended at least 1 NPMI group. About 57% reported current chronic pain. Attendance at any NPMI group (for the whole sample and the subset with chronic pain) was significantly associated with acute reductions in current pain intensity, anxiety, depression, and stress, and acute increases in current energy and happiness. Attendance at Coping with Pain and Juggling Group was also associated with acute increases in compassion. CONCLUSIONS Coping with Pain, Wii-Covery, and Juggling Group are feasible to conduct in MMT, and acute improvements in current pain intensity and specific mood states associated with a single session attendance point to the importance of examining systematically the efficacy of these and other NPMIs in MMT.
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Affiliation(s)
- Kimberly A DiMeola
- APT Foundation, Inc., New Haven, CT (KAD, JH, MB, MB, LMM, CJC, AR, MG, XZ, DTB), Yale School of Medicine, New Haven, CT (MB, LMM, CJC, AR, MG, DTB), Yale College, New Haven, CT (XZ)
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209
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Grecco GG, Muñoz B, Di Prisco GV, Doud EH, Fritz BM, Maulucci D, Gao Y, Mosley AL, Baucum AJ, Atwood BK. Prenatal Opioid Exposure Impairs Endocannabinoid and Glutamate Transmission in the Dorsal Striatum. eNeuro 2022; 9:ENEURO. [PMID: 35396255 DOI: 10.1523/ENEURO.0119-22.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 03/24/2022] [Indexed: 02/04/2023] Open
Abstract
The opioid crisis has contributed to a growing population of children exposed to opioids during fetal development; however, many of the long-term effects of opioid exposure on development are unknown. We previously demonstrated that opioids have deleterious effects on endocannabinoid plasticity at glutamate synapses in the dorsal striatum of adolescent rodents, but it is unclear whether prenatal opioid exposure produces similar neuroadaptations. Using a mouse model of prenatal methadone exposure (PME), we performed proteomics, phosphoproteomics, and patch-clamp electrophysiology in the dorsolateral striatum (DLS) and dorsomedial striatum (DMS) to examine synaptic functioning in adolescent PME offspring. PME impacted the proteome and phosphoproteome in a region- and sex-dependent manner. Many proteins and phosphorylated proteins associated with glutamate transmission were differentially abundant in PME offspring, which was associated with reduced glutamate release in the DLS and altered the rise time of excitatory events in the DMS. Similarly, the intrinsic excitability properties of DMS neurons were significantly affected by PME. Last, pathway analyses revealed an enrichment in retrograde endocannabinoid signaling in the DLS, but not in the DMS, of males. Electrophysiology studies confirmed that endocannabinoid-mediated synaptic depression was impaired in the DLS, but not DMS, of PME-males. These results indicate that PME induces persistent neuroadaptations in the dorsal striatum and could contribute to the aberrant behavioral development described in offspring with prenatal opioid exposure.
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210
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DeVito EE, Poling J, Babuscio T, Nich C, Carroll KM, Sofuoglu M. Modafinil Does Not Reduce Cocaine Use in Methadone-Maintained Individuals. Drug Alcohol Depend Rep 2022; 2:100032. [PMID: 36310662 PMCID: PMC9615926 DOI: 10.1016/j.dadr.2022.100032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Introduction There are no approved medications for the treatment of cocaine use disorder (CUD). Modafinil, a cognitive-enhancer with weak stimulant-like effects, has shown promise in initial studies as a treatment for CUD. Its potential efficacy has not been examined in individuals dually dependent on cocaine and opioids. Methods This study examined the efficacy of modafinil, in combination with contingency management (CM), for reducing cocaine and opioid use and improving cognitive function in methadone-stabilized individuals with opioid and cocaine dependence. We conducted a 17-week, double-blind, randomized controlled trial in which participants were randomized to one of four conditions: 1) modafinil + CM; 2) modafinil + yoked-control (YC); 3) placebo +CM; or 4) placebo + YC. Additionally, all subjects received platform treatments of cognitive behavioral therapy (CBT) and methadone. While the original planned sample size was N=160, a total of 91 participants were randomized. The two primary cocaine use outcomes were percentage of urine specimens positive for cocaine and percent of days of self-reported abstinence from cocaine during treatment. Cognitive function, opioid use, and secondary cocaine use outcomes were also considered. Results Modafinil was well-tolerated with minimal reports of adverse effects. Modafinil was no more effective than placebo in reducing cocaine or opioid use or improving cognitive performance. Conclusions In the context of a trial with robust control conditions and platform treatments, findings did not provide support for the efficacy of modafinil treatment for the treatment of CUD in methadone-stabilized individuals with dual opioid and cocaine dependence.
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Affiliation(s)
- Elise E. DeVito
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - James Poling
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States,VA Connecticut Healthcare System, West Haven, CT, United States
| | - Theresa Babuscio
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Charla Nich
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Kathleen M. Carroll
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Mehmet Sofuoglu
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States,VA Connecticut Healthcare System, West Haven, CT, United States,Corresponding author at: VA Connecticut Healthcare System, 950 Campbell Ave., Bldg. 36/116A4, West Haven, CT 06516.
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211
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Ozberk D, Haywood A, Sutherland HG, Yu C, Albury CL, Zunk M, George R, Good P, Griffiths LR, Hardy J, Haupt LM. Association of polymorphisms in ARRB2 and clinical response to methadone for pain in advanced cancer. Pharmacogenomics 2022; 23:281-289. [PMID: 35189719 DOI: 10.2217/pgs-2021-0139] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: The prescription of methadone in advanced cancer poses multiple challenges due to the considerable interpatient variation seen in effective dose and toxicity. Previous reports have suggested that ARRB2 influences the response to methadone in opioid substitution therapy. Associations with opioid response for pain management in advanced cancer are conflicting, with no studies including methadone as the primary intervention. Methods: In a prospective, multicenter, open-label dose individualization study, we investigated whether polymorphisms in ARRB2 were associated with methadone dose requirements and pain severity. Results: Significant associations were found for rs3786047, rs1045280, rs2036657 and pain score. Conclusion: While studies are few and the sample size small, ARRB2 genotyping may assist in individualized management of the most feared symptom in advanced cancer.
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Affiliation(s)
- Deniz Ozberk
- School of Pharmacy & Medical Sciences, Griffith University, Gold Coast campus, QLD, 4222, Australia
| | - Alison Haywood
- School of Pharmacy & Medical Sciences, Griffith University, Gold Coast campus, QLD, 4222, Australia.,Mater Research Institute, The University of Queensland, South Brisbane, QLD, 4101, Australia
| | - Heidi G Sutherland
- Centre for Genomics & Personalised Health, Genomics Research Centre, School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, 4001, Australia
| | - Chieh Yu
- Centre for Genomics & Personalised Health, Genomics Research Centre, School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, 4001, Australia.,Department of Cell & Tissue Biology, University of California, San Francisco, CA 94143, USA
| | - Cassie L Albury
- Centre for Genomics & Personalised Health, Genomics Research Centre, School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, 4001, Australia
| | - Mathew Zunk
- School of Pharmacy & Medical Sciences, Griffith University, Gold Coast campus, QLD, 4222, Australia
| | - Rani George
- School of Pharmacy & Medical Sciences, Griffith University, Gold Coast campus, QLD, 4222, Australia.,Cancer Trials Unit, Division of Cancer Services, Metro South Health, Woolloongabba, QLD, 4102, Australia
| | - Phillip Good
- Mater Research Institute, The University of Queensland, South Brisbane, QLD, 4101, Australia.,Department of Palliative Care, St Vincent's Private Hospital, Kangaroo Point, QLD, 4169, Australia.,Department of Palliative & Supportive Care, Mater Health, South Brisbane, QLD, 4101, Australia
| | - Lyn R Griffiths
- Centre for Genomics & Personalised Health, Genomics Research Centre, School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, 4001, Australia
| | - Janet Hardy
- Mater Research Institute, The University of Queensland, South Brisbane, QLD, 4101, Australia.,Department of Palliative & Supportive Care, Mater Health, South Brisbane, QLD, 4101, Australia
| | - Larisa M Haupt
- Centre for Genomics & Personalised Health, Genomics Research Centre, School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, 4001, Australia
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212
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Murnion BP, Demirkol A. Opioid use disorder in anaesthesia and intensive care: Prevention, diagnosis and management. Anaesth Intensive Care 2022; 50:95-107. [PMID: 35189716 DOI: 10.1177/0310057x211066929] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Opioid misuse is common, as is opioid agonist treatment of opioid dependence. Almost 3% of Australians and over 3.5% of those living in New Zealand report misuse of analgesics. Over 50,000 Australians receive opioid agonist treatment with methadone or buprenorphine for management of severe opioid use disorder.The perioperative period is an opportunity to identify pre-existing opioid misuse, and to introduce interventions to reduce the risk of development of opioid use disorder. Challenges of acute perioperative pain management or intensive care management of patients receiving opioid agonist treatment include opioid tolerance and ongoing prescribing of methadone or buprenorphine. There has been some ambiguity about the optimal perioperative management of buprenorphine, a partial agonist at the mu receptor.In this article, a framework to identify emerging opioid misuse problems, identify risk of overdose and to manage the opioid-dependent patient on opioid agonist treatment perioperatively or in the intensive care unit is provided. Diagnostic criteria and risk stratification criteria are presented. Management strategies include trauma-informed care, care planning and care coordination with community practitioners and opioid agonist treatment providers. Continuing methadone or buprenorphine perioperatively with additional opioid and non-opioid analgesia is generally recommended. Increased opioid agonist treatment doses may be required on discharge. An algorithm for decisions about opioid agonist treatment management in the intensive care unit based on the risks of opioid withdrawal and toxicity is considered. Strategies for managing the opioid-dependent patient who is not in treatment are also discussed.
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Affiliation(s)
- Bridin P Murnion
- Drug and Alcohol Services, Western Sydney Local Health District, Sydney, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Apo Demirkol
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
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213
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Vallecillo G, Pedro-Botet J, Fernandez S, Román I, Elosua R, Camps A, Torrens M, Marrugat J. High cardiovascular risk in older patients with opioid use disorder: Differences with the general population. Drug Alcohol Rev 2022; 41:1078-1084. [PMID: 35178806 DOI: 10.1111/dar.13449] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Cardiovascular disease is a health concern in ageing population with opioid use disorders (OUD). The study aims to analyse the cardiovascular risk factors in individuals with OUD. METHODS An observational study was carried out to compare cardiovascular risk factors of adults >50 years with OUD on methadone therapy from public outpatient drug treatment centres, with that of an age- and gender-matched sample (ratio of 1:5) of subjects from a sample of the Spanish population (REGICOR cohort). High cardiovascular risk (HCVR) at 10 years was defined according to Framingham-REGICOR and SCORE risk functions. RESULTS The individuals studied included 94 people with OUD and 495 from the general population; the mean age was 55.7 ± 4.8 years and 432 (72.7%) were men. Obesity (21.2% vs. 35.2%), hypertension (26.3% vs. 42.1%), total cholesterol (30.3% vs. 65.4%) and LDL-cholesterol ≥130 mg/dL (27.2% vs. 59.3%) were significantly more prevalent in the general population group, while tobacco smoking (96.0% vs. 25.9%), low HDL-cholesterol (46.5% vs. 21.2%), hypertriglyceridaemia (39.4% vs. 18.8%) and atherogenic dyslipidaemia (30.3% vs. 10.5%) were significantly higher in individuals with OUD. Differences in abdominal obesity (62.6% vs. 65.3%) were not significant. HCVR was more prevalent in patients with OUD: 15.2% versus 5.8% (Framingham-REGICOR function) and 21.2% versus 11.3% (SCORE function). DISCUSSION AND CONCLUSIONS Older adults with OUD on methadone therapy have a different prevalence of cardiovascular risk factors and HCVR than the general population. Preventive measures, particularly tobacco smoking cessation and weight control, should be included in the routine care of individuals with OUD.
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Affiliation(s)
- Gabriel Vallecillo
- Drug Addiction Program, Instituto de Neuropsiquiatría y Adicciones, Barcelona, Spain.,IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Juan Pedro-Botet
- Lipid and Cardiovascular Risk Unit, Department of Endocrinology, Hospital del Mar, Barcelona, Spain.,Departmento de Medicina, Universidad Autonoma de Barcelona, Barcelona, Spain
| | - Silvia Fernandez
- Registre Gironí del COR (REGICOR) Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Irene Román
- Registre Gironí del COR (REGICOR) Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.,Cardiovascular Epidemiology and Genetics Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Roberto Elosua
- Cardiovascular Epidemiology and Genetics Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.,CIBERCV of Cardiovascular Research, Madrid, Spain
| | - Anna Camps
- Registre Gironí del COR (REGICOR) Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Marta Torrens
- Drug Addiction Program, Instituto de Neuropsiquiatría y Adicciones, Barcelona, Spain.,IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.,Departmento de Medicina, Universidad Autonoma de Barcelona, Barcelona, Spain
| | - Jaume Marrugat
- Registre Gironí del COR (REGICOR) Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.,CIBERCV of Cardiovascular Research, Madrid, Spain
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214
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Song MJ, Westenberg JN, Kianpoor K, Nikoo M, Kazemi A, Schuetz C, Jang K, Gholami A, Akhondzadeh S, Krausz M. Substance of choice, impact of heroin or opium on treatment retention in a multicentre randomised controlled trial in Iran. Drug Alcohol Rev 2022; 41:895-901. [PMID: 35170124 DOI: 10.1111/dar.13445] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/23/2021] [Accepted: 01/13/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In the Middle East and Asia, illicit opioid use exists across a spectrum between heroin and opium. The impact of primary opioid of choice on opioid agonist treatment retention has not been well evaluated previously, especially for opium tincture, an increasingly popular form of opioid agonist treatment in Iran. This study investigates the relationship between primary opioid of choice, namely heroin or opium, and retention in opium tincture and methadone treatment. METHODS Participants with opioid use disorder (n = 204) were randomised to receive opium tincture or methadone. All participants were categorised as mainly using opium or heroin. Bivariate analyses between treatment retention and primary opioid of choice (P < 0.05) and logistic regression were conducted. RESULTS Among the 191 participants included in this analysis, heroin was the primary substance of choice for 135 participants (70.7%) and opium for 56 (29.3%). Bivariate analysis showed that the opium group was more likely to be satisfied with family situation, employed and retained in treatment than the heroin group while less likely to experience incarceration and use multiple substances. When adjusting for covariates, primary opioid of choice was not significantly associated with retention in either methadone or opium tincture treatment arm. DISCUSSION AND CONCLUSIONS Positive factors, such as employment, housing and family support, seem to collectively explain the higher retention in treatment among those who primarily use opium compared to those who use heroin. To optimise retention in opioid agonist treatment, biopsychosocial care models should be further evaluated to improve psychosocial functioning.
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Affiliation(s)
- Michael Jae Song
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | | | - Kiana Kianpoor
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Mohammadali Nikoo
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Alireza Kazemi
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Christian Schuetz
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Kerry Jang
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Ali Gholami
- Kian Methadone Maintenance Treatment Clinic, Private Practice and Mazandaran University of Medical Sciences, Sari, Iran
| | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Michael Krausz
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
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215
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Matos AC, Marques IA, Pires AS, Valentim A, Abrantes AM, Botelho MF. The Potential Effect of Lidocaine, Ropivacaine, Levobupivacaine and Morphine on Breast Cancer Pre-Clinical Models: A Systematic Review. Int J Mol Sci 2022; 23:1894. [PMID: 35163815 DOI: 10.3390/ijms23031894] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/25/2022] [Accepted: 02/05/2022] [Indexed: 12/04/2022] Open
Abstract
Breast cancer (BC) is one of the most common types of cancer and the second leading cause of death in women. Local anaesthetics (LAs) and opioids have been shown to influence cancer progression and metastasis formation in several pre-clinical studies. However, their effects do not seem to promote consensus. A systematic review was conducted using the databases Medline (via PubMed), Scopus, and Web of Science (2010 to December 2021). Search terms included "lidocaine", "ropivacaine", "levobupivacaine", "morphine", "methadone", "breast cancer", "breast carcinoma" and "breast neoplasms" in diverse combinations. The search yielded a total of 784 abstracts for initial review, 23 of which met the inclusion criteria. Here we summarise recent studies on the effect of analgesics and LAs on BC cell lines and animal models and in combination with other treatment regimens. The results suggest that local anaesthetics have anti-tumorigenic properties, hence their clinical application holds therapeutic potential. Regarding morphine, the findings are conflicting, but this opioid appears to be a tumour-promoting agent. Methadone-related results are scarce. Additional research is clearly required to further study the mechanisms underlying the controversial effects of each analgesic or LA to establish the implications upon the outcome and prognosis of BC patients' treatment.
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216
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Zahra E, Chen R, Nielsen S, Tran AD, Santo T, Degenhardt L, Farrell M, Byrne J, Ali R, Larance B. Examining the cost and impact of dosing fees among clients in opioid agonist treatment: Results from a cross-sectional survey of Australian treatment clients. Drug Alcohol Rev 2022; 41:841-850. [PMID: 35130368 PMCID: PMC9398207 DOI: 10.1111/dar.13437] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 12/12/2021] [Accepted: 01/08/2022] [Indexed: 12/26/2022]
Abstract
Introduction Opioid agonist treatment (OAT) clients frequently bear costs associated with their treatment, including dosing fees. This study aimed to explore the financial and social impact of dosing fees upon clients. Methods Cross‐sectional survey of people who use opioids regularly (N = 402) between December 2017 and March 2018, conducted in Australia. Dosing fees were calculated and expressed as percentage of income, by OAT type. Consequences and strategies for difficulties making payments were examined as proportions. Results A total of N = 360 participants had ever been in OAT and N = 245 participants currently engaged in OAT reported data on dosing fees, of them 53% (n = 129) reported paying dosing fees. Compared to clients with high levels of dosing supervision, those with moderate or low levels of supervision were more likely to pay dosing fees. The median 28‐day dosing fee was AUD$110 (interquartile range AUD$80); median 28‐day income was AUD$1520 (interquartile range AUD$700). For those who paid dosing fees, the fee comprised <10% of total monthly income for 70% of participants; however, 23% of participants paid fees comprising 10% to <20%, and 7% of participants paid fees comprising 20% or more of monthly income. Among those that had ever been in OAT, 72% experienced difficulties in paying treatment costs; 36% left treatment earlier than intended and 25% had been excluded due to payment difficulties. Discussion and Conclusions Negative consequences of treatment costs to clients, particularly dosing fees, are evident. These costs impact treatment access and retention that may negatively impact clients' physical health, mental health and social wellbeing.
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Affiliation(s)
- Emma Zahra
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Rory Chen
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Melbourne, Australia
| | - Anh Dam Tran
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Thomas Santo
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Jude Byrne
- Australian Injecting and Illicit Drug Users League, Canberra, Australia
| | - Robert Ali
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.,School of Psychology, University of Wollongong, Wollongong, Australia.,Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, Australia
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217
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Gonzalez AM, Arlandson ME, Patel A, Premkumar A. Does self-reported consumption of heroin correlate with dose of methadone among pregnant people with opioid use disorder? Am J Obstet Gynecol MFM 2022; 4:100587. [PMID: 35123114 DOI: 10.1016/j.ajogmf.2022.100587] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/23/2022] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND The prevalence of opioid use disorder (OUD) during pregnancy is increasing in the United States. However, evidence to guide appropriate dosing of pharmacotherapy for treatment of OUD, such as methadone, based on self-reported opioid use during pregnancy is scant. OBJECTIVE To examine the relationship between self-reported consumption of heroin and methadone dose among pregnant people with opioid use disorder (OUD) admitted to the hospital for methadone (MTD) titration. STUDY DESIGN This is an analysis of a single-site retrospective cohort of pregnant people admitted for management of OUD at an urban, tertiary care center between 2013 and 2020. Patient-reported consumption of heroin was evaluated by clinical staff and described as self-reported dollar amount of heroin consumed per day. The primary outcome was MTD dose at the time of discharge. The secondary outcome was MTD dose at time of delivery. Bivariate and linear regression modeling were performed. A priori covariates included in the model were: epoch of admission, Clinical Opioid Withdrawal Scale score at time of admission, gestational age at admission, and need for readmission due to recurrent opioid use. A sensitivity analysis was performed using propensity score matching. Statistical significance was set at p < 0.05. RESULTS Of 100 people admitted during the study period, 53 and 47 individuals met inclusion criteria for the primary and secondary outcome, respectively. On bivariate and multivariate linear regression modeling, self-reported dollar amount of heroin consumed per day was independently associated with dose of MTD at the time of discharge. For every ten dollars of heroin consumed, the dose of MTD increased by 1.3 mg (95% CI: 0.4 mg to 2.2 mg). On sensitivity analysis with use of a propensity score, self-reported dollar amount of heroin consumed per day was independently associated with dose of MTD at the time of discharge. There was no significant relationship between self-reported dollar amount of heroin consumed per day and MTD dose at time of delivery. CONCLUSIONS Self-reported dollar amount of heroin consumed per day was independently associated with dose of MTD at the time of discharge, but not at time of delivery. These data can be useful in clinical counseling and management of pregnant people with OUD admitted for initiation of MTD.
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Affiliation(s)
- Alba M Gonzalez
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago IL USA
| | - Mary E Arlandson
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago IL USA; Department of Obstetrics and Gynecology, John H. Stroger, Jr. Hospital of Cook County, Chicago IL USA
| | - Ashlesha Patel
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago IL USA; Department of Obstetrics and Gynecology, John H. Stroger, Jr. Hospital of Cook County, Chicago IL USA
| | - Ashish Premkumar
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago IL USA; Department of Obstetrics and Gynecology, John H. Stroger, Jr. Hospital of Cook County, Chicago IL USA; Department of Anthropology, The Graduate School, Northwestern University, Evanston IL USA.
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218
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Pytell JD, Sklar MD, Carrese J, Rastegar DA, Gunn C, Chander G. "I'm a Survivor": Perceptions of Chronic Disease and Survivorship Among Individuals in Long-Term Remission from Opioid Use Disorder. J Gen Intern Med 2022; 37:593-600. [PMID: 34027611 PMCID: PMC8141362 DOI: 10.1007/s11606-021-06925-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/07/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND While opioid use disorder (OUD) is prevalent, little is known about what patients with OUD in sustained remission think about the chronic disease model of OUD and their perspectives of the cause, course, and ongoing treatment needs of their OUD. OBJECTIVE To (1) examine patient perceptions of the chronic disease model of addiction and disease identity and (2) use an explanatory model framework to explore how these perceptions inform ongoing treatment needs and help maintain abstinence. DESIGN Qualitative study of a cross-sectional cohort of patients with OUD in long-term sustained remission currently receiving methadone or buprenorphine. Participants completed a single in-depth, semi-structured individual interview. PARTICIPANTS Twenty adults were recruited from two opioid treatment programs and two office-based opioid treatment programs in Baltimore, MD. Half of the participants were Black, had a median (IQR) age of 46.5 (43-52) years and the median (IQR) time since the last non-prescribed opioid was 12 (8-15) years. APPROACH Hybrid deductive-inductive thematic analysis of the transcribed interviews. KEY RESULTS Some participants described a chronic OUD disease identity where they continue to live with OUD. Participants who maintain an OUD identity describe inherent traits or predetermination of developing OUD. Maintaining a disease identity helps them remain vigilant against returning to drug use. Others described a post-OUD/survivor identity where they no longer felt they had OUD, but the experience remains. Each perspective informed attitudes about continued treatment with methadone or buprenorphine and strategies to remain in remission. CONCLUSIONS The identity that people with OUD in sustained remission maintain was the lens through which they viewed other aspects of their OUD including cause and ongoing treatment needs. An alternative, post-OUD/survivorship model emerged or was accepted by participants who did not identify as currently having OUD. Understanding patient perspectives of OUD identity might improve patient-centered care and improve outcomes.
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Affiliation(s)
- Jarratt D Pytell
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Medicine, Division of Addiction Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Michael D Sklar
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Joseph Carrese
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Darius A Rastegar
- Department of Medicine, Division of Addiction Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Christine Gunn
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Geetanjali Chander
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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219
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Jazdarehee A, Huget-Penner S, Pawlowska M. Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0100. [PMID: 35212265 PMCID: PMC8897593 DOI: 10.1530/edm-21-0100] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/02/2022] [Indexed: 11/11/2022] Open
Abstract
SUMMARY Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting. LEARNING POINTS Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.
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Key Words
- adolescent/young adult
- adult
- geriatric
- neonatal
- paediatric
- pregnant adult
- female
- male
- american indian or alaska native
- asian - bangladeshi
- asian - chinese
- asian - filipino
- asian - indian
- asian - japanese
- asian - korean
- asian - pakistani
- asian - vietnamese
- asian - other
- black - african
- black - caribbean
- black - other
- hispanic or latino - central american or south american
- hispanic or latino - cuban
- hispanic or latino - dominican
- hispanic or latino - mexican, mexican american, chicano
- hispanic or latino - puerto rican
- hispanic or latino - other
- native hawaiian/other pacific islander
- white
- other
- afghanistan
- aland islands
- albania
- algeria
- american samoa
- andorra
- angola
- anguilla
- antarctica
- antigua and barbuda
- argentina
- armenia
- aruba
- australia
- austria
- azerbaijan
- bahamas
- bahrain
- bangladesh
- barbados
- belarus
- belgium
- belize
- benin
- bermuda
- bhutan
- bolivia
- bosnia and herzegovina
- botswana
- bouvet island
- brazil
- british indian ocean territory
- brunei darussalam
- bulgaria
- burkina faso
- burundi
- cambodia
- cameroon
- canada
- cape verde
- cayman islands
- central african republic
- chad
- chile
- china
- christmas island
- cocos (keeling) islands
- colombia
- comoros
- congo
- congo, the democratic republic of the
- cook islands
- costa rica
- côte d'ivoire
- croatia
- cuba
- cyprus
- czech republic
- denmark
- djibouti
- dominica
- dominican republic
- ecuador
- egypt
- el salvador
- equatorial guinea
- eritrea
- estonia
- ethiopia
- falkland islands (malvinas)
- faroe islands
- fiji
- finland
- france
- french guiana
- french polynesia
- french southern territories
- gabon
- gambia
- georgia
- germany
- ghana
- gibraltar
- greece
- greenland
- grenada
- guadeloupe
- guam
- guatemala
- guernsey
- guinea
- guinea-bissau
- guyana
- haiti
- heard island and mcdonald islands
- holy see (vatican city state)
- honduras
- hong kong
- hungary
- iceland
- india
- indonesia
- iran, islamic republic of
- iraq
- ireland
- isle of man
- israel
- italy
- jamaica
- japan
- jersey
- jordan
- kazakhstan
- kenya
- kiribati
- korea, democratic people's republic of
- korea, republic of
- kuwait
- kyrgyzstan
- lao people's democratic republic
- latvia
- lebanon
- lesotho
- liberia
- libyan arab jamahiriya
- liechtenstein
- lithuania
- luxembourg
- macao
- macedonia, the former yugoslav republic of
- madagascar
- malawi
- malaysia
- maldives
- mali
- malta
- marshall islands
- martinique
- mauritania
- mauritius
- mayotte
- mexico
- micronesia, federated states of
- moldova, republic of
- monaco
- mongolia
- montenegro
- montserrat
- morocco
- mozambique
- myanmar
- namibia
- nauru
- nepal
- netherlands
- netherlands antilles
- new caledonia
- new zealand
- nicaragua
- niger
- nigeria
- niue
- norfolk island
- northern mariana islands
- norway
- oman
- pakistan
- palau
- palestinian territory, occupied
- panama
- papua new guinea
- paraguay
- peru
- philippines
- pitcairn
- poland
- portugal
- puerto rico
- qatar
- réunion
- romania
- russian federation
- rwanda
- saint barthélemy
- saint helena
- saint kitts and nevis
- saint lucia
- saint martin
- saint pierre and miquelon
- saint vincent and the grenadines
- samoa
- san marino
- sao tome and principe
- saudi arabia
- senegal
- serbia
- seychelles
- sierra leone
- singapore
- slovakia
- slovenia
- solomon islands
- somalia
- south africa
- south georgia and the south sandwich islands
- spain
- sri lanka
- sudan
- suriname
- svalbard and jan mayen
- swaziland
- sweden
- switzerland
- syrian arab republic
- taiwan, province of china
- tajikistan
- tanzania, united republic of
- thailand
- timor-leste
- togo
- tokelau
- tonga
- trinidad and tobago
- tunisia
- turkey
- turkmenistan
- turks and caicos islands
- tuvalu
- uganda
- ukraine
- united arab emirates
- united kingdom
- united states
- united states minor outlying islands
- uruguay
- uzbekistan
- vanuatu
- vatican city state
- venezuela
- viet nam
- virgin islands, british
- virgin islands, u.s.
- wallis and futuna
- western sahara
- yemen
- zambia
- zimbabwe
- maylaysia
- adipose tissue
- adrenal
- bone
- duodenum
- heart
- hypothalamus
- kidney
- liver
- ovaries
- pancreas
- parathyroid
- pineal
- pituitary
- placenta
- skin
- stomach
- testes
- thymus
- thyroid
- andrology
- autoimmunity
- cardiovascular endocrinology
- developmental endocrinology
- diabetes
- emergency
- endocrine disruptors
- endocrine-related cancer
- epigenetics
- genetics and mutation
- growth factors
- gynaecological endocrinology
- immunology
- infectious diseases
- late effects of cancer therapy
- mineral
- neuroendocrinology
- obesity
- ophthalmology
- paediatric endocrinology
- puberty
- tumours and neoplasia
- vitamin d
- 17ohp
- acth
- adiponectin
- adrenaline
- aldosterone
- amh
- androgens
- androstenedione
- androsterone
- angiotensin
- antidiuretic hormone
- atrial natriuretic hormone
- avp
- beta-endorphin
- big igf2
- brain natriuretic peptide
- calcitonin
- calcitriol
- cck
- corticosterone
- corticotrophin
- cortisol
- cortisone
- crh
- dehydroepiandrostenedione
- deoxycorticosterone
- deoxycortisol
- dhea
- dihydrotestosterone
- dopamine
- endothelin
- enkephalin
- epitestosterone
- epo
- fgf23
- fsh
- gastrin
- gh
- ghrelin
- ghrh
- gip
- glp1
- glp2
- glucagon
- glucocorticoids
- gnrh
- gonadotropins
- hcg
- hepcidin
- histamine
- human placental lactogen
- hydroxypregnenolone
- igf1
- igf2
- inhibin
- insulin
- kisspeptin
- leptin
- lh
- melanocyte-stimulating hormone
- melatonin
- metanephrines
- mineralocorticoids
- motilin
- nandrolone
- neuropeptide y
- noradrenaline
- normetanephrine
- oestetrol (e4)
- oestradiol (e2)
- oestriol (e3)
- oestrogens
- oestrone (e1)
- osteocalcin
- oxyntomodulin
- oxytocin
- pancreatic polypeptide
- peptide yy
- pregnenolone
- procalcitonin
- progesterone
- prolactin
- prostaglandins
- pth
- relaxin
- renin
- resistin
- secretin
- somatostatin
- testosterone
- thpo
- thymosin
- thymulin
- thyroxine (t4)
- trh
- triiodothyronine (t3)
- tsh
- vip
- 17-alpha hydroxylase/17,20 lyase deficiency
- 17-beta-hydroxysteroid dehydrogenase type 3 deficiency
- 3-m syndrome
- 22q11 deletion syndrome
- 49xxxxy syndrome
- abscess
- acanthosis nigricans
- acromegaly
- acute adrenocortical insufficiency
- addisonian crisis
- addison's disease
- adenocarcinoma
- aip gene mutation
- adrenal insufficiency
- adrenal salt-wasting crisis
- adrenarche
- adrenocortical adenoma
- adrenocortical carcinoma
- adrenoleukodystrophy
- aip gene variant
- amenorrhoea (primary)
- amenorrhoea (secondary)
- amyloid goitre
- amyloidosis
- anaplastic thyroid cancer
- anaemia
- aneuploidy
- androgen insensitivity syndrome
- anti-phospholipid antibody syndrome
- asthma
- autoimmune disorders
- autoimmune polyendocrine syndrome 1
- autoimmune polyendocrine syndrome 2
- autoimmune polyglandular syndrome
- autoimmune hypophysitis
- autosomal dominant hypophosphataemic rickets
- autosomal dominant osteopetrosis
- bardet-biedl syndrome
- bartter syndrome
- bilateral adrenal hyperplasia
- biliary calculi
- breast cancer
- brenner tumour
- brown tumour
- burkitt's lymphoma
- casr gene mutation
- catecholamine secreting carotid body paraganglionoma
- cancer-prone syndrome
- carcinoid syndrome
- carcinoid tumour
- carney complex
- carotid body paraganglioma
- c-cell hyperplasia
- cerebrospinal fluid leakage
- chronic fatigue syndrome
- circadian rhythm sleep disorders
- congenital adrenal hyperplasia
- congenital hypothyroidism
- congenital hyperinsulinism
- conn's syndrome
- corticotrophic adenoma
- craniopharyngioma
- cretinism
- crohn's disease
- cryptorchidism
- cushing's disease
- cushing's syndrome
- cystolithiasis
- de quervain's thyroiditis
- denys-drash syndrome
- desynchronosis
- developmental abnormalities
- diabetes - lipoatrophic
- diabetes - mitochondrial
- diabetes - steroid-induced
- diabetes insipidus - dipsogenic
- diabetes insipidus - gestational
- diabetes insipidus - nephrogenic
- diabetes insipidus - neurogenic/central
- diabetes mellitus type 1
- diabetes mellitus type 2
- diabetic foot syndrome
- diabetic hypoglycaemia
- diabetic ketoacidosis
- diabetic muscle infarction
- diabetic nephropathy
- diverticular disease
- donohue syndrome
- down syndrome
- eating disorders
- ectopic acth syndrome
- ectopic cushing's syndrome
- ectopic parathyroid adenoma
- empty sella syndrome
- endometrial cancer
- endometriosis
- eosinophilic myositis
- euthyroid sick syndrome
- familial hypocalciuric hypercalcaemia
- familial dysalbuminaemic hyperthyroxinaemia
- familial euthyroid hyperthyroxinaemia
- fat necrosis
- female athlete triad syndrome
- fetal demise
- fetal macrosomia
- follicular thyroid cancer
- fractures
- frasier syndrome
- friedreich's ataxia
- functional parathyroid cyst
- galactorrhoea
- gastrinoma
- gastritis
- gastrointestinal perforation
- gastrointestinal stromal tumour
- gck mutation
- gender identity disorder
- gestational diabetes mellitus
- giant ovarian cysts
- gigantism
- gitelman syndrome
- glucagonoma
- glucocorticoid remediable aldosteronism
- glycogen storage disease
- goitre
- goitre (multinodular)
- gonadal dysgenesis
- gonadoblastoma
- gonadotrophic adenoma
- gorham's disease
- granuloma
- granulosa cell tumour
- graves' disease
- graves' ophthalmopathy
- growth hormone deficiency (adult)
- growth hormone deficiency (childhood onset)
- gynaecomastia
- hamman's syndrome
- haemorrhage
- hajdu-cheney syndrome
- hashimoto's disease
- hemihypertrophy
- hepatitis c
- hereditary multiple osteochondroma
- hirsutism
- histiocytosis
- huntington's disease
- hürthle cell adenoma
- hyperaldosteronism
- hyperandrogenism
- hypercalcaemia
- hypercalcaemic crisis
- hyperglucogonaemia
- hyperglycaemia
- hypergonadotropic hypogonadism
- hypergonadotropism
- hyperinsulinaemia
- hyperinsulinaemic hypoglycaemia
- hyperkalaemia
- hyperlipidaemia
- hypernatraemia
- hyperosmolar hyperglycaemic state
- hyperparathyroidism (primary)
- hyperparathyroidism (secondary)
- hyperparathyroidism (tertiary)
- hyperpituitarism
- hyperprolactinaemia
- hypersexuality
- hypertension
- hyperthyroidism
- hypoaldosteronism
- hypocalcaemia
- hypoestrogenism
- hypoglycaemia
- hypoglycaemic coma
- hypogonadism
- hypogonadotrophic hypogonadism
- hypoinsulinaemia
- hypokalaemia
- hyponatraemia
- hypoparathyroidism
- hypophosphataemia
- hypophosphatasia
- hypophysitis
- hypopituitarism
- hypothyroidism
- iatrogenic disorder
- idiopathic bilateral adrenal hyperplasia
- idiopathic pituitary hyperplasia
- igg4-related systemic disease
- inappropriate tsh secretion
- incidentaloma
- infertility
- insulin autoimmune syndrome
- insulin resistance
- insulinoma
- intracranial vasospasm
- intrauterine growth retardation
- iodine allergy
- ischaemic heart disease
- kallmann syndrome
- ketoacidosis
- klinefelter syndrome
- kwashiorkor
- kwashiorkor (marasmic)
- leg ulcer
- laron syndrome
- latent autoimmune diabetes of adults (lada)
- laurence-moon syndrome
- left ventricular hypertrophy
- leukocytoclastic vasculitis
- leydig cell tumour
- lipodystrophy
- lipomatosis
- liver failure
- lung metastases
- luteoma
- lymphadenopathy
- macronodular adrenal hyperplasia
- macronodular hyperplasia
- macroprolactinoma
- marasmus
- maturity onset diabetes of young (mody)
- mccune-albright syndrome
- mckittrick-wheelock syndrome
- medullary thyroid cancer
- meigs syndrome
- membranous nephropathy
- men1
- men2a
- men2b
- men4
- menarche
- meningitis
- menopause
- metabolic acidosis
- metabolic syndrome
- metastatic carcinoma
- metastatic chromaffin cell tumour
- metastatic gastrinoma
- metastatic melanoma
- metastatic tumour
- microadenoma
- microprolactinoma
- motor neurone disease
- myasthenia gravis
- myelolipoma
- myocardial infarction
- myositis
- myotonic dystrophy type 1
- myotonic dystrophy type 2
- myxoedema
- myxoedema coma
- nelson's syndrome
- neonatal diabetes
- nephrolithiasis
- neuroblastoma
- neuroendocrine tumour
- neurofibromatosis
- nodular hyperplasia
- non-functioning pituitary adenoma
- non-hodgkin lymphoma
- non-islet-cell tumour hypoglycaemia
- noonan syndrome
- oculocerebrorenal syndrome
- osteogenesis imperfecta
- osteomalacia
- osteomyelitis
- osteoporosis
- osteoporosis (pregnancy/lactation-associated)
- osteosclerosis
- ovarian cancer
- ovarian dysgenesis
- ovarian hyperstimulation syndrome
- ovarian tumour
- paget's disease
- paget's disease (juvenille)
- pancreatic neuroendocrine tumour
- pancreatitis
- panhypopituitarism
- papillary thyroid cancer
- paraganglioma
- paranasal sinus lesion
- paraneoplastic syndromes
- parasitic thyroid nodules
- parathyroid adenoma
- parathyroid adenoma (ectopic)
- parathyroid carcinoma
- parathyroid cyst
- parathroid hyperplasia
- pcos
- periodontal disease
- phaeochromocytoma
- phaeochromocytoma crisis
- pickardt syndrome
- pituitary abscess
- pituitary adenoma
- pituitary apoplexy
- pituitary carcinoma
- pituitary cyst
- pituitary haemorrhage
- pituitary hyperplasia
- pituitary hypoplasia
- pituitary tumour (malignant)
- plurihormonal pituitary adenoma
- poems syndrome
- polycythaemia
- porphyria
- pneumonia
- posterior reversible encephalopathy syndrome
- post-prandial hypoglycaemia
- prader-willi syndrome
- prediabetes
- pre-eclampsia
- pregnancy
- premature ovarian failure
- premenstrual dysphoric disorder
- premenstrual syndrome
- primary hypertrophic osteoarthropathy
- prolactinoma
- prostate cancer
- pseudohypoaldosteronism type 1
- pseudohypoaldosteronism type 2
- pseudohypoparathyroidism
- psychosocial short stature
- puberty (delayed or absent)
- puberty (precocious)
- pulmonary oedema
- quadrantanopia
- rabson-mendenhall syndrome
- rhabdomyolysis
- rheumatoid arthritis
- rickets
- schwannoma
- sellar reossification
- sertoli cell tumour
- sertoli-leydig cell tumour
- sexual development disorders
- sheehan's syndrome
- short stature
- siadh
- small-cell carcinoma
- small intestine neuroendocrine tumour
- solitary fibrous tumour
- solitary sellar plasmacytoma
- somatostatinoma
- somatotrophic adenoma
- squamous cell thyroid carcinoma
- stiff person syndrome
- struma ovarii
- subcutaneous insulin resistance
- systemic lupus erythematosus
- takotsubo cardiomyopathy
- tarts
- testicular cancer
- thecoma
- thyroid adenoma
- thyroid carcinoma
- thyroid cyst
- thyroid dysgenesis
- thyroid fibromatosis
- thyroid hormone resistance syndrome
- thyroid lymphoma
- thyroid nodule
- thyroid storm
- thyroiditis
- thyrotoxicosis
- thyrotrophic adenoma
- traumatic brain injury
- tuberculosis
- tuberous sclerosis complex
- tumour-induced osteomalacia
- turner syndrome
- unilateral adrenal hyperplasia
- ureterolithiasis
- urolithiasis
- von hippel-lindau disease
- wagr syndrome
- waterhouse-friderichsen syndrome
- williams syndrome
- wolcott-rallison syndrome
- wolfram syndrome
- xanthogranulomatous hypophysitis
- xlaad/ipex
- zollinger-ellison syndrome
- abdominal adiposity
- abdominal distension
- abdominal cramp
- abdominal discomfort
- abdominal guarding
- abdominal lump
- abdominal pain
- abdominal tenderness
- abnormal posture
- abdominal wall defects
- abrasion
- acalculia
- accelerated growth
- acne
- acrochorda
- acroosteolysis
- acute stress reaction
- adverse breast development
- aggression
- agitation
- agnosia
- akathisia
- akinesia
- albuminuria
- alcohol intolerance
- alexia
- alopecia
- altered level of consciousness
- amaurosis
- amaurosis fugax
- ambiguous genitalia
- amblyopia
- amenorrhoea
- ameurosis
- amnesia
- amusia
- anasarca
- angiomyxoma
- anhedonia
- anisocoria
- ankle swelling
- anorchia
- anorectal malformations
- anorexia
- anosmia
- anosognosia
- anovulation
- antepartum haemorrhage
- anuria
- anxiety
- apathy
- aphasia
- aphonia
- apnoea
- appendicitis
- appetite increase
- appetite reduction/loss
- apraxia
- aqueductal stenosis
- arteriosclerosis
- arthralgia
- articulation impairment
- ascites
- asperger syndrome
- asphyxia
- asthenia
- astigmatism
- asymptomatic
- ataxia
- atrial fibrillation
- atrial myxoma
- atrophy
- adhd
- autism
- autonomic neuropathy
- avulsion
- babinski's sign
- back pain
- bacteraemia
- behavioural problems
- belching
- bifid scrotum
- biliary colic
- bitemporal hemianopsia
- blindness
- blistering
- bloating
- bloody show
- boil(s)
- bone cyst
- bone fracture(s)
- bone lesions
- bone pain
- bony metastases
- borborygmus
- bowel movements - bleeding
- bowel movements - increased frequency
- bowel movements - pain
- bowel obstruction
- bowel perforation
- brachycephaly
- brachydactyly
- bradycardia
- bradykinesia
- bradyphrenia
- bradypnea
- breast contour change
- breast enlargement
- breast lump
- breast reduction
- breast tenderness
- breastfeeding difficulties
- breathing difficulties
- bronchospasms
- brushfield spots
- bruxism
- buffalo hump
- cachexia
- calcification
- cardiac fibrosis
- cardiac malformations
- cardiac tamponade
- cardiogenic shock
- cardiomegaly
- cardiomyopathy
- cardiopulmonary arrest
- carpal tunnel syndrome
- caruncle - inflammation
- cataplexy
- cataract(s)
- catathrenia
- central obesity
- cerebrospinal fluid rhinorrhoea
- cervical pain
- cheeks - full
- cheiloschisis
- chemosis
- chest pain
- chest pain (pleuritic)
- chest pain (precordial)
- cheyne-stokes respiration
- chills
- cholecystitis
- cholestasis
- chondrocalcinosis
- chordee
- chorea
- choroidal atrophy
- chronic pain
- circulatory collapse
- cirrhosis
- citraturia
- claudication
- clitoromegaly
- cloacal exstrophy
- clonus
- club foot
- clumsiness
- coagulopathy
- coarctation
- coeliac disease
- cognitive problems
- cold intolerance
- collapse
- colour blindness
- coma
- concentration difficulties
- confusion
- congenital heart defect
- conjunctivitis
- constipation
- convulsions
- coordination difficulties
- coughing
- crackles
- cramps
- craniofacial abnormalities
- craniotabes
- cutaneous ischaemia
- cutaneous myxoma
- cutaneous pigmentation
- cyanosis
- dalrymple's sign
- deafness
- deep vein thrombosis
- dehydration
- delayed puberty
- delirium
- dementia
- dental abscess(es)
- dental problems
- depression
- diabetes insipidus
- diabetic neuropathy
- diabetic foot infection
- diabetic foot neuropathy
- diabetic foot ulceration
- diarrhoea
- diplopia
- dizziness
- duodenal atresia
- duplex kidney(s)
- dysarthria
- dysdiadochokinesia
- dysgraphia
- dyslexia
- dyslipidaemia
- dysmenorrhoea
- dyspareunia
- dyspepsia
- dysphagia
- dysphonia
- dysphoria
- dyspnoea
- dystonia
- dysuria
- ear, nose and/or throat infection
- early menarche
- ears - low set
- ears - pinna abnormalities
- ears - small
- ecchymoses
- ectopic ureter
- emotional immaturity
- encopresis
- endometrial hyperplasia
- enlarged bladder
- enlarged prostate
- eosinophilia
- epicanthic fold
- epilepsy
- epistaxis
- erectile dysfunction
- erythema
- euphoria
- eyebrows - bushy
- eyelid retraction
- eyelid swelling
- eyelids - redness
- eyes - almond-shaped
- eyes - dry
- eyes - feeling of grittiness
- eyes - inflammation
- eyes - irritation
- eyes - itching
- eyes - pain (gazing down)
- eyes - pain (gazing up)
- eyes - redness
- eyes - watering
- face - change in appearance
- face - coarse features
- face - numbness
- facial fullness
- facial palsy
- facial plethora
- facial weakness
- facies - abnormal
- facies - hippocratic
- facies - moon
- faecal incontinence
- failure to thrive
- fallopian tube hyperplasia
- fasciculation
- fatigue
- fatigue (post-exertional)
- feet - cold
- feet - increased size
- feet - large
- feet - pain
- feet - small
- fingers - thick
- flaccid paralysis
- flatulence
- flushing
- fontanelles - enlarged
- frontal bossing
- fungating lesion
- fungating mass
- funny turns
- gait abnormality
- gait unsteadiness
- gallbladder calculi
- gallstones
- gangrene
- gastro-oesophageal reflux
- genital oedema
- genu valgum
- genu varum
- gestational diabetes
- glaucoma
- glucose intolerance
- glucosuria
- growth hormone deficiency
- growth retardation
- haematemesis
- haematochezia
- haematoma
- haematuria
- haemoglobinuria
- haemoptysis
- hair - coarse
- hair - dry
- hair - temporal balding
- hairline - low
- hallucination
- hands - enlargement
- hands - large
- hands - single palmar crease
- hands - small
- head - large
- headache
- hearing loss
- heart failure
- heart murmur
- heat intolerance
- height loss
- hemiballismus
- hemianopia
- hemiparesis
- hemispatial neglect
- hepatic cysts
- hepatic metastases
- hepatomegaly
- hidradenitis suppurativa
- high-arched palate
- hip dislocation
- hippocampal dysgenesis
- hirschsprung's disease
- hot flushes
- hydronephrosis
- hypolipidaemia
- hyperactivity
- hyperacusis
- hyperandrogenaemia
- hypercalciuria
- hypercapnea
- hypercholesterolaemia
- hypercortisolaemia
- hyperflexibility
- hyperglucagonaemia
- hyperhidrosis
- hyperhomocysteinaemia
- hypernasal speech
- hyperopia
- hyperoxaluria
- hyperpigmentation
- hyperplasia
- hyperpnoea
- hypersalivation
- hyperseborrhea
- hypersomnia
- hyperthermia
- hypertrichosis
- hypertrophy
- hyperuricaemia
- hyperventilation
- hypoadrenalism
- hypoalbuminaemia
- hypocalciuria
- hypocitraturia
- hypomagnesaemia
- hypopigmentation
- hypoplastic scrotum
- hypopotassaemia
- hypoprolactinaemia
- hyporeflexia
- hyposmia
- hypospadias
- hypotension
- hypothermia
- hypotonia
- hypoventilation
- hypovitaminosis d
- hypovolaemia
- hypovolaemic shock
- hypoxia
- immunodeficiency
- impulsivity
- inattention
- infections
- inflexibility
- insomnia
- instability
- intussusception
- irritability
- ischaemia
- ischuria
- itching
- jaundice
- keratoconus
- ketonuria
- ketotic odour
- kidney dysplasia
- kidney stones
- kyphoscoliosis
- kyphosis
- labioscrotal fold abnormalities
- laceration
- late dentition
- learning difficulties
- leg pain
- legs - increased length
- leukaemia
- leukocytosis
- libido increase
- libido reduction/loss
- lichen sclerosus
- lips - dry
- lips - thin
- little finger - in-curved
- little finger - short
- liver masses
- lordosis
- lordosis (loss of)
- lymphadenectomy
- lymphadenitis
- lymphocytosis
- lymphoedema
- macroglossia
- malaise
- malaise (post-exertional)
- malodorous perspiration
- mania
- marcus gunn pupil
- mastalgia
- meckel's diverticulum
- melena
- menorrhagia
- menstrual disorder
- mesenteric ischaemia
- metabolic alkalosis
- microalbuminuria
- microcephaly
- micrognathia
- micropenis
- milk-alkali syndrome
- miscarriage
- mood changes/swings
- mouth - down-turned
- mouth - small
- movement - limited range of
- mucosal pigmentation
- muscle atrophy
- muscle freezing
- muscle hypertrophy
- muscle rigidity
- myalgia
- myasthaenia
- mydriasis
- myelodysplasia
- myeloma
- myoclonus
- myodesopsia
- myokymia
- myopathy
- myopia
- myosis
- nail clubbing
- nail dystrophy
- nasal obstruction
- nausea
- neck - loose skin (nape)
- neck - short
- neck mass
- neck pain/discomfort
- necrolytic migratory erythema
- necrosis
- nephrocalcinosis
- nephropathy
- neurofibromas
- night terrors
- nipple change
- nipple discharge
- nipple inversion
- nipple retraction
- nipples widely spaced
- nocturia
- normochromic normocytic anaemia
- nose - depressed bridge
- nose - flat bridge
- nose - thickening
- nystagmus
- obsessive-compulsive disorder
- obstetrical haemorrhage
- obstructive sleep apnoea
- odynophagia
- oedema
- oesophageal atresia
- oesophagitis
- oligomenorrhoea
- oliguria
- onychauxis
- oophoritis
- ophthalmoplegia
- optic atrophy
- orbital fat prolapse
- orbital hypertelorism
- orthostatic hypotension
- osteoarthritis
- osteopenia
- otitis media
- ovarian cysts
- ovarian hyperplasia
- palatoschisis
- pallor
- palmar erythema
- palpebral fissure (downslanted)
- palpebral fissure (extended)
- palpebral fissure (reduced)
- palpebral fissure (upslanted)
- palpitations
- pancreatic fibrosis
- pancytopaenia
- panic attacks
- papilloedema
- paraesthesia
- paralysis
- paranoia
- patellar dislocation
- patellar subluxation
- pedal ulceration
- pellagra
- pelvic mass
- pelvic pain
- penile agenesis
- peptic ulcer
- pericardial effusion
- periodontitis
- periosteal bone reactions
- peripheral oedema
- personality change
- pes cavus
- petechiae
- peyronie's disease
- pharyngitis
- philtrum - long
- philtrum - short
- phosphaturia
- photophobia
- photosensitivity
- pleurisy
- poikiloderma
- polydactyly
- polydipsia
- polyphagia
- polyuria
- poor wound healing
- postmenopausal bleeding
- post-nasal drip
- postprandial fullness
- postural instability
- prehypertension
- premature birth
- premature labour
- prenatal growth retardation
- presbyopia
- pretibial myxoedema
- proctalgia fugax
- prognathism
- proptosis
- prosopagnosia
- proteinuria
- pruritus
- pruritus scroti
- pruritus vulvae
- pseudarthrosis
- psoriatic arthritis
- psychiatric problems
- psychomotor retardation
- psychosis
- pterygium colli
- ptosis
- puberty (delayed/absent)
- puberty (early/precocious)
- puffiness
- pulmonary embolism
- purpura
- pyelonephritis
- pyloric stenosis
- pyrexia
- pyrosis
- pyuria
- rash
- rectal pain
- rectorrhagia
- refractory anemia
- reluctance to weight-bear
- renal agenesis
- renal clubbing
- renal colic
- renal cyst
- renal failure
- renal insufficiency
- renal phosphate wasting (isolated)
- renal tubular acidosis
- respiratory failure
- reticulocytosis
- retinitis pigmentosa
- retinopathy
- retrobulbar pain
- retrograde ejaculation
- retroperitoneal fibrosis
- salivary gland swelling
- salpingitis
- salt craving
- salt wasting
- sarcoidosis
- schizophrenia
- scoliosis
- scotoma
- seborrhoeic dermatitis
- seizures
- sensory loss
- sepsis
- septic arthritis
- septic shock
- shivering
- singultus
- sinusitis
- sixth nerve palsy
- skeletal deformity
- skeletal dysplasia
- skin - texture change
- skin infections
- skin necrosis
- skin pigmentation - spotty
- skin thickening
- skin thinning
- sleep apnoea
- sleep difficulties
- sleep disturbance
- sleep hyperhidrosis
- slow growth
- slurred speech
- social difficulties
- soft tissue swelling
- somnambulism
- somniloquy
- somnolence
- sore throat
- spasms
- spastic paraplegia
- spasticity
- speech delay
- spider naevi
- splenomegaly
- sputum production
- steatorrhoea
- stomatitis
- strabismus
- strangury
- striae
- stridor
- stroke
- subfertility
- suicidal ideation
- supraclavicular fat pads
- supranuclear gaze palsy
- sweating
- syncope
- syndactyly
- tachycardia
- tachypnoea
- teeth gapping
- telangiectasias
- telecanthus
- tetraparesis
- t-reflex (absent)
- t-reflex (depressed)
- tetany
- thermodysregulation
- thrombocytopenia
- thrombocytosis
- thrombophilia
- thrush
- tics
- tinnitus
- toe clubbing
- toe deformities
- toes - thick
- toes - widely spaced
- tongue - protruding
- tracheo-oesophageal compression
- tracheo-oesophageal fistula
- tremulousness
- tricuspid insufficiency
- umbilical hernia
- uraemia
- ureter duplex
- uricaemia
- urinary frequency
- urinary incontinence
- urogenital sinus
- urticaria
- uterine hyperplasia
- uterus duplex
- vagina duplex
- vaginal bleeding
- vaginal discharge
- vaginal dryness
- vaginal pain/tenderness
- vaginism
- ventricular fibrillation
- ventricular hypertrophy
- vertigo
- viraemia
- virilisation (abnormal)
- vision - acuity reduction
- vision - blurred
- visual disturbance
- visual field defect
- visual impairment
- visual loss
- vitiligo
- vocal cord paresis
- vomiting
- von graefe's sign
- weight gain
- weight loss
- wheezing
- widened joint space(s)
- xeroderma
- xerostomia
- 3-methoxy 4-hydroxy mandelic acid
- 17-hydroxypregnenolone (urine)
- 17-ketosteroids
- 25-hydroxyvitamin-d3
- 5hiaa
- aberrant adrenal receptors
- acid-base balance
- acth stimulation
- activated partial thromboplastin time
- acyl-ghrelin
- adrenal antibodies
- adrenal function
- adrenal scintigraphy
- adrenal venous sampling
- afp tumour marker
- alanine aminotransferase
- albumin
- albumin to creatinine ratio
- aldosterone (24-hour urine)
- aldosterone (blood)
- aldosterone (plasma)
- aldosterone (serum)
- aldosterone to renin ratio
- alkaline phosphatase
- alkaline phosphatase (bone-specific)
- alpha-fetoprotein
- ammonia
- amniocentesis
- amylase
- angiography
- anion gap
- anti-acetylcholine antibodies
- anticardiolipin antibody
- anti-insulin antibodies
- anti-islet cell antibody
- anti-gh antibodies
- antinuclear antibody
- anti-tyrosine phosphatase antibodies
- asvs
- barium studies
- basal insulin
- base excess
- apolipoprotein h
- beta-hydroxybutyrate
- bicarbonate
- bilirubin
- biopsy
- blood film
- blood pressure
- bmi
- body fat mass
- bone age
- bone biopsy
- bone mineral content
- bone mineral density
- bone mineral density test
- bone scintigraphy
- bone sialoprotein
- bound insulin
- brca1/brca2
- c1np
- c3 complement
- c4 complement
- ca125
- calcifediol
- calcium (serum)
- calcium (urine)
- calcium to creatinine clearance ratio
- carcinoembryonic antigen
- cardiac index
- catecholamines (24-hour urine)
- catecholamines (plasma)
- cd-56
- chemokines
- chest auscultation
- chloride
- chorionic villus sampling
- chromatography
- chromogranin a
- chromosomal analysis
- clomid challenge
- clonidine suppression
- collagen
- colonoscopy
- colposcopy
- continuous glucose monitoring
- core needle biopsy
- corticotropin-releasing hormone stimulation test
- cortisol (9am)
- cortisol (plasma)
- cortisol (midnight)
- cortisol (salivary)
- cortisol (serum)
- cortisol day curve
- cortisol, free (24-hour urine)
- c-peptide (24-hour urine)
- c-peptide (blood)
- c-reactive protein
- creatinine
- creatine kinase
- creatinine (24-hour urine)
- creatinine (serum)
- creatinine clearance
- crh stimulation
- ctpa scan
- ct scan
- c-telopeptide
- cytokines
- deoxypyridinoline
- dexa scan
- dexamethasone suppression
- dexamethasone suppression (high dose)
- dexamethasone suppression (low dose)
- dhea sulphate
- discectomy
- dldl cholesterol
- dmsa scan
- dna sequencing
- domperidone
- down syndrome screening
- ductal lavage
- echocardiogram
- eeg
- electrocardiogram
- electrolytes
- electromyography
- endoscopic ultrasound
- endoscopy
- endosonography
- enzyme immunoassay
- epinephrine (plasma)
- epinephrine (urine)
- erythrocyte sedimentation rate
- estimated glomerular filtration rate
- ethanol ablation
- ewing and clarke autonomic function
- exercise tolerance
- fbc
- ferritin
- fine needle aspiration biopsy
- flow cytometry
- fludrocortisone suppression
- fluticasone-propionate-17-beta carboxylic acid
- fmri
- folate
- ft3
- ft4
- gada
- gallium nitrate
- gallium scan
- gastric biopsy
- genetic analysis
- genitography
- gh day curve
- gh stimulation
- gh suppression
- glp-1
- glp-2
- glucose suppression test
- glucose (blood)
- glucose (blood, fasting)
- glucose (blood, postprandial)
- glucose (urine)
- glucose tolerance
- glucose tolerance (intravenous)
- glucose tolerance (oral)
- glucose tolerance (prolonged)
- gluten sensitivity
- gnrh stimulation
- gonadotrophins
- growth hormone-releasing peptide-2 test
- gut hormones (fasting)
- haematoxylin and eosin staining
- haemoglobin
- haemoglobin a1c
- hcg (serum)
- hcg (urine)
- hcg stimulation
- hdl cholesterol
- hearing test
- heart rate
- hepatic venous sampling with arterial stimulation
- high-sensitivity c-reactive protein
- histopathology
- hla genotyping
- holter monitoring
- homa
- homocysteine
- hyaluronic acid
- hydrocortisone day curve
- hydroxyproline
- hydroxyprogesterone
- hysteroscopy
- igfbp2
- igfbp3
- igg4/igg ratio
- immunocytochemistry
- immunohistochemistry
- immunoglobulins
- immunoglobulin g2
- immunoglobulin g4
- immunoglobulin a
- immunoglobulin m
- immunostaining
- inferior petrosal sinus sampling
- inhibin b
- insulin (fasting)
- insulin suppression
- insulin tissue resistance tests
- insulin tolerance
- intracranial pressure
- irm imaging
- ketones (plasma)
- ketones (urine)
- kidney function
- lactate
- lactate dehydrogenase
- laparoscopy
- laparoscopy and dye
- laparotomy
- ldl cholesterol
- leuprolide acetate stimulation
- leukocyte esterase (urine)
- levothyroxine absorption
- lipase (serum)
- lipid profile
- liquid-based cytology
- liquid chromatography-mass spectrometry
- liver biopsy
- liver function
- lumbar puncture
- lung function testing
- luteinising hormone releasing hormone test
- macroprolactin
- magnesium
- mag3 scan
- mammogram
- mantoux test
- metanephrines (plasma)
- metanephrines (urinary)
- methoxytyramine
- metoclopramide
- metyrapone cortisol day curve
- metyrapone suppression
- metyrapone test dose
- mibg scan
- microarray analysis
- molecular genetic analysis
- mri
- myocardial biopsy
- nerve conduction study
- neuroendocrine markers
- neuron-specific enolase
- norepinephrine
- ntx
- oct
- octreotide scan
- octreotide suppression test
- osmolality
- ovarian venous sampling
- p1np
- palpation
- pap test
- parathyroid scintigraphy
- pentagastrin
- perchlorate discharge
- percutaneous umbilical blood sampling
- peripheral blood film
- pet scan
- ph (blood)
- phosphate (serum)
- phosphate (urine)
- pituitary function
- plasma osmolality
- plasma viscosity
- platelet count
- pneumococcal antigen
- pneumococcal pcr
- polymerase chain reaction
- polysomnography
- porter-silber chromogens
- potassium
- pregnancy test
- proinsulin
- prostate-specific antigen
- protein electrophoresis
- protein fingerprinting
- protein folding analysis
- psychiatric assessment
- psychometric assessment
- pulse oximetry
- pyelography
- pyridinium crosslinks
- quicki
- plasma renin activity
- radioimmunoassay
- radionuclide imaging
- raiu test
- red blood cell count
- renal biopsy
- renin (24-hour urine)
- respiratory status
- renin (blood)
- renin plasma activity
- rheumatoid factor
- salt loading
- sdldl cholesterol
- secretin stimulation
- selective parathyroid venous sampling
- selective transhepatic portal venous sampling
- semen analysis
- serotonin
- serum osmolality
- serum free insulin
- sestamibi scan
- sex hormone binding globulin
- shbg
- skeletal muscle mass
- skin biopsy
- sleep diary
- sodium
- spect scan
- supervised 72-hour fast
- surgical biopsy
- sweat test
- synaptophysin
- systemic vascular resistance index
- tanner scale
- thoracocentesis
- thyroid transcription factor-1
- thyroglobulin
- thyroid antibodies
- thyroid function
- thyroid scintigraphy
- thyroid ultrasonography
- total cholesterol
- total ghrelin
- total t3
- total t4
- trabecular thickness
- transaminase
- transvaginal ultrasound
- trap 5b
- trh stimulation
- triglycerides
- triiodothyronine (t3) suppression
- troponin
- tsh receptor antibodies
- type 3 precollagen
- type 4 collagen
- ultrasound-guided biopsy
- ultrasound scan
- urea and electrolytes
- uric acid (blood)
- uric acid (urine)
- urinalysis
- urinary free cortisol
- urine 24-hour volume
- urine osmolality
- vaginal examination
- vanillylmandelic acid (24-hour urine)
- visual field assessment
- vitamin b12
- vitamin e
- waist circumference
- water deprivation
- water load
- weight
- western blotting
- white blood cell count
- white blood cell differential count
- x-ray
- zinc
- abscess drainage
- acetic acid injection
- adhesiolysis
- adrenalectomy
- amputation
- analgesics
- angioplasty
- arthrodesis
- assisted reproduction techniques
- bariatric surgery
- bilateral salpingo-oophorectomy
- blood transfusion
- bone grafting
- caesarean section
- cardiac transplantation
- cardiac pacemaker
- cataract extraction
- chemoembolisation
- chemotherapy
- chemoradiotherapy
- clitoroplasty
- continuous renal replacement therapy
- contraception
- cordotomy
- counselling
- craniotomy
- cryopreservation
- cryosurgical ablation
- debridement
- dialysis
- diazoxide
- diet
- duodenotomy
- endonasal endoscopic surgery
- exercise
- external fixation
- extracorporeal shock wave lithotripsy
- extraocular muscle surgery
- eye surgery
- eyelid surgery
- fasciotomy
- fluid repletion
- fluid restriction
- gamma knife radiosurgery
- gastrectomy
- gastrostomy
- gender reassignment surgery
- gonadectomy
- heart transplantation
- hormone replacement
- hormone suppression
- hypophysectomy
- hysterectomy
- inguinal orchiectomy
- internal fixation
- intra-cardiac defibrillator
- islet transplantation
- ivf
- kidney transplantation
- laparoscopic adrenalectomy
- laryngoplasty
- laryngoscopy
- laser lithotripsy
- light treatment
- liver transplantation
- lumpectomy
- lymph node dissection
- mastectomy
- molecularly targeted therapy
- neuroendoscopic surgery
- oophorectomy
- orbital decompression
- orbital radiation
- orchidectomy
- orthopaedic surgery
- osteotomy
- ovarian cystectomy
- ovarian diathermy
- oxygen therapy
- pancreas transplantation
- pancreatectomy
- pancreaticoduodenectomy
- parathyroidectomy
- percutaneous adrenal ablation
- percutaneous nephrolithotomy
- pericardiocentesis
- pericardiotomy
- physiotherapy
- pituitary adenomectomy
- plasma exchange
- plasmapheresis
- psychotherapy
- radiofrequency ablation
- radionuclide therapy
- radiotherapy
- reconstruction of genitalia
- resection of tumour
- right-sided hemicolectomy
- salpingo-oophorectomy
- small bowel resection
- speech and language therapy
- spinal surgery
- splenectomy
- stereotactic radiosurgery
- termination of pregnancy
- thymic transplantation
- thyroidectomy
- tracheostomy
- transcranial surgery
- transsphenoidal surgery
- transtentorial surgery
- vaginoplasty
- vagotomy
- 5-alpha-reductase inhibitors
- 17?-estradiol
- abiraterone
- acarbose
- acetazolamide
- acetohexamide
- adalimumab
- albiglutide
- alendronate
- alogliptin
- alpha-blockers
- alphacalcidol
- alpha-glucosidase inhibitors
- amiloride
- amlodipine
- amoxicillin
- anastrozole
- angiotensin-converting enzyme inhibitors
- angiotensin receptor antagonists
- anthracyclines
- antiandrogens
- antibiotics
- antiemetics
- antiepileptics
- antipsychotics
- antithyroid drugs
- antiseptic
- antivirals
- aripiprazole
- aromatase inhibitors
- aspirin
- astragalus membranaceus
- ativan
- atenolol
- atorvastatin
- avp receptor antagonists
- axitinib
- azathioprine
- bendroflumethiazide
- benzodiazepines
- beta-blockers
- betamethasone
- bexlosteride
- bicalutamide
- bisphosphonates
- bleomycin
- botulinum toxin
- bromocriptine
- cabergoline
- cabozantinib
- calcimimetics
- calcitonin (salmon)
- calcium
- calcium carbonate
- calcium chloride
- calcium dobesilate
- calcium edta
- calcium gluconate
- calcium-l-aspartate
- calcium polystyrene sulphonate
- canagliflozin
- capecitabine
- captopril
- carbimazole
- carboplatin
- carbutamide
- carvedilol
- ceftriaxone
- chlorothiazide
- chlorpropamide
- cholecalciferol
- cholinesterase inhibitors
- ciclosporin
- cinacalcet
- cisplatin
- clodronate
- clomifene
- clomiphene citrate
- clopidogrel
- co-cyprindiol
- codeine
- colonic polyps
- combined oral contraceptive pill
- conivaptan
- cortisone acetate
- continuous subcutaneous hydrocortisone infusion
- continuous subcutaneous insulin infusion
- coumadin
- corticosteroids
- cortisol
- cyproterone acetate
- dacarbazine
- danazol
- dapagliflozin
- daunorubicin
- deferiprone
- demeclocycline
- denosumab
- desmopressin
- dexamethasone
- diazepam
- diethylstilbestrol
- digoxin
- diltiazem
- diphenhydramine
- diuretics
- docetaxel
- dopamine agonists
- dopamine antagonists
- dopamine receptor agonists
- doxazosin
- doxepin
- doxorubicin
- dpp4 inhibitors
- dutasteride
- dutogliptin
- eflornithine
- enoxaparin
- empagliflozin
- epinephrine
- epirubicin
- eplerenone
- epristeride
- equilenin
- equilin
- erlotinib
- ethinylestradiol
- etidronate
- etomidate
- etoposide
- everolimus
- exenatide
- fenofibrate
- finasteride
- fluconazole
- fluticasone
- fludrocortisone
- fluorouracil
- fluoxetine
- flutamide
- furosemide
- gaba receptor antagonists
- gefitinib
- gemcitabine
- gemigliptin
- ginkgo biloba
- glibenclamide
- glibornuride
- gliclazide
- glimepiride
- glipizide
- gliquidone
- glisoxepide
- glp1 agonists
- glucose
- glyclopyramide
- gnrh analogue
- gnrh antagonists
- heparin
- hrt (menopause)
- hydrochlorothiazide
- hydrocortisone
- ibandronate
- ibuprofen
- idarubicin
- idebenone
- imatinib
- immunoglobulin therapy
- implanon
- indapamide
- infliximab
- iron supplements
- isoniazid
- insulin aspart
- insulin glargine
- insulin glulisine
- insulin lispro
- interferon
- intrauterine system
- iopanoic acid
- ipilimumab
- ipragliflozin
- irbesartan
- izonsteride
- ketoconazole
- labetalol
- lactulose
- lanreotide
- leuprolide acetate
- levatinib
- levodopa
- levonorgestrel
- levothyroxine
- linagliptin
- liothyronine
- liraglutide
- lithium
- lisinopril
- lixivaptan
- loperamide
- loprazolam
- lormetazepam
- losartan
- low calcium formula
- magnesium glycerophosphate
- magnesium sulphate
- mecasermin
- medronate
- medroxyprogesterone acetate
- meglitinides
- menotropin
- metformin
- methadone
- methimazole
- methylprednisolone
- metoprolol
- metyrapone
- miglitol
- mitotane
- mitoxantrone
- mozavaptan
- mtor inhibitors
- multivitamins
- naproxen
- natalizumab
- nateglinide
- nelivaptan
- neridronate
- nifedipine
- nilutamide
- nitrazepam
- nivolumab
- nsaid
- octreotide
- oestradiol valerate
- olanzapine
- olpadronate
- omeprazole
- opioids
- oral contraceptives
- orlistat
- ornipressin
- otelixizumab
- oxandrolone
- oxidronate
- oxybutynin
- paclitaxel
- pamidronate
- pancreatic enzymes
- pantoprazole
- paracetamol
- paroxetine
- pasireotide
- pegvisomant
- perindopril
- phenobarbital
- phenoxybenzamine
- phosphate binders
- phosphate supplements
- phytohaemagglutinin induced interferon gamma
- pioglitazone
- plicamycin
- potassium chloride
- potassium iodide
- pramlintide
- prazosin
- prednisolone
- prednisone
- premarin
- promethazine
- propranolol
- propylthiouracil
- protease inhibitors
- proton pump inhibitors
- pyridostigmine
- quetiapine
- quinagolide
- quinestrol
- radioactive mibg
- radioactive octreotide
- radioiodine
- raloxifene
- ramipril
- relcovaptan
- remogliflozin etabonate
- repaglinide
- risperidone
- risedronate
- rituximab
- romidepsin
- rosiglitazone
- salbutamol
- saline
- salmeterol
- salt supplements
- satavaptan
- saxagliptin
- selective progesterone receptor modulators
- selenium
- sglt2 inhibitors
- sildenafil
- simvastatin
- sirolimus
- sitagliptin
- sodium bicarbonate
- sodium chloride
- sodium polystyrene sulfonate (kayexalate)
- somatostatin analogues
- sorafenib
- spironolactone
- ssris
- statins
- streptozotocin
- steroids
- strontium ranelate
- sucralfate
- sulphonylureas
- sunitinib
- tamoxifen
- taspoglutide
- temazepam
- temozolomide
- teplizumab
- terazosin
- teriparatide
- testolactone
- testosterone enanthate esters
- tetrabenazine
- thalidomide
- thiazolidinediones
- thyrotropin alpha
- tibolone
- tiludronate
- tiratricol (triac)
- tofogliflozin
- tolazamide
- tolbutamide
- tolvaptan
- tramadol
- trastuzumab
- trazodone
- triamcinolone
- triamterene
- trimipramine
- troglitazone
- tryptophan
- turosteride
- tyrosine-kinase inhibitors
- valproic acid
- valrubicin
- vandetanib
- vaptans
- vildagliptin
- vinorelbine
- voglibose
- vorinostat
- warfarin
- zaleplon
- z-drugs
- zoledronic acid
- zolpidem
- zopiclone
- cardiology
- dermatology
- gastroenterology
- general practice
- genetics
- geriatrics
- gynaecology
- nephrology
- neurology
- nursing
- obstetrics
- oncology
- otolaryngology
- paediatrics
- pathology
- podiatry
- psychology/psychiatry
- radiology/rheumatology
- rehabilitation
- surgery
- urology
- insight into disease pathogenesis or mechanism of therapy
- novel diagnostic procedure
- novel treatment
- unique/unexpected symptoms or presentations of a disease
- new disease or syndrome: presentations/diagnosis/management
- unusual effects of medical treatment
- error in diagnosis/pitfalls and caveats
- february
- 2022
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Affiliation(s)
- Aria Jazdarehee
- Department of Medicine and Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Sawyer Huget-Penner
- Division of Endocrinology and Metabolism, Fraser Health Authority, British Columbia, Canada
| | - Monika Pawlowska
- Division of Endocrinology and Metabolism, University of British Columbia, British Columbia, Canada
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Abstract
Introduction: The treatment of most severe COVID-19 patients included the large-scale use of sedatives and analgesics-possibly in higher doses than usual-which was reported in the literature. The use of drugs that decrease mortality is necessary and opioids are important agents in procedures such as orotracheal intubation. However, these drugs seem to have been overestimated in the COVID-19 pandemic. We performed a review of the PubMed-Medline database to evaluate the use of opioids during this period. The following descriptors were used to enhance the search for papers: "Opioids", "COVID-19," "COVID-19 pandemic," "SARS-CoV-2," "Opioid use disorder," "Opioid dependence" and the names of the drugs used. We also evaluated the distribution of COVID-19 patients in Brazil and the applicability of opioids in our country during the COVID-19 pandemic. Results: Several positive points were found in the use of opioids in the COVID-19 pandemic, for instance, they can be used for analgesia in orotracheal intubation, for chronic pain management, and as coadjutant in the management of acute intensification of pain. However, high doses of opioids might exacerbate the respiratory depression found in COVID-19 patients, their chronic use can trigger opioid tolerance and the higher doses used during the pandemic might result in greater adverse effects. Unfortunately, the pandemic also affected individuals with opioid use disorder, not only those individuals are at higher risk of mortality, hospitalization and need for ventilatory support, but measures taken to decrease the SARS-CoV-2 spread such as social isolation, might negatively affect the treatment for opioid use disorder. In Brazil, only morphine, remifentanil and fentanyl are available in the basic health care system for the treatment of COVID-19 patients. Out of the 5,273,598 opioid units used in this period all over the country, morphine, fentanyl, and remifentanil, accounted for, respectively, 559,270 (10.6%), 4,624,328 (87.6%), and 90,000 (1.8%) units. Many Brazilian regions with high number of confirmed cases of COVID-19 had few units of opioids available, as the Southeast region, with a 0.23 units of opioids per confirmed COVID-19 case, and the South region, with 0.05 units. In the COVID-19 pandemic scenario, positive points related to opioids were mainly the occurrence of analgesia, to facilitate intubation and their use as coadjutants in the management of acute intensification of pain, whereas the negative points were indiscriminate use, the presence of human immunosuppressor response and increased adverse effects due to higher doses of the drug. Conclusion: The importance of rational and individualized use of analgesic hypnotics and sedative anesthetics should be considered at all times, especially in situations of high demand such as the COVID-19 pandemic.
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Affiliation(s)
- Camila Vantini Capasso Palamim
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
| | - Matheus Negri Boschiero
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
| | - Aléthea Guimarães Faria
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
| | - Felipe Eduardo Valencise
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
| | - Fernando Augusto Lima Marson
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
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Benedetti F, Zoletto S, Salerno A, Avagnina I, Benini F. Old Drug, New Pain. Roles and Challenges of Methadone Therapy in Pediatric Palliative Care: A Systematic Review. Front Pediatr 2022; 10:874529. [PMID: 35712616 PMCID: PMC9196103 DOI: 10.3389/fped.2022.874529] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pediatric palliative care (PPC) is defined as the prevention and relief from suffering of families and children with life-limiting (LLDs) or life-threatening diseases (LTDs). These patients often experience pain, with morphine being the most widely used drug to treat it. Few studies investigated the role of methadone in PPC patients, although it is considered among the most effective and underutilized drugs in PPC. OBJECTIVES Our aim was to evaluate the efficacy, safety, and dosage of methadone in PPC. METHODS Between August and October 2021 PubMed, Scopus and the Cochrane Library were searched for studies on the use of methadone in children with LLDs and LTDs. Articles were included if they met the following criteria: published in the last 10 years, English language, patients aged 0-23 years; children enrolled in a PPC center or receiving declared support from a PPC service; reporting of specific data on methadone in interventional trials, observational studies, or case series on >10 patients. The reporting of the article was guided by the PRISMA guidelines, and a critical appraisal of the included studies was performed using the JBI-tool. RESULTS After duplicates removal and full-text assessment, four studies were included and another one was added after checking the references of the retrieved papers. All were retrospective, and the literature is concordant in documenting the lack of evidence. A total of 116 children received methadone in PPC. From our review emerges the poor quality of data collection: in only one study pain was assessed with standardized scales. All studies documented the effectiveness of methadone in treating complex pain, either nociceptive or neuropathic. No serious adverse events were reported, with no cases of cardiac arrhythmias. CONCLUSION Our results suggest that methadone could represent a suitable strategy for treating pain in PPC. However, the evidence base is insufficient, and further research is warranted.
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Affiliation(s)
| | - Silvia Zoletto
- Pediatric Residency Program, University of Padova, Padova, Italy
| | - Annalisa Salerno
- Pediatric Residency Program, University of Padova, Padova, Italy
| | - Irene Avagnina
- Pediatric Pain and Palliative Care Service, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Franca Benini
- Pediatric Pain and Palliative Care Service, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
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Andraka-Christou B, Clark MH, Atkins DN, del Pozo B. Criminal problem-solving and civil dependency court policies regarding medications for opioid use disorder. Subst Abuse 2022; 43:425-432. [PMID: 34236297 PMCID: PMC9518695 DOI: 10.1080/08897077.2021.1944958] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Criminal problem-solving courts and civil dependency courts often have participants with substance use disorder (SUD), including opioid use disorder (OUD). These courts refer participants to treatment and set treatment-related requirements for court participants to avoid incarceration or to regain custody of children. Medications for opioid use disorder (MOUD) are the most effective treatment for OUD but are underutilized by court system participants. Little is known about variation in court policies for different MOUDs. Also, more information is needed about types of policies for each MOUD, including whether participants may begin MOUD, continue previously begun MOUD, or complete the court program with MOUD. Methods: An online survey was distributed to criminal problem-solving and civil dependency judges in Florida in 2019 and 2020, yielding data from 58 judges (a 24% response rate). We used nonparametric statistics to test hypotheses with ordinal data. A Friedman's test for related samples or Cochran's Q was used to make within-group comparisons between policies and MOUDs. Results: We found considerable policy variation, with more permissive policies for naltrexone than buprenorphine or methadone, and more permissive policies for continuing MOUD than for initiating MOUD or completing a court program with MOUD. For each medication, less than one quarter of judges indicated their court always permits MOUD, with most indicating that MOUD is permitted sometimes or usually. Conclusion: Because respondents rarely chose "never" or "always" for any MOUD policy, most courts appear to be making MOUD decisions on a case-by-case basis. A clearer understanding of this decision-making process is needed. Some court participants may be required to discontinue MOUD before completing a court program, even if they were permitted to start or continue MOUD treatment. Discontinuation of MOUD without medical justification is contrary to the standard of care for individuals with OUD and increases their risk of overdose.
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Affiliation(s)
- Barbara Andraka-Christou
- Department of Health Management and Informatics, University of Central Florida, Orlando, FL, USA,Department of Internal Medicine (Joint Secondary Appointment), University of Central Florida, Orlando, FL, USA
| | - MH Clark
- Department of Learning Sciences and Educational Research, University of Central Florida, Orlando, FL, USA
| | - Danielle N. Atkins
- Department of Health Management and Informatics, University of Central Florida, Orlando, FL, USA
| | - Brandon del Pozo
- Warren Alpert Medical School, Brown University, Providence, RI, USA
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Suen LW, Castellanos S, Joshi N, Satterwhite S, Knight KR. "The idea is to help people achieve greater success and liberty": A qualitative study of expanded methadone take-home access in opioid use disorder treatment. Subst Abuse 2022; 43:1143-1150. [PMID: 35499469 PMCID: PMC9710250 DOI: 10.1080/08897077.2022.2060438] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Prior to the COVID-19 pandemic, the United States (US) was already facing an epidemic of opioid overdose deaths. Overdose deaths continued to surge during the pandemic. To limit COVID-19 spread and to avoid disruptions in access to medications for opioid use disorder (MOUD), including buprenorphine and methadone, US federal and state agencies granted unprecedented exemptions to existing MOUD guidelines for Opioid Treatment Programs (OTPs), including loosening criteria for unsupervised take-home doses. We conducted a qualitative study to evaluate the impact of these policy changes on MOUD treatment experiences for providers and patients at an OTP in California. Methods: We interviewed 10 providers (including two physicians, five social worker associates, and three nurse practitioners) and 20 patients receiving MOUD. We transcribed, coded, and analyzed all interviews to identify emergent themes. Results: Patient participants were middle-aged (median age 51 years) and were predominantly men (53%). Providers discussed clinical decision-making processes and experiences providing take-homes. Implementation of expanded take-home policies was cautious. Providers reported making individualized decisions, using patient factors to decide if benefits outweighed risks of overdose and misuse. Decision-making factors included patient drug use, overdose risk, housing status, and vulnerability to COVID-19. New patient groups started receiving take-homes and providers noted few adverse events. Patients who received take-homes reported increased autonomy and treatment flexibility, which in turn increased likelihood of treatment stabilization and engagement. Patients who remained ineligible for take-homes, usually due to ongoing non-prescribed opioid or benzodiazepine use, desired greater transparency and shared decision-making. Conclusion: Federal exemptions in response to COVID-19 led to the unprecedented expansion of access to MOUD take-homes within OTPs. Providers and patients perceived benefits to expanding access to take-homes and experienced few adverse outcomes, suggesting expanded take-home policies should remain post-COVID-19. Future studies should explore whether these findings are generalizable to other OTPs and assess larger samples to quantify patient-level outcomes resulting from expanded take-home policies.
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Affiliation(s)
- Leslie W. Suen
- UCSF National Clinician Scholars Program, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, United States,San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
| | - Stacy Castellanos
- UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA, United States,Department of Humanities and Social Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Neena Joshi
- Department of Humanities and Social Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Shannon Satterwhite
- Department of Family and Community Medicine, University of California, Davis, Davis, CA, United States
| | - Kelly R. Knight
- Department of Humanities and Social Sciences, University of California San Francisco, San Francisco, CA, United States
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224
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Han BH, Cotton BP, Polydorou S, Sherman SE, Ferris R, Arcila-Mesa M, Qian Y, McNeely J. Geriatric Conditions Among Middle-aged and Older Adults on Methadone Maintenance Treatment: A Pilot Study. J Addict Med 2022; 16:110-3. [PMID: 33395146 DOI: 10.1097/ADM.0000000000000808] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The number of older adults on methadone maintenance treatment (MMT) for opioid use disorder is increasing, but little is known about the characteristics and healthcare needs of this aging treatment population. This population may experience accelerated aging due to comorbidities and health behaviors. The aim of this study was to compare the prevalence of geriatric conditions among adults age ≥50 on MMT to a nationally representative sample of community-dwelling older adults. METHODS We performed a geriatric assessment on 47 adults age ≥50 currently on MMT enrolled in 2 opioid treatment programs, in New York City and in East Providence, Rhode Island. We collected data on self-reported geriatric conditions, healthcare utilization, chronic medical conditions, physical function, and substance use. The results were compared to 470 age, sex, and race/ethnicity-matched adults in the national Health and Retirement Study. RESULTS The mean age of the study sample was 58.8 years and 23.4% were female. The most common chronic diseases were hypertension (59.6%) and arthritis (55.3%) with 66% reporting ≥2 diseases. For geriatric conditions, adults on MMT had a significantly higher prevalence of mobility, hearing, and visual impairments as well as falls, urinary incontinence, chronic pain, and insomnia than the Health and Retirement Study sample. CONCLUSIONS Older adults on MMT in 2 large opioid treatment programs have a high prevalence of geriatric conditions. An interdisciplinary, geriatric-based approach to care that focuses on function and addresses geriatric conditions is needed to improve the health of this growing population.
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225
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Pasman E, Lee G, Kollin R, Rodriguez B, Agius E, Madden EF, Resko SM. Attitudes toward Medication for Opioid Use Disorder among Substance Use Treatment Providers. Subst Use Misuse 2022; 57:1828-1836. [PMID: 36041008 DOI: 10.1080/10826084.2022.2115853] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Background: Provider attitudes can be a powerful reinforcer of stigma toward medication for opioid use disorder (MOUD). This study examines attitudes toward MOUD among substance use treatment providers and identifies personal and professional characteristics associated with more positive attitudes. Methods: Treatment providers (N = 570) working at publicly-funded substance use programs in Michigan self-administered a web-based survey (November 2020 through July 2021), reporting their socio-demographics, professional experience, and attitudes toward MOUD. Linear regression was used to identify factors associated with general attitudes toward MOUD and three logistic regression models were calculated to identify factors associated with perceptions of each medication. Results: Half of providers considered methadone an effective treatment (53.0%); 62.9% considered buprenorphine effective, and 70.3% considered naltrexone effective. Receipt of training (B = 1.433, p = .009) and serving pregnant women or women with children (B = 1.662, p < .001) were associated with more positive attitudes toward MOUD. Providers with advanced degrees were more likely to consider methadone (OR = 2.264, p = .006), buprenorphine (OR = 2.192, p = .009), and naltrexone (OR = 2.310, p = .011) effective. Rural providers were more likely to consider naltrexone effective (OR = 2.708, p = .003). Providers working with criminal legal populations were more likely to consider buprenorphine (OR = 2.948, p = .041) and naltrexone (OR = 4.108, p = .010) effective, but not methadone. Conclusion: Treatment providers' attitudes remain poorly aligned with the evidence base. Increased efforts are needed to address attitudes toward MOUD among the specialized treatment workforce.
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Affiliation(s)
- Emily Pasman
- School of Social Work, Wayne State University, Detroit, Michigan, USA
| | - Guijin Lee
- School of Social Work, Wayne State University, Detroit, Michigan, USA.,Center for Behavioral Health and Justice, Wayne State University, Detroit, Michigan, USA
| | - Rachel Kollin
- School of Social Work, Wayne State University, Detroit, Michigan, USA
| | - Brooke Rodriguez
- School of Social Work, Wayne State University, Detroit, Michigan, USA
| | - Elizabeth Agius
- School of Social Work, Wayne State University, Detroit, Michigan, USA
| | - Erin Fanning Madden
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Stella M Resko
- School of Social Work, Wayne State University, Detroit, Michigan, USA.,Merrill Palmer Skillman Institute, Wayne State University, Detroit, Michigan, USA
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226
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Hser YI, Zhu Y, Fei Z, Mooney LJ, Evans EA, Kelleghan A, Matthews A, Yoo C, Saxon AJ. Long-term follow-up assessment of opioid use outcomes among individuals with comorbid mental disorders and opioid use disorder treated with buprenorphine or methadone in a randomized clinical trial. Addiction 2022; 117:151-161. [PMID: 34105213 PMCID: PMC8710136 DOI: 10.1111/add.15594] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/04/2021] [Accepted: 05/26/2021] [Indexed: 12/30/2022]
Abstract
AIMS To investigate whether reduction in opioid use differs when treated by either buprenorphine-naloxone (BUP) or methadone (MET) among adults with comorbid opioid use disorder (OUD) and mental disorders. DESIGN, SETTING AND PARTICIPANTS In a randomized controlled trial, adults with OUD were randomized to 24 weeks of either BUP or MET treatment and were followed up in 3-yearly assessments. The present secondary analyses were based on 597 participants who completed all assessments. MEASUREMENTS The outcome measure was the number of days of using opioids per month during the follow-up period. The Mini-International Neuropsychiatric Interview (MINI) was used to classify participants into three groups: life-time mood disorder (n = 302), life-time mental disorder other than mood disorder (n = 114) and no mental disorder (n = 181). Medication treatment (BUP, MET, no treatment) during the follow-up period was a time-varying predictor. FINDINGS Based on zero-inflated Poisson (ZIP) mixed regression analysis, it was found that relative to no treatment, opioid use during the follow-up was significantly reduced by BUP [odds ratio (OR) = 0.12, 95% confidence interval (CI) = 0.07-0.21 for any use; risk ratio (RR) = 0.77, 95% CI =0.66-0.89 for days of use] and by MET [OR = 0.33, 95% CI = 0.25-0.45 for any use; RR = 0.78, 95% CI = 0.72-0.84 for days of use]. Relative to MET, BUP was associated with a lower likelihood of any opioid use among participants with mood disorders (OR = 0.52, 95% CI = 0.36-0.74) and for participants without mental disorder (OR = 0.37, 95% CI = 0.21-0.66) and fewer number of days using opioids (RR = 0.37, 95% CI = 0.25-0.56) among participants with other mental disorders. CONCLUSIONS Among adults with comorbid opioid use disorder and mental disorders, treatment with buprenorphine-naloxone produced greater reductions in opioid use than treatment with methadone.
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Affiliation(s)
- Yih-Ing Hser
- Department of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Yuhui Zhu
- Department of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Zhe Fei
- Department of Biostatistics, University of California, Los Angeles, USA
| | - Larissa J. Mooney
- Department of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine, University of California, Los Angeles, USA,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Elizabeth A. Evans
- Department of Health Promotion and Policy, University of Massachusetts Amherst, Amherst, MA, USA
| | - Annemarie Kelleghan
- Department of Psychology, University of Southern California, Los Angeles, USA
| | | | - Caroline Yoo
- Department of Health Policy and Management at the Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Andrew J. Saxon
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, WA, Seattle, USA,Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
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227
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Paul N, Kennedy AJ, Taubenberger S, Chang JC, Hacker K. Provider perceptions of medication for opioid used disorder (MOUD): A qualitative study in communities with high opioid overdose death rates. Subst Abus 2022; 43:742-748. [PMID: 35100094 PMCID: PMC10960355 DOI: 10.1080/08897077.2021.2007518] [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: 10/19/2022]
Abstract
BACKGROUND Medication for Opioid Use Disorder (MOUD) has been shown to be a safe, cost-effective intervention that successfully lowers risk of opioid overdose. However, access to and use of MOUD has been limited. Our objective was to explore attitudes, opinions, and beliefs regarding MOUD among healthcare and social service providers in a community highly impacted by the opioid overdose epidemic. METHODS As part of a larger ethnographic study examining neighborhoods in Allegheny County, PA, with the highest opioid overdose death rates, semi-structured qualitative in-person and telephone interviews were conducted with forty-five providers treating persons with opioid use disorders in these communities. An open coding approach was used to code interview transcripts followed by thematic analysis. RESULTS Three major themes were identified related to MOUD from the perspectives of our provider participants. Within a variety of health and substance use service roles and settings, provider reflections revealed: (1) different opinions about MOUD as a transition to abstinence or as a long-term treatment; (2) perceived lack of uniformity and dissemination of accurate information of MOUD care, permitting differences in care, and (3) observed barriers to entry and navigation of MOUD, including referrals as a "word-of-mouth insider system" and challenges of getting patients MOUD services when they need it. CONCLUSIONS Even in communities hard hit by the opioid overdose epidemic, healthcare providers' disagreement about the standard of care for MOUD can be a relevant obstacle. These insights can inform efforts to improve MOUD treatment and access for people with opioid use disorders.
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Affiliation(s)
- Nicole Paul
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amy J. Kennedy
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Judy C. Chang
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Karen Hacker
- Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Georgia, USA
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228
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Mitchell SG, Nordeck CD, Lertch E, Ross TE, Welsh C, Schwartz RP, Gryczynski J. Patients with substance use disorders receiving continued care in skilled nursing facilities following hospitalization. Subst Abus 2022; 43:848-854. [PMID: 35179452 PMCID: PMC9793431 DOI: 10.1080/08897077.2021.2007512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.
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Affiliation(s)
| | - Courtney D. Nordeck
- Friends Research Institute, Inc., Baltimore, MD,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | - Christopher Welsh
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
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229
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Sarfi M, Eikemo M, Konijnenberg C. Children born to women in opioid maintenance treatment: A longitudinal study of child behavioral problems and parenting stress. Front Pediatr 2022; 10:1087956. [PMID: 36619511 PMCID: PMC9816796 DOI: 10.3389/fped.2022.1087956] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022] Open
Abstract
In the wake of the "opioid epidemic", there is considerable concern regarding potential harmful long-term effects of prenatal opioid exposure. Opioid misuse and addiction confer increased exposure to lifestyle stressors and health burdens. Accordingly, it is challenging to disentangle effects of prenatal opioid exposure per se from factors related to maternal stress. In this study, we followed 36 women enrolled in comprehensive opioid maintenance treatment (OMT) program and their children alongside 36 age-matched mother-child dyads from a community sample (COMP) from pregnancy until child-age 8 years. Across five sessions, we used a battery of well-established questionnaires to investigate trajectories of parenting stress and mental health symptoms as well as child behavior problems. The 8-year retention was relatively high (OMT: 72%, COMP: 67%), and the OMT sample remarkably stable and well-functioning, with minimal concomitant illicit drug use. Mixed effects regressions showed significantly different trajectories of child behavior problems (F = 3.8, p = 0.024) and parenting stress (F = 3.1, p = 0.016) in the two groups. Differences in experienced stress were largely explained by more distress specifically related to the parenting role in the OMT group (F = 9.7, p = 0.003). The OMT sample also reported higher psychological distress (F = 15.6, p < 0.001) than the comparison group, but notably few participants presented with problems that warranted clinical intervention. The results underscore the benefits of tailored follow-up of children prenatally exposed to opioids and their families beyond infancy and toddlerhood. Long-term direct effects of prenatal opioid exposure on behavior problems are likely modest, given an otherwise stable caregiving environment conducive to healthy development.
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Affiliation(s)
- Monica Sarfi
- Norwegian Centre for Addiction Research (SERAF), Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marie Eikemo
- Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway
| | - Carolien Konijnenberg
- Department of Psychology, Inland Norway University of Applied Sciences, Lillehammer, Norway
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230
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McCarty D, Chan B, Buchheit BM, Bougatsos C, Grusing S, Chou R. Effectiveness of and Access to Medications for Opioid Use Disorder for Adolescents and Young Adults: A Scoping Review. J Addict Med 2022; 16:e157-64. [PMID: 34282085 DOI: 10.1097/ADM.0000000000000898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE A scoping review assessed access to medications for opioid use disorder (MOUD) and treatment outcomes among adolescents (12 - 17 years) and young adults (18 - 25 years). METHODS Studies addressing adolescent and young adult opioid use disorder and treatment with MOUD on patient outcomes (eg, retention in care) were included. Randomized trials and controlled observational studies were prioritized. Investigators extracted key information, summarized findings, noted methodological weaknesses, and tabled the details. RESULTS The search identified 4 randomized trials (N = 241), 1 systematic review with 52 studies (total N = 125,994), and 5 retrospective analyses of health insurance claims. The trials reported buprenorphine and extended-release naltrexone reduced opioid use. Return to use was observed when pharmacotherapy ceased. A systematic review concluded that adolescents and young adults had lower retention in care than older adults. The observational studies found that adolescents were unlikely to receive MOUD. There was some evidence that non-Hispanic Black adolescents and young adults were less likely than non-Hispanic Whites to receive MOUD. CONCLUSIONS MOUD therapies reduce opioid use among adolescent and young adults but few receive MOUD. MOUD services for adolescents and young adults should be developed and tested. Randomized clinical trials are necessary to develop appropriate clinical guidelines for using MOUD with adolescents and young adults.
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231
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Cruz-Lebrón A, Johnson R, Mazahery C, Troyer Z, Joussef-Piña S, Quiñones-Mateu ME, Strauch CM, Hazen SL, Levine AD. Chronic opioid use modulates human enteric microbiota and intestinal barrier integrity. Gut Microbes 2021; 13:1946368. [PMID: 34313547 PMCID: PMC8317955 DOI: 10.1080/19490976.2021.1946368] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Over the past three decades the United States has experienced a devastating opioid epidemic. One of the many debilitating side effects of chronic opioid use is opioid-induced bowel dysfunction. We investigated the impact of methadone maintenance treatment (MMT) on the gut microbiome, the gut bacterial metabolite profile, and intestinal barrier integrity. An imbalance in key bacterial communities required for production of short-chain fatty acids (SCFAs), mucus degradation, and maintenance of barrier integrity was identified. Consistent with dysbiosis, levels of fecal SCFAs were reduced in MMT. We demonstrated that metabolites synthesized by Akkermansia muciniphila modulate intestinal barrier integrity in vitro by strengthening the pore pathway and regulating tight junction protein expression. This study provides essential information about the therapeutic potential of A. muciniphila and warrants development of new clinical strategies that aim to normalize the gut microbiome in individuals affected by chronic opioid use.
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Affiliation(s)
- Angélica Cruz-Lebrón
- Departments of Molecular Biology and Microbiology, Case Western Reserve University, Cleveland, USA
| | - Ramona Johnson
- Departments of Molecular Biology and Microbiology, Case Western Reserve University, Cleveland, USA
| | - Claire Mazahery
- Department of Pathology, Case Western Reserve University, Cleveland, USA
| | - Zach Troyer
- Departments of Molecular Biology and Microbiology, Case Western Reserve University, Cleveland, USA
| | | | - Miguel E. Quiñones-Mateu
- Department of Microbiology and Immunology, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Christopher M Strauch
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland, USA
| | - Stanley L. Hazen
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland, USA
| | - Alan D. Levine
- Departments of Molecular Biology and Microbiology, Case Western Reserve University, Cleveland, USA,Department of Pathology, Case Western Reserve University, Cleveland, USA,Departments of Pharmacology, Medicine, and Pediatrics, Case Western Reserve University, Cleveland, USA,CONTACT Alan D. Levine Case Western Reserve University School of Medicine (Wood W217C), 10900 Euclid Avenue, Cleveland, Ohio44106-4960
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232
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Hovelius E, Lindén E, Bengtsson H, Håkansson A. Self-Schema, Attachment Style, and Treatment Outcome of Patients in an Opiate Maintenance Treatment Unit. Front Psychol 2021; 12:595883. [PMID: 34916983 PMCID: PMC8670402 DOI: 10.3389/fpsyg.2021.595883] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/28/2021] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to explore self-schemas and attachment style among patients in a methadone or buprenorphine maintenance treatment program of opiate dependence, in relation to treatment outcome (relapse in substance use). The study included 84 patients (21 women and 63 men) in a psychiatric clinic in Malmö, Sweden, providing maintenance treatment of opiate dependence. Three self-report instruments were employed, Young Schema Questionnaire Short version (YSQ-S) and Young Parenting Inventory (YPI) for studying self-schemas and Experiences in Close Relationships–Relationship Structures questionnaire (ECR-RS) for studying attachment style. Demographical data and relapse in substance abuse were registered. The study demonstrated, unsurprisingly, that an insecure attachment style was more common in the group of patients compared to available general population reference data. Significant correlations were found between attachment style and core beliefs about the self (self-schemas). Memories of parenting experiences from childhood (YPI) showed correlations with ongoing self-schemas (YSQ-S). Treatment outcome, defined as relapses in substance abuse, was associated to a minor degree with self-schemas but showed no correlation with attachment style. Patients who did not work or study had more maladaptive self-schemas and insecure attachment style, and a higher incidence of relapse in abuse than patients who were working or studying.
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Affiliation(s)
- Emelie Hovelius
- Malmö Addiction Centre, Region Skåne, Malmö, Sweden.,Department of Psychology, Lund University, Lund, Sweden
| | - Ellen Lindén
- Department of Psychology, Lund University, Lund, Sweden
| | | | - Anders Håkansson
- Malmö Addiction Centre, Region Skåne, Malmö, Sweden.,Department of Clinical Science, Lund University, Lund, Sweden
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233
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Mozgunov P, Cro S, Lingford-Hughes A, Paterson LM, Jaki T. A dose-finding design for dual-agent trials with patient-specific doses for one agent with application to an opiate detoxification trial. Pharm Stat 2021; 21:476-495. [PMID: 34891221 PMCID: PMC7612599 DOI: 10.1002/pst.2181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 08/31/2021] [Accepted: 11/21/2021] [Indexed: 11/08/2022]
Abstract
There is a growing interest in early phase dose-finding clinical trials studying combinations of several treatments. While the majority of dose finding designs for such setting were proposed for oncology trials, the corresponding designs are also essential in other therapeutic areas. Furthermore, there is increased recognition of recommending the patient-specific doses/combinations, rather than a single target one that would be recommended to all patients in later phases regardless of their characteristics. In this paper, we propose a dose-finding design for a dual-agent combination trial motivated by an opiate detoxification trial. The distinguishing feature of the trial is that the (continuous) dose of one compound is defined externally by the clinicians and is individual for every patient. The objective of the trial is to define the dosing function that for each patient would recommend the optimal dosage of the second compound. Via a simulation study, we have found that the proposed design results in high accuracy of individual dose recommendation and is robust to the model misspecification and assumptions on the distribution of externally defined doses.
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Affiliation(s)
- Pavel Mozgunov
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Suzie Cro
- Imperial Clinical Trials Unit, School of Public Health, Imperial College, London, UK
| | - Anne Lingford-Hughes
- Division of Psychiatry, Department of Brain Sciences, Imperial College, London, UK
| | - Louise M Paterson
- Division of Psychiatry, Department of Brain Sciences, Imperial College, London, UK
| | - Thomas Jaki
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK.,Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
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234
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Wang DJ, Song P, Nault KM. Impact of intraoperative methadone use on postoperative opioid requirements after cardiac surgery. Am J Health Syst Pharm 2021; 79:636-642. [PMID: 34874991 DOI: 10.1093/ajhp/zxab459] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Inadequate pain control after cardiac surgery increases postoperative morbidity. Increasing evidence suggests that perioperative intravenous (IV) methadone results in improved analgesia. This study evaluated the effect of intraoperative IV methadone on postoperative opioid requirements and surgical recovery. METHODS A retrospective review of patients undergoing coronary artery bypass graft (CABG), valvular surgery or both between April 2017 and August 2018 was conducted. Patients were separated into a usual care cohort of those who received short-acting opioids (ie, IV fentanyl, hydromorphone, or morphine) alone or a methadone cohort of those who received IV methadone plus short-acting opioids. Opioid requirements were assessed within the first 24 hours of surgery (postoperative day [POD] 0) and 25 to 48 hours after surgery (POD 1) as oral morphine milligram equivalents (MME). Postoperative pain scores, adjunctive analgesia, time to extubation, use of noninvasive respiratory support (continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]), and intensive care unit (ICU) and hospital length of stay (LOS) were also evaluated. RESULTS A total of 117 patients were evaluated (methadone cohort, n = 52; usual care cohort, n = 65). Median cumulative intraoperative opioid consumption was less in the methadone cohort (150 MME vs 314.1 MME; P < 0.0001). The methadone cohort required 44% fewer MME than the usual care cohort on POD 0 (median MME, 15.8 vs 36; P = 0.025), with low and not significantly different opioid use in both cohorts on POD 1 (15.5 MME vs 7.5 MME; P = 0.47). Weight-based methadone dosing ranged from 0.1 to 0.4 mg/kg (mean, 0.22 mg/kg). There were no significant differences in pain scores, time to extubation, use of CPAP or BiPAP, or ICU and hospital LOS. CONCLUSION Intraoperative IV methadone in cardiac surgery patients was safe and significantly reduced intraoperative and postoperative opioid requirements on POD 0.
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Affiliation(s)
- David J Wang
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA
| | - Pingping Song
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Katharine M Nault
- Department of Pharmacy, Lahey Hospital & Medical Center, Burlington, MA, USA
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235
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Treillet E, Giet O, Picard S, Laurent S, Seresse L. Methadone Switching for Cancer Pain: A New Classification of Initiation Protocols, Based on a Critical Literature Review. J Palliat Med 2021; 24:1884-1894. [PMID: 34851186 DOI: 10.1089/jpm.2021.0309] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The initiation of methadone, a known effective analgesic for cancer pain, is complex. The existing protocols are often inadequately described; therefore, a classification of literature is needed. We reviewed and classified the recent literature on methadone initiation protocols in cancer patients experiencing severe pain. Objective: To provide a new classification of initiation protocols, based on a critical literature review. Data Sources: The MEDLINE database was searched for articles published until March 25, 2021, using the terms "cancer pain," "methadone," "methadone introduction," or "methadone initiation." The search was limited to human studies, randomized controlled trials (RCTs), other clinical trials, meta-analyses, and case reports. Selected articles were assessed for initiation details (rapid or progressive), administered dose (fixed rescue dose or ad libitum), and dose calculation (fixed or progressive ratios using morphine equivalent daily dose [MEDD] for daily or unitary dose). Results: Twenty-four publications that met our inclusion criteria were analyzed. No large-scale prospective double-blind RCTs with robust design were identified. Most studies assessed relatively small numbers of patients. Eight initiation types were identified, of which three involved seven "high quality" studies: "rapid switch-fixed doses and rescue dose-progressive daily ratio," "progressive switch-fixed dose and rescue dose-progressive daily ratio," and "rapid switch-ad libitum-fixed ratio for unitary dose" protocols. This classification provides the latest information on methadone initiation protocols. The total daily dose of methadone varied largely across protocols. Conclusion: We recommend a maximal daily methadone dose of 100 mg (3 doses of 30 mg or 5 doses of 20 mg) for MEDD <500 mg, when the two "ad libitum" protocols are used. Further clinical research on this topic is warranted.
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Affiliation(s)
- Erwan Treillet
- Pain Unit, Colmar Civil Hospital, Colmar, France.,Palliative Care Mobile Unit, Santé Centre Alsace, Colmar, France.,Pain Unit, APHP Lariboisiere Hospital, Paris, France
| | - Olivier Giet
- Palliative Care Unit, Colmar Civil Hospital, Colmar, France
| | - Stéphane Picard
- Palliative Care Unit, Hopital Diaconnesse Croix Saint Simon, Paris, France
| | | | - Laure Seresse
- Palliative Care Mobile Unit, APHP Pitie Salpetriere Hospital, Paris, France
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236
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Ching JH, Owens DK, Trafton JA, Goldhaber-Fiebert JD, Salomon JA. Impact of treatment duration on mortality among Veterans with opioid use disorder in the United States Veterans Health Administration. Addiction 2021; 116:3494-3503. [PMID: 33999485 PMCID: PMC8578188 DOI: 10.1111/add.15574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/18/2021] [Accepted: 05/05/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS While long-term medication-assisted treatment (MAT) using methadone or buprenorphine is associated with significantly lower all-cause mortality for individuals with opioid use disorder (OUD), periods of initiating or discontinuing treatment are associated with higher mortality risks relative to stable treatment. This study aimed to identify the OUD treatment durations necessary for the elevated mortality risks during treatment transitions to be balanced by reductions in mortality while receiving treatment. DESIGN Simulation model based on a compartmental model of OUD diagnosis, MAT receipt and all-cause mortality among Veterans with OUD in the United States Veterans Health Administration (VA) in 2017-2018. We simulated methadone and buprenorphine treatments of varying durations using parameters obtained through calibration and published meta-analyses of studies from North America, Europe and Australia. SETTING United States. PARTICIPANTS Simulated cohorts of 10 000 individuals with OUD. MEASUREMENTS All-cause mortality over 12 months. FINDINGS Receiving methadone for 4 months or longer or buprenorphine for 2 months or longer resulted in 54 [95% confidence interval (CI) = 5-90] and 65 (95% CI = 21-89) fewer deaths relative to not receiving MAT for the same duration, using VA-specific mortality rates. We estimated shorter treatment durations necessary to achieve net mortality benefits of 2 months or longer for methadone and 1 month or longer for buprenorphine, using non-VA population literature estimates. Sensitivity analyses demonstrated that necessary treatment durations increased more with smaller mortality reductions on treatment than with larger relative risks during treatment transitions. CONCLUSIONS Short periods (< 6 months) of treatment with either methadone or buprenorphine are likely to yield net mortality benefits for people with opioid use disorder relative to receiving no medications, despite periods of elevated all-cause mortality risk during transitions into and out of treatment. Retaining people with opioid use disorder in treatment longer can increase these benefits.
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Affiliation(s)
- Jack H. Ching
- Center for Health Policy and Center for Primary Care & Outcomes Research, Stanford University School of Medicine, Stanford, CA,Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, VA Palo Alto Health Care System, Menlo Park, CA
| | - Douglas K. Owens
- Center for Health Policy and Center for Primary Care & Outcomes Research, Stanford University School of Medicine, Stanford, CA,VA Palo Alto Health Care System, Palo Alto, CA
| | - Jodie A. Trafton
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, VA Palo Alto Health Care System, Menlo Park, CA
| | - Jeremy D. Goldhaber-Fiebert
- Center for Health Policy and Center for Primary Care & Outcomes Research, Stanford University School of Medicine, Stanford, CA
| | - Joshua A. Salomon
- Center for Health Policy and Center for Primary Care & Outcomes Research, Stanford University School of Medicine, Stanford, CA
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237
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Soyka M. Transition From Full Mu Opioid Agonists to Buprenorphine in Opioid Dependent Patients-A Critical Review. Front Pharmacol 2021; 12:718811. [PMID: 34887748 PMCID: PMC8650116 DOI: 10.3389/fphar.2021.718811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/05/2021] [Indexed: 12/28/2022] Open
Abstract
Methadone, a full opioid agonist at the mu-, kappa-, and delta-receptor, and buprenorphine, a partial agonist at the mu receptor, are first-line medications in opioid maintenance treatment. Transition from methadone to buprenorphine may precipitate withdrawal, and no accepted algorithm for this procedure has been developed. Current treatment strategies recommend transfer from methadone to buprenorphine predominantly in patients at low doses of methadone (30-40 mg/day). There are some reports indicating that transition from higher doses of methadone may be possible. A number of dosing strategies have been proposed to soften withdrawal symptoms and facilitate transfer including use of other opioids or medications and especially microdosing techniques for buprenorphine. The case series and studies available thus far are reviewed.
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Affiliation(s)
- Michael Soyka
- Psychiatric Hospital, University of Munich, Munich, Germany
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238
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Lloyd AR, Savage R, Eaton EF. Opioid use disorder: a neglected human immunodeficiency virus risk in American adolescents. AIDS 2021; 35:2237-2247. [PMID: 34387219 PMCID: PMC8563394 DOI: 10.1097/qad.0000000000003051] [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: 11/26/2022]
Abstract
In 2017 alone, 783 000 children aged 12-17 years misused opioids with 14 000 using heroin. Opioid misuse and opioid use disorder (OUD) in adolescents and young adults are significant barriers to ending the HIV epidemic. To address these synergistic scourges requires dedicated practitioners and improved access to life-saving evidence-based treatment. Adolescents and young adults make up over one in five new HIV diagnoses even though they are less likely to be tested or know they are infected. Adolescents and young adults living with HIV are less likely to be retained in care or achieve virological suppression. OUD further leads to increased rates of risky behaviours (like sex without condoms), deceased retention in HIV care and decreased rates of viral suppression in this vulnerable population. Medications for opioid use disorder (MOUD) are recommended for adolescents and young adults with severe OUD and help retain youth in HIV treatment and decrease risk of death. However, due to stigma and lack of experience prescribing MOUD in adolescents, MOUD is often perceived as a last line option. MOUD remains difficult to access for adolescents with a shortage of providers and decreased options for treatment as compared to adults. Addiction treatment is infection prevention, and integrated addiction and HIV services are recommended to improve health outcomes. A multipronged approach including patient education, provider training and policy changes to improve access to treatment and harm reduction are urgently needed confront the drug use epidemic in youth.
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Affiliation(s)
- Audrey R Lloyd
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham
| | - Rebekah Savage
- Division of Adolescent Medicine, University of Alabama at Birmingham
| | - Ellen F Eaton
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabamas, USA
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239
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Smith K, Wang M, Abdukalikov R, McAullife A, Whitesell D, Richard J, Sauer W, Quaye A. Pain Management Considerations in Patients with Opioid Use Disorder Requiring Critical Care. J Clin Pharmacol 2021; 62:449-462. [PMID: 34775634 DOI: 10.1002/jcph.1999] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/07/2021] [Indexed: 11/07/2022]
Abstract
The opioid epidemic has resulted in increased opioid-related critical care admissions, presenting challenges in acute pain management. Limited guidance exists in the management of critically ill patients with opioid use disorder (OUD). This narrative review provides the intensive care unit (ICU) clinician with guidance and treatment options, including non-opioid analgesia, for patients receiving medications for opioid use disorder (MOUD) and for patients actively misusing opioids. Verification and continuation of the patient's outpatient MOUD regimen, specifically buprenorphine and methadone formulations, assessment of pain and opioid withdrawal, and treatment of acute pain with non-opioid analgesia, nonpharmacologic strategies, and short-acting opioids as needed, are all essential to adequate management of acute pain in patients with OUD. A multidisciplinary approach to treatment and discharge planning in patients with OUD may be beneficial to engage patients with OUD early in their hospital stay to prevent withdrawal, stabilize their OUD, and to reduce the risk of unplanned discharge and other associated morbidity. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Kathryn Smith
- Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Michelle Wang
- Department of Pharmacy, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Ruslan Abdukalikov
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Amy McAullife
- Department of Psychiatry, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Dena Whitesell
- Department of Psychiatry, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Janelle Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - William Sauer
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.,Spectrum Healthcare Partners, 324 Gannett Dr, Suite 200, South Portland, ME, 04106, USA.,Department of Critical Care, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Aurora Quaye
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.,Spectrum Healthcare Partners, 324 Gannett Dr, Suite 200, South Portland, ME, 04106, USA
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240
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Bell J. What are the considerations in the pharmacological management of opioid addiction in adolescents? Expert Opin Pharmacother 2021; 23:155-157. [PMID: 34693842 DOI: 10.1080/14656566.2021.1998456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- James Bell
- School of Social Policy, University of New South Wales, Kings Cross, Australia.,Addictions Department, King's College London, London, UK
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241
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Chenworth M, Perrone J, Love JS, Graves R, Hogg-Bremer W, Sarker A. Methadone and suboxone ® mentions on twitter: thematic and sentiment analysis. Clin Toxicol (Phila) 2021; 59:982-991. [PMID: 33821724 PMCID: PMC9177078 DOI: 10.1080/15563650.2021.1893742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND According to the latest medical evidence, Methadone and buprenorphine-naloxone (Suboxone®) are effective treatments for opioid use disorder (OUD). While the evidence basis for the use of these medications is favorable, less is known about the perceptions of the general public about them. OBJECTIVE This study aimed to use Twitter to assess the public perceptions about methadone and buprenorphine-naloxone, and to compare their discussion contents based on themes/topics, subthemes, and sentiment. METHODS We conducted a descriptive analysis of a small and automatic analysis of a large volume of microposts ("tweets") that mentioned "methadone" or "suboxone". In the manual analysis, we categorized the tweets into themes and subthemes, as well as by sentiment and personal experience, and compared the information posted about these two medications. We performed automatic topic modeling and sentiment analysis over large volumes of posts and compared the outputs to those from the manual analyses. RESULTS We manually analyzed 900 tweets, most of which related to access (15.3% for methadone; 14.3% for buprenorphine-naloxone), stigma (17.0%; 15.5%), and OUD treatment (12.8%; 15.6%). Only a small proportion of tweets (16.4% for Suboxone® and 9.3% for methadone) expressed positive sentiments about the medications, with few tweets describing personal experiences. Tweets mentioning both medications primarily discussed MOUD broadly, rather than comparing the two medications directly. Automatic topic modeling revealed topics from the larger dataset that corresponded closely to the manually identified themes, but sentiment analysis did not reveal any notable differences in chatter regarding the two medications. CONCLUSIONS Twitter content about methadone and Suboxone® is similar, with the same major themes and similar sub-themes. Despite the proven effectiveness of these medications, there was little dialogue related to their benefits or efficacy in the treatment of OUD. Perceptions of these medications may contribute to their underutilization in combatting OUDs.
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Affiliation(s)
- Megan Chenworth
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer S. Love
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Rachel Graves
- Department of Emergency Medicine, Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Whitney Hogg-Bremer
- Department of Biomedical Informatics, School of Medicine, Emory University, Atlanta, GA, USA
| | - Abeed Sarker
- Department of Biomedical Informatics, School of Medicine, Emory University, Atlanta, GA, USA
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242
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Menard S, Jhawar A. Microdose induction of buprenorphine-naloxone in a patient using high dose methadone: A case report. Ment Health Clin 2021; 11:369-372. [PMID: 34824962 PMCID: PMC8582770 DOI: 10.9740/mhc.2021.11.369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 10/04/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Buprenorphine is a partial mu-opioid receptor agonist approved for the treatment of opioid dependence. The risk of withdrawal symptoms and wait time required to safely initiate buprenorphine provides challenges to both patients and providers. Microdose induction is proposed as a possible solution to ease the transition to buprenorphine; however, little data has been published to date on patients stabilized on methadone doses greater than 100 mg. CASE REPORT A 29-year-old patient stabilized on methadone 105 mg was successfully transitioned to sublingual buprenorphine-naloxone using a 7-day microdose protocol on an inpatient psychiatric service. During the transition, the patient reported only minimal symptoms. CONCLUSION This report adds to the growing literature supporting the use of a microdose induction to initiate buprenorphine-naloxone. Additionally, this approach may be significant for patients stabilized on high doses of methadone who may not be able to tolerate a traditional buprenorphine induction.
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Affiliation(s)
- Shannon Menard
- Clinical Pharmacy Specialist, Department of Pharmacy Services, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois; Clinical Pharmacy Specialist, University of Illinois at Chicago, College of Pharmacy, Chicago, Illinois
| | - Archana Jhawar
- Clinical Pharmacy Specialist, Department of Pharmacy Services, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois; Clinical Pharmacy Specialist, University of Illinois at Chicago, College of Pharmacy, Chicago, Illinois
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243
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Bharat C, Larney S, Barbieri S, Dobbins T, Jones NR, Hickman M, Gisev N, Ali R, Degenhardt L. The effect of person, treatment and prescriber characteristics on retention in opioid agonist treatment: a 15-year retrospective cohort study. Addiction 2021; 116:3139-3152. [PMID: 33979008 DOI: 10.1111/add.15514] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/30/2020] [Accepted: 03/24/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND AIMS There is limited evidence on the relationship between retention in opioid agonist treatment for opioid dependence and characteristics of treatment prescribers. This study estimated retention in buprenorphine and methadone treatment and its relationship with person, treatment and prescriber characteristics. DESIGN Retrospective longitudinal study. SETTING New South Wales, Australia. PARTICIPANTS People entering the opioid agonist treatment programme for the first time between August 2001 and December 2015. MEASUREMENTS Time in opioid agonist treatment (primary outcome) was modelled using a generalized estimating equation model to estimate associations with person, treatment and prescriber characteristics. FINDINGS The impact of medication type on opioid agonist treatment retention reduced over time; the risk of leaving treatment when on buprenorphine compared with methadone was higher among those who entered treatment earlier [e.g. 2001-03: odds ratio (OR) = 1.59, 95% confidence interval (CI) = 1.45-1.75] and lowest among those who entered most recently (2013-15: OR = 1.23, 95% CI = 1.11-1.36). In adjusted analyses, risk of leaving was reduced among people whose prescriber had longer tenure of prescribing (e.g. 3 versus 8 years: OR = 0.94, 95% CI = 0.93-0.95) compared with prescribers with shorter tenure. Aboriginal and Torres Strait Islander people, being of younger age, past-year psychosis disorder and having been convicted of more criminal charges in the year prior to treatment entry were associated with increased risk of leaving treatment. CONCLUSION In New South Wales, Australia, retention in buprenorphine treatment for opioid dependence, compared with methadone, has improved over time since its introduction in 2001. Opioid agonist treatment retention is affected not only by characteristics of the person and his or her treatment, but also of the prescriber, with those of longer prescribing tenure associated with increased retention of people in opioid agonist treatment.
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Affiliation(s)
- Chrianna Bharat
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Sarah Larney
- Université de Montréal and Centre de Recherche du CHUM, Montreal, Canada
| | | | - Timothy Dobbins
- School of Population Health, UNSW Sydney, Sydney, NSW, Australia
| | - Nicola R Jones
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Robert Ali
- Department of Pharmacology, University of Adelaide, Adelaide, SA, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
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244
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Logan G, Mirajkar A, Houck J, Rivera-Alvarez F, Drone E, Patel P, Craen A, Dub L, Elahi N, Lebowitz D, Walker A, Ganti L. Physician-Perceived Barriers to Treating Opioid Use Disorder in the Emergency Department. Cureus 2021; 13:e19923. [PMID: 34966614 PMCID: PMC8710303 DOI: 10.7759/cureus.19923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2021] [Indexed: 11/17/2022] Open
Abstract
Objective We aimed to assess physicians' perceptions of barriers to starting medication-assisted treatment (MAT) in the Emergency Department (ED), views of the utility of MAT, and abilities to link patients with opioid use disorder (OUD) to MAT programs in their respective communities. Methods This was a cross-sectional survey study of American emergency medicine (EM) physicians with a self-administered online survey via SurveyMonkey (Survey Monkey, San Mateo, California). The survey was emailed to the Council of Residency Directors in Emergency Medicine (CORD) listserv and HCA Healthcare affiliated EM residency programs' listservs. Attendings and residents of all post-graduate years participated. Questions assessed perceptions of barriers to starting OUD patients on MAT, knowledge of the X-waiver, and knowledge of MAT details. Statistics were performed with JMP software (SAS Institute Inc., Cary, NC) using the two-tailed Z-test for proportions. Results There were 98 responses, with 33% female, 55% resident physicians, and an overall 17% response rate. Residents were more eager to start OUD patients on MAT (71% vs 52%, p=0.04) than attendings but were less familiar with the X-waiver (38% vs 73%, p=0.001) or where community outpatient MAT facilities were (21% vs 43%, p=0.02). Conclusion Barriers in the ED were identified as a shortage of qualified prescribers, the lengthy X-waiver process, and the poor availability of outpatient MAT resources. EM residents showed more willingness to prescribe MAT but lacked a core understanding of the process. This shows an area of improvement for residency training as well as advocacy among attendings.
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Affiliation(s)
- Gideon Logan
- Emergency Medicine, University of Central Florida/Hospital Corporation of America Graduate Medical Education (HCA GME) Consortium Emergency Medicine Residency Program of Greater Orlando, Orlando, USA
- Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
| | - Amber Mirajkar
- Emergency Medicine, University of Central Florida/Hospital Corporation of America Graduate Medical Education (HCA GME) Consortium Emergency Medicine Residency Program of Greater Orlando, Orlando, USA
- Emergency Medicine, Envision Physician Services, Plantation, USA
- Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
| | - Jessica Houck
- Emergency Medicine, University of Kentucky College of Medicine, Lexington, USA
| | - Fernando Rivera-Alvarez
- Emergency Medicine, University of Central Florida/Hospital Corporation of America Graduate Medical Education (HCA GME) Consortium Emergency Medicine Residency Program of Greater Orlando, Orlando, USA
- Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
| | - Emily Drone
- Department of Pediatric Emergency Medicine, Orlando Health, Orlando, USA
| | - Parth Patel
- Emergency Medicine, University of Central Florida/Hospital Corporation of America Graduate Medical Education (HCA GME) Consortium Emergency Medicine Residency Program of Greater Orlando, Orlando, USA
- Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
| | - Alexandra Craen
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Larissa Dub
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
- Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
| | - Nubaha Elahi
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
- Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
| | - David Lebowitz
- Emergency Medicine, University of Central Florida/Hospital Corporation of America Graduate Medical Education (HCA GME) Consortium Emergency Medicine Residency Program of Greater Orlando, Orlando, USA
- Emergency Medicine, Envision Physician Services, Plantation, USA
- Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
- Clinical Sciences, University of Central Florida College of Medicine, Orlando, USA
| | - Ayanna Walker
- Emergency Medicine, University of Central Florida College of Medicine/Hospital Corporation of America (HCA) Healthcare Graduate Medical Education Consortium of Greater Orlando, Orlando, USA
- Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
| | - Latha Ganti
- Emergency Medicine, University of Central Florida/Hospital Corporation of America Graduate Medical Education (HCA GME) Consortium Emergency Medicine Residency Program of Greater Orlando, Orlando, USA
- Emergency Medicine, Envision Physician Services, Plantation, USA
- Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
- Clinical Sciences, University of Central Florida College of Medicine, Orlando, USA
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Maina G, Marshall K, Sherstobitof J. Untangling the Complexities of Substance Use Initiation and Recovery: Client Reflections on Opioid Use Prevention and Recovery From a Social-Ecological Perspective. Subst Abuse 2021; 15:11782218211050372. [PMID: 34675526 PMCID: PMC8524687 DOI: 10.1177/11782218211050372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/15/2021] [Indexed: 11/17/2022]
Abstract
Background: In Canada, the rate of opioid use, opioid use disorder (OUD), and associated
mortality and morbidity are higher among Indigenous Peoples than the general
population. Indigenous Peoples on medications for opioid use disorders
(MOUD) often face distinct barriers that hinder their clinical progress,
leading to treatment attrition. Methods: We used a social-ecological model to inquire into clients’ experiences with a
history of treatment failure for OUD. We used exploratory qualitative
research to engage 22 clients with a history of OUD treatment dropouts and
who are currently on MOUD. In-depth, semi-structured interviews lasting an
average of 30 minutes were conducted on-site. Results: We identified 4 themes from the study: (a) risk for substance use; (b)
factors sustaining substance use; (c) factors leading to treatment, and (d)
treatment failure and re-enrollment. Conclusion: Using a socio-ecological model helps to understand factors that influence an
individual’s risk for OUD, decision to pursue treatment, and treatment
outcomes. Furthermore, social ecological model also creates possibilities to
develop supportive, multilevel interventions to prevent OUD risks and
support for clients on MOUD. Such interventions include mitigating adverse
childhood experiences, supporting families, and creating safe community
environments.
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Giannetto C, Macrì F, Falcone A, Giudice E, Crupi R, Cicero L, Cassata G, Staffieri F, Di Pietro S. Evaluation of Tear Production as Measured by Schirmer Test I in Dogs after Acepromazine and Acepromazine- Methadone Premedication. Animals (Basel) 2021; 11:3015. [PMID: 34827748 DOI: 10.3390/ani11113015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Different sedatives and anesthetic drugs have been reported to cause adverse ocular side effects, such as an exposure keratopathy due to loss of eyelid reflex, lagophthalmos, reduced stability of the tear film and decreased basal tear production. In the present study, the effects of two sedation protocols, acepromazine (ACP) and acepromazine–methadone (ACP–MET) combination, on tear production measured by the Schirmer Tear Test (STT) 1 on canine eyes were investigated, hypothesizing that both sedation protocols cause a reduction in canine tear production for a variable time. A significant decrease in tear production until 2 h after drug administration compared to basal tear values was observed in the ACP experimental protocol, while in the ACP + MET protocol, this reduction persisted until 8 h. In the ACP + MET group, after 40 min, 100% of dogs showed STT 1 readings lower than 15 mm/min, which could predispose them to corneal injuries. The major reduction in tear production due to the ACP + MET protocol proves the need for adequate corneal hydration, particularly to discourage its use in animals with altered tear production. Abstract The purpose of the current study was to investigate the effects of two commonly used sedation protocols in dogs, acepromazine (ACP) and acepromazine–methadone (ACP–MET) combination, on tear production measured by the Schirmer Tear Test (STT) 1. We hypothesized that both sedation protocols cause a reduction in canine tear production for a variable time. Fifteen client-owned dogs were recruited for the study. Each dog was subjected to sedation twice, 2–3 weeks apart, and they were randomly allocated to one of two groups receiving ACP (0.015 mg kg−1) or ACP–MET (0.010 mg kg−1 and 0.2 mg kg−1) intramuscularly. In both eyes, tear production was measured 15 min before sedation (T0) and 20 min (T20 m), 40 min (T40 m), 1 h (T1), 2 h (T2), 4 h (T4) and 8 h (T8), after drug administration. Two-way repeated measures ANOVA, followed by the Bonferroni post hoc test (p < 0.05), showed a significant effect of time (p < 0.0001) and treatment (p < 0.0001). A significant decrease in tear production at T20 m, T40 m, T1 and T2 compared to T0 was observed in the ACP experimental protocol, while in the ACP + MET protocol, this reduction persisted until T8. Comparing the two experimental protocols, no statistically significant differences were observed at T0 or T20 m, and STT 1 values were statistically lower in the ACP + MET than the ACP protocol at the other data points. In the ACP + MET group, at T40 m, 100% of dogs showed STT 1 readings lower than 15 mm/min. This finding is clinically relevant as it can predispose dogs to corneal injuries. The major reduction in tear production due to the ACP + MET protocol proves the need for adequate corneal hydration, particularly to discourage its use in animals with altered tear production. The data obtained provide important information helping clinicians to better manage the drug’s effects on tear production.
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Amram O, Amiri S, Panwala V, Lutz R, Joudrey PJ, Socias E. The impact of relaxation of methadone take-home protocols on treatment outcomes in the COVID-19 era. Am J Drug Alcohol Abuse 2021; 47:722-729. [PMID: 34670453 DOI: 10.1080/00952990.2021.1979991] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Background: In response to the COVID-19 pandemic, the US Substance Abuse and Mental Health Services Administration (SAMHSA) allowed for an increase in methadone take-home doses for the treatment of Opioid Use Disorder (OUD) in March 2020. OBJECTIVE To evaluate the effects of the SAMSHA exemption on methadone adherence and OUD-related outcomes. METHODS A convenience sample of 183 clients (58% female) were recruited from a methadone clinic in the fall of 2019 for a cross-sectional survey. Survey data was linked to clinical records, including urine drug testing (UDT) results for methadone and emergency department (ED) visits at the local hospital. Participants were on stable methadone dosing for 9 months prior to and following March 2020. Methadone adherence was assessed by UDTs; OUD-related outcomes were assessed by overdose events and ED visits. Logistic regression was used to assess the association between change in take-home methadone doses and outcomes. RESULTS Mean take-home doses increased nearly 200% (11.4 doses/30 days pre-COVID-19 vs. 22.3 post-SAMHSA exemption). ED visits dropped from 74 (40.4%) pre-COVID-19 to 56 (30.6%) post-SAMHSA exemption (p = <0.001). No significant changes were observed in either the number of clients experiencing overdose or those who experienced one or more methadone negative UDTs in the post-SAMHSA exemption period. Adjusted models did not show a significant association between changes in take-home doses and associated outcomes. CONCLUSIONS Despite a near-doubling of take-home methadone doses during the COVID-19 exemption period, the increase in take-home doses was not associated with negative treatment outcomes in methadone-adherent clients.
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Affiliation(s)
- Ofer Amram
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA.,Paul G. Allen School for Global Animal Health, Washington State University, Pullman, WA, USA
| | - Solmaz Amiri
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Victoria Panwala
- Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Robert Lutz
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA.,Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Paul J Joudrey
- Yale Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Eugenia Socias
- Faculty of Medicine, British Columbia Centre on Substance Use, University of British Columbia, Vancouver, Canada.,Department of Medicine, University of British Columbia, Vancouver, Canada
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248
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Murakami S, Asada T, Kubota T, Kawakami H, Kokubun H, Uezono Y. A Successful Case of Switching Treatment from Ketamine to Methadone for Complex Neuropathic Pain. J Palliat Med 2021; 25:686-689. [PMID: 34665046 DOI: 10.1089/jpm.2021.0056] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Methadone is frequently used for the management of complex pain at the end of life by palliative care specialists. It is also used in low doses as an add-on therapy to chronic opioid treatment of cancer-related pain, usually with good effect, and without any reported severe adverse effects. However, there are few reports of switching from ketamine to methadone. Case: We report a case of a patient with rectal cancer and intractable pain. Switching from ketamine to methadone to maintain analgesia was successfully carried out without impacting activities of daily living. Established measurement tools, such as numerical rating scale, Douleur Neuropathique, Functional Independence Measure, and Barthel Index, were used. Conclusion: Switching from ketamine to methadone may be beneficial in relieving refractory cancer-related neuropathic pain without decreasing functioning.
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Affiliation(s)
- Satoshi Murakami
- Department of Palliative Medicine, Seirei Sakura Citizen Hospital, Chiba, Japan
| | - Takaaki Asada
- Department of Rehabilitation, Chiba Emergency Medical Center, Chiba, Japan
| | - Toru Kubota
- Department of Palliative Medicine, Seirei Sakura Citizen Hospital, Chiba, Japan
| | - Hiroyuki Kawakami
- Department of Radiation Oncology, Seirei Sakura Citizen Hospital, Chiba, Japan
| | - Hideya Kokubun
- Center for Experiential Pharmacy Practice, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Yasuhito Uezono
- Department of Pain Control Research, The Jikei University School of Medicine, Tokyo, Japan
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249
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Zhu J, Wang S, Liu Y, Wang F, Li Q, Li Z, Sun Y, Li W, Wang W. The influence of methadone on cerebral gray matter and functional connectivity. Ann Palliat Med 2021; 10:9497-9507. [PMID: 34628875 DOI: 10.21037/apm-21-2012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/18/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Methadone maintenance treatment (MMT) is widely used for heroin use disorder. Although its curative effect is remarkable, there are problems associated with its use. While previous studies have found that methadone use may have certain effects on cerebral white matter, its effect on gray matter (GM) and its related neural networks is unclear. This study aimed to observe the effects of long-term methadone use on cerebral GM and the changes in related neural networks. METHODS Patients receiving MMT treatment for heroin use disorder (N=50) were recruited. Longitudinal self-control was adopted, and the voxel-based morphometry (VBM) was used to compare the difference in cerebral GM volume before and after 1 year of methadone use, then we select the brain region where the GM volume changed as the region of interest (ROI), and use the DPARSF software for the whole brain function connection, and the differences in brain function connections before and after 1year MMT treatment were compared. RESULTS Our results demonstrated that, after 1 year of MMT, patients showed smaller GM volume in the bilateral insula, occipital lingual gyrus, right cingulate gyrus, middle temporal gyrus, left inferior parietal lobule, caudate nucleus, temporal, and occipital regions, and the resting neural network of the brain also changed. CONCLUSIONS We speculate that long-term methadone use can lead to damage to GM structure and adaptive changes in the neural network of patients with heroin use disorder, mainly involving emotional perception, spatial localization, working memory, and other related functions.
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Affiliation(s)
- Jia Zhu
- Department of Radiology, Tangdu Hospital, the Air Force Medical University, Xi'an, China
| | - Shu Wang
- Canon Organization, Canon Medical Systems (China) Co., LTD, MR Division, Xi'an, China
| | - Yan Liu
- Department of Radiology, Tangdu Hospital, the Air Force Medical University, Xi'an, China
| | - Fan Wang
- Department of Radiology, Tangdu Hospital, the Air Force Medical University, Xi'an, China
| | - Qiang Li
- Department of Radiology, Tangdu Hospital, the Air Force Medical University, Xi'an, China
| | - Zhe Li
- Department of Radiology, Tangdu Hospital, the Air Force Medical University, Xi'an, China
| | - Yichen Sun
- Department of Radiology, Tangdu Hospital, the Air Force Medical University, Xi'an, China
| | - Wei Li
- Department of Radiology, Tangdu Hospital, the Air Force Medical University, Xi'an, China
| | - Wei Wang
- Department of Radiology, Tangdu Hospital, the Air Force Medical University, Xi'an, China
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Abstract
Pharmacological treatments for opioid use disorders (OUDs) may have mixed efficacy across diverse groups, i.e., sex/gender, race/ethnicity, and socioeconomic status (SES). The present systematic review aims to examine how diverse groups have been included in U.S. randomized clinical trials examining pharmacological treatments (i.e., methadone, buprenorphine, or naltrexone) for OUDs. PubMed was systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The initial search yielded 567 articles. After exclusion of ineligible articles, 50 remained for the present review. Of the included articles, 14.0% (n = 7) reported both full (i.e., accounting for all participants) sex/gender and race/ethnicity information; only two of those articles also included information about any SES indicators. Moreover, only 22.0% (n = 11) reported full sex/gender information, and 42.0% (n = 21) reported full racial/ethnic information. Furthermore, only 10.0% (n = 5) reported that their lack of subgroup analyses or diverse samples was a limitation to their studies. Particularly underrepresented were American Indian/Alaska Native (AI/AN), Asian, Native Hawaiian/Other Pacific Islander (NH/OPI), and multiracial individuals. These results also varied by medication type; Black individuals were underrepresented in buprenorphine randomized controlled trials (RCTs) but were well represented in RCTs for methadone and/or naltrexone. In conclusion, it is critical that all people receive efficacious pharmacological care for OUDs given the ongoing opioid epidemic. Findings from the present review, however, support that participants from diverse or marginalized backgrounds are underrepresented in treatment trials, despite being at increased risk for disparities related to OUDs. Suggestions for future research are advanced. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Tessa Nalven
- Department of Psychology, University of Rhode Island
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