Buprenorphine for managing opioid withdrawal

Sex differences in comorbid pain and opioid use disorder: A scoping review

Opioid use disorder (OUD) and chronic pain are commonly co-occurring disorders which can exacerbate each other. Sex/gender differences have been shown in aspects of the clinical course and biological underpinnings of both OUD and chronic pain. The purpose of this scoping review is to summarize literature which has addressed sex/gender differences in relation to the confluence of OUD and chronic pain. This review focused on peer-reviewed journal articles with human subjects and addressing (a) opioid misuse, chronic opioid use or opioid use disorder (OUD), (b) chronic or persistent pain and (c) sex/gender differences in relation to OUD and/or chronic pain. Of the 146 papers identified by the search strategy, 30 met the criteria for inclusion. Charting focused on a priori themes of chronic pain, opioid misuse/OUD and sex/gender in sample, predictor and outcome variables, and key study findings. The majority of research identified was cross-sectional in nature, and sex/gender differences and treatment effects were largely included as post-hoc analyses. Together, the results of this early work align with higher prevalence for OUD in men/males and chronic pain in women/females, while adding critical information with respect to potential sex/gender differences in the development and treatment of their co-occurrence across a range of biological and psychosocial factors. Findings underline the importance of considering sex and gender in the intersection of the development and treatment of OUD and chronic pain.

A historical perspective on clonidine as an alpha-2A receptor agonist in the treatment of addictive behaviors: Focus on opioid dependence

Clonidine operates through agonism at the alpha-2A receptor, a specific subtype of the alpha-2-adrenergic receptor located predominantly in the prefrontal cortex. By inhibiting the release of norepinephrine, which is responsible for withdrawal symptoms, clonidine effectively addresses withdrawal-related conditions such as anxiety, hypertension, and tachycardia. The groundbreaking work by Gold et al. demonstrated clonidine's ability to counteract the effects of locus coeruleus stimulation, reshaping the understanding of opioid withdrawal within the field. In the 1980s, the efficacy of clonidine in facilitating the transition to long-acting injectable naltrexone was confirmed for individuals motivated to overcome opioid use disorders (OUDs), including physicians and executives. Despite challenges with compliance, naltrexone offers sustained blockade of opioid receptors, reducing the risk of overdose, intoxication, and relapse in motivated patients in recovery. The development of clonidine and naltrexone as treatment modalities for OUDs, and potentially other addictions, including behavioral ones, underscores the potential for translating neurobiological advancements from preclinical models (bench) to clinical practice (bedside), ushering in innovative approaches to addiction treatment.

At a Crossroads: Opioid Use Disorder, the X-Waiver, and the Road Ahead

Background: Buprenorphine/naloxone (Suboxone) is widely considered the first-line treatment for opioid use disorder (OUD), which causes significant morbidity and mortality in the United States, but prior to 2023, practitioners interested in prescribing buprenorphine/naloxone for OUD needed a special Drug Enforcement Administration certification (the X-Waiver) that imposed a patient cap and other limitations. The Consolidated Appropriations Act of 2023 considerably decreased the restrictions on prescribing practitioners. Buprenorphine/naloxone can now be prescribed like any other prescription opioid, excluding methadone. The historic context for the opioid crisis, OUD, the X-Waiver, and additional initiatives that may be needed beyond legislative change to effectively address OUD are the subjects of this review. Methods: To develop this review of the opioid crisis, OUD, and OUD treatment, we conducted a literature search of the PubMed database and constructed a timeline of the opioid crisis and changes in OUD treatment, specifically the X-Waiver, to characterize the historic context of OUD and the X-Waiver against the background of the opioid crisis. Results: The opioid crisis has had pervasive public health and economic impacts in the United States. Major changes to the treatment of OUD have occurred as a result of the Drug Addiction Treatment Act of 2000 that imposed the X-Waiver and the Consolidated Appropriations Act of 2023 that repealed the X-Waiver. Conclusion: The repeal of the X-Waiver is predicted to increase the accessibility of buprenorphine/naloxone in the United States. However, additional work beyond legislative change, including institutional support and reduction of stigma and disparities, is needed to substantially improve outcomes for OUD patients.

Prevalence and correlates of DSM-5 opioid withdrawal syndrome in U.S. adults with non-medical use of prescription opioids: results from a national sample

Background: In the U.S. non-medical use of prescription opioids (NMOU) is prevalent and often accompanied by opioid withdrawal syndrome (OWS). OWS has not been studied using nationally representative data.Objectives: We examined the prevalence and clinical correlates of OWS among U.S. adults with NMOU.Methods: We used data from 36,309 U.S. adult participants in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, 1,527 of whom reported past 12-month NMOU. Adjusted linear and logistic regression models examined associations between OWS and its clinical correlates, including psychiatric disorders, opioid use disorder (OUD; excluding the withdrawal criterion), medical conditions, and healthcare utilization among people with regular (i.e. ≥3 days/week) NMOU (n = 534).Results: Over half (50.4%) of the sample was male. Approximately 9% of people with NMOU met criteria for DSM-5 OWS, with greater prevalence of OWS (∼20%) among people with regular NMOU. Individuals with bipolar disorder, dysthymia, panic disorder, and borderline personality disorder had greater odds of OWS (aOR range = 2.71-4.63). People with OWS had lower mental health-related quality of life (β=-8.32, p < .001). Individuals with OUD also had greater odds of OWS (aOR range = 26.02-27.77), an association that increased with more severe OUD. People using substance use-related healthcare services also had greater odds of OWS (aOR range = 6.93-7.69).Conclusion: OWS was prevalent among people with OUD and some psychiatric disorders. These findings support screening for OWS in people with NMOU and suggest that providing medication- assisted treatments and behavioral interventions could help to reduce the burden of withdrawal in this patient population.

Case report: The lesson from opioid withdrawal symptoms mimicking paraganglioma recurrence during opioid deprescribing in cancer pain

Pain is one of the predominant and troublesome symptoms that burden cancer patients during their whole disease trajectory: adequate pain management is a fundamental component of cancer care. Opioid are the cornerstone of cancer pain relief therapy and their skillful management must be owned by physicians approaching cancer pain patients. In light of the increased survival of cancer patients due to advances in therapy, deprescription should be considered as a part of the opioid prescribing regime, from therapy initiation, dose titration, and changing or adding drugs, to switching or ceasing. In clinical practice, opioid tapering after pain remission could be challenging due to withdrawal symptoms' onset. Animal models and observations in patients with opioid addiction suggested that somatic and motivational symptoms accompanying opioid withdrawal are secondary to the activation of stress-related process (mainly cortisol and catecholamines mediated). In this narrative review, we highlight how the lack of validated guidelines and tools for cancer patients can lead to a lower diagnostic awareness of opioid-related disorders, increasing the risk of developing withdrawal symptoms. We also described an experience-based approach to opioid withdrawal, starting from a case-report of a symptomatic patient with a history of metastatic pheochromocytoma-paraganglioma.

Trial protocol of an open label pilot study of lisdexamfetamine for the treatment of acute methamphetamine withdrawal

Introduction

Methamphetamine (MA) use disorder is an important public health concern. MA withdrawal is often the first step in ceasing or reducing use. There are no evidence-based withdrawal treatments, and no medication is approved for the treatment of MA withdrawal. Lisdexamfetamine (LDX) dimesilate, used in the treatment of attention deficit hyperactivity disorder and binge eating disorder has the potential as an agonist therapy to ameliorate withdrawal symptoms, and improve outcomes for patients.

Methods

A single arm, open-label pilot study to test the safety and feasibility of LDX for the treatment of MA withdrawal. Participants will be inpatients in a drug and alcohol withdrawal unit, and will receive a tapering dose of LDX over five days: 250mg LDX on Day 1, reducing by 50mg per day to 50mg on Day 5. Optional inpatient Days 6 and 7 will allow for participants to transition to ongoing treatment. Participants will be followed-up on Days 14, 21 and 28. All participants will also receive standard inpatient withdrawal care. The primary outcomes are safety (measured by adverse events, changes in vital signs, changes in suicidality and psychosis) and feasibility (the time taken to enrol the sample, proportion of screen / pre-screen failures). Secondary outcomes are acceptability (treatment satisfaction questionnaire, medication adherence, concomitant medications, qualitative interviews), retention to protocol (proportion retained to primary and secondary endpoints), changes in withdrawal symptoms (Amphetamine Withdrawal Questionnaire) and craving for MA (visual analogue scale), and sleep outcomes (continuous actigraphy and daily sleep diary).

Discussion

This is the first study to assess lisdexamfetamine for the treatment of acute MA withdrawal. If safe and feasible results will go to informing the development of multi-centre randomised controlled trials to determine the efficacy of the intervention.

Discovery of the cyclotide caripe 11 as a ligand of the cholecystokinin-2 receptor

The cholecystokinin-2 receptor (CCK2R) is a G protein-coupled receptor (GPCR) that is expressed in peripheral tissues and the central nervous system and constitutes a promising target for drug development in several diseases, such as gastrointestinal cancer. The search for ligands of this receptor over the past years mainly resulted in the discovery of a set of distinct synthetic small molecule chemicals. Here, we carried out a pharmacological screening of cyclotide-containing plant extracts using HEK293 cells transiently-expressing mouse CCK2R, and inositol phosphate (IP1) production as a readout. Our data demonstrated that cyclotide-enriched plant extracts from Oldenlandia affinis, Viola tricolor and Carapichea ipecacuanha activate the CCK2R as measured by the production of IP1. These findings prompted the isolation of a representative cyclotide, namely caripe 11 from C. ipecacuanha for detailed pharmacological analysis. Caripe 11 is a partial agonist of the CCK2R (Emax = 71%) with a moderate potency of 8.5 µM, in comparison to the endogenous full agonist cholecystokinin-8 (CCK-8; EC50 = 11.5 nM). The partial agonism of caripe 11 is further characterized by an increase on basal activity (at low concentrations) and a dextral-shift of the potency of CCK-8 (at higher concentrations) following its co-incubation with the cyclotide. Therefore, cyclotides such as caripe 11 may be explored in the future for the design and development of cyclotide-based ligands or imaging probes targeting the CCK2R and related peptide GPCRs.

Innovating for real-world care: A systematic review of interventions to improve post-detoxification outcomes for opioid use disorder

BACKGROUND

Inpatient detoxification is a common health care entry point for people with Opioid Use Disorder (OUD). However, many patients return to opioid use after discharge and also do not access OUD treatment. This systematic review reports on the features and findings of research on interventions developed specifically to improve substance use outcomes and treatment linkage after inpatient detoxification for OUD.

METHODS

Of 6419 articles, 64 met inclusion criteria for the current review. Articles were coded on key domains including sample characteristics, study methods and outcome measures, bias indicators, intervention type, and findings.

RESULTS

Many studies did not report sample characteristics, including demographics and co-occurring psychiatric and substance use disorders, which may impact postdetoxification OUD treatment outcomes and the generalizability of interventions. Slightly more than half of studies examined interventions that were primarily medical in nature, though only a third focused on initiating medication treatment beyond detoxification. Medical and combination interventions that focused on initiating medications for OUD generally performed well, as did psychological interventions with one or more reinforcement-based components.

CONCLUSIONS

Research efforts to improve post-detoxification outcomes would benefit from clearer reporting of sample characteristics that are associated with treatment and recovery outcomes, including diagnostic comorbidities. Findings also support the need to identify ways to introduce medication for opioid use disorder (MOUD) and other effective treatments including reinforcement-based interventions during detoxification or soon after.

Opium Addiction: Practical Issues in ICU

How to cite this article: Das AK, Sharma A, Kothari N, Goyal S. Opium Addiction: Practical Issues in ICU. Indian J Crit Care Med 2021;25(9):1082–1083.

'Not at all what I had expected': Discontinuing treatment with extended-release naltrexone (XR-NTX): A qualitative study

BACKGROUND

Extended-release naltrexone (XR-NTX), an opioid antagonist, has demonstrated equal treatment outcomes, in terms of safety, opioid use, and retention, to the recommended OMT medication buprenorphine. However, premature discontinuation of XR-NTX treatment is still common and poorly understood. Research on patient experiences of XR-NTX treatment is limited. We sought to explore participants' experiences with discontinuation of treatment with XR-NTX, particularly motivation for XR-NTX, experiences of initiation and treatment, and rationale for leaving treatment.

METHODS

We conducted qualitative, semi-structured interviews with participants from a clinical trial of XR-NTX. The study participants (N = 13) included seven women and six men with opioid dependence, who had received a minimum of one and maximum of four injections of XR-NTX. The study team analyzed transcribed interviews, employing thematic analysis with a critical realist approach.

FINDINGS

The research team identified three themes, and we present them as a chronological narrative: theme 1: Entering treatment - I thought I knew what I was going into; theme 2: Life with XR-NTX - I had something in me that I didn't want; and theme 3: Leaving treatment - I want to go somewhere in life. Patients' unfulfilled expectations of how XR-NTX would lead to a better life were central to decisions about discontinuation, including unexpected physical, emotional, or mental reactions as well as a lack of expected effects, notably some described an opioid effect from buprenorphine. A few participants ended treatment because they had reached their treatment goal, but most expressed disappointment about not achieving this goal. Some also expressed renewed acceptance of OMT. The participants' motivation for abstinence from illegal substances generally remained.

CONCLUSION

Our findings emphasize that a dynamic understanding of discontinuation of treatment is necessary to achieve a long-term approach to recovery: the field should understand discontinuation as a feature of typical treatment trajectories, and discontinuation can be followed by re-initiation of treatment.

Posttraumatic stress disorder in individuals seeking treatment for opioid use disorder in Vermont

Posttraumatic stress disorder (PTSD) and opioid use disorder (OUD) may be associated with poor outcomes in rural areas where access to mental health services and opioid agonist treatment (OAT) is limited. This study examined the characteristics associated with a history of PTSD among a sample of individuals seeking buprenorphine treatment for OUD in Vermont, the second-most rural state in the US. Participants were 89 adults with OUD who participated in one of two ongoing randomized clinical trials examining the efficacy of an interim buprenorphine dosing protocol for reducing illicit opioid use during waitlist delays to OAT. Thirty-one percent of participants reported a history of PTSD. Those who did (PTSD+; n = 28) and did not (PTSD-; n = 61) report a history of PTSD were similar on sociodemographic and drug use characteristics. However, the PTSD+ group was less likely to have received prior OUD treatment compared to the PTSD- group (p = .02) despite being more likely to have a primary care physician (p = .009) and medical insurance (p = .002). PTSD+ individuals also reported greater mental health service utilization, more severe psychiatric, medical and drug use consequences, and greater pain severity and interference vs. PTSD- individuals (ps < 0.05). These findings indicate that a history of PTSD is prevalent and associated with worse outcomes among individuals seeking treatment for OUD in Vermont. Dissemination of screening measures and targeted interventions may help address the psychiatric and medical needs of rural individuals with OUD and a history of PTSD.

Problematic Opioid Use Among Older Adults: Epidemiology, Adverse Outcomes and Treatment Considerations

With the aging population, an increasing number of older adults (> 65 years) will be affected by problematic opioid use and opioid use disorder (OUD), with both illicit and prescription opioids. Problematic opioid use is defined as the use of opioids resulting in social, medical or psychological consequences, whereas OUD is a form of problematic use that meets diagnostic criteria as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Problematic use of opioids by older adults is associated with a number of pertinent adverse effects, including sedation, cognitive impairment, falls, fractures and constipation. Risk factors for problematic opioid use in this population include pain, comorbid medical illnesses, concurrent alcohol use disorder and depression. Treatment of OUD consists of acute detoxification and maintenance therapy. At this time, there have been no randomized controlled trials examining the effectiveness of pharmacological interventions for OUD in this population, with recommendations based on data from younger adults. Despite this, opioid agonist therapy (OAT) is recommended for both stages of treatment in older adults with OUD. Buprenorphine is recommended as a first line agent over methadone in the older adult population, due to a more favourable safety profile and relative accessibility. Use of methadone in this population is complicated by risk of QT interval prolongation and respiratory depression. Available observational data suggests that older adults respond well to OAT and age should not be a barrier to treatment. Further research is required to inform treatment decisions in this population.

Impact of Current Pain Status on Low-Barrier Buprenorphine Treatment Response Among Patients with Opioid Use Disorder

OBJECTIVE

Chronic non-cancer pain (CNCP) is prevalent among individuals with opioid use disorder (OUD). However, the impact of CNCP on buprenorphine treatment outcomes is largely unknown. In this secondary analysis, we examined treatment outcomes among individuals with and without CNCP who received a low-barrier buprenorphine maintenance regimen during waitlist delays to more comprehensive opioid treatment.

METHODS

Participants were 28 adults with OUD who received 12 weeks of buprenorphine treatment involving bimonthly clinic visits, computerized medication dispensing, and phone-based monitoring. At intake and monthly follow-up assessments, participants completed the Brief Pain Inventory, Beck Anxiety Inventory, Beck Depression Inventory (BDI-II), Brief Symptom Inventory (BSI), Addiction Severity Index, and staff-observed urinalysis.

RESULTS

Participants with CNCP (n = 10) achieved comparable rates of illicit opioid abstinence as those without CNCP (n = 18) at weeks 4 (90% vs 94%), 8 (80% vs 83%), and 12 (70% vs 67%) (P = 0.99). Study retention was also similar, with 90% and 83% of participants with and without CNCP completing the 12-week study, respectively (P = 0.99). Furthermore, individuals with CNCP demonstrated significant improvements on the BDI-II and Global Severity Index subscale of the BSI (P < 0.05). However, those with CNCP reported more severe medical problems and smaller reductions in legal problems relative to those without CNCP (P = 0.03).

CONCLUSIONS

Despite research suggesting that chronic pain may influence OUD treatment outcomes, participants with and without CNCP achieved similar rates of treatment retention and significant reductions in illicit opioid use and psychiatric symptomatology during low-barrier buprenorphine treatment.

Translational value of non-human primates in opioid research

Preclinical opioid research using animal models not only provides mechanistic insights into the modulation of opioid analgesia and its associated side effects, but also validates drug candidates for improved treatment options for opioid use disorder. Non-human primates (NHPs) have served as a surrogate species for humans in opioid research for more than five decades. The translational value of NHP models is supported by the documented species differences between rodents and primates regarding their behavioral and physiological responses to opioid-related ligands and that NHP studies have provided more concordant results with human studies. This review highlights the utilization of NHP models in five aspects of opioid research, i.e., analgesia, abuse liability, respiratory depression, physical dependence, and pruritus. Recent NHP studies have found that (1) mixed mu opioid and nociceptin/orphanin FQ peptide receptor partial agonists appear to be safe, non-addictive analgesics and (2) mu opioid receptor- and mixed opioid receptor subtype-based medications remain the only two classes of drugs that are effective in alleviating opioid-induced adverse effects. Given the recent advances in pharmaceutical sciences and discoveries of novel targets, NHP studies are posed to identify the translational gap and validate therapeutic targets for the treatment of opioid use disorder. Pharmacological studies using NHPs along with multiple outcome measures (e.g., behavior, physiologic function, and neuroimaging) will continue to facilitate the research and development of improved medications to curb the opioid epidemic.

Factors That Affect Patient Attrition in Buprenorphine Treatment for Opioid Use Disorder: A Retrospective Real-World Study Using Electronic Health Records

PURPOSE

To describe attrition patterns of opioid use disorder (OUD) patients treated with buprenorphine (BUP) and to assess how clinical, sociodemographic, or BUP medication dosing features are associated with attrition.

PATIENTS AND METHODS

Electronic health records of adults (16+ year-olds) with OUD treated with BUP from 23 different substance use or mental health care programs across 11 US states were examined for one year following BUP initiation in inpatient (IP), intensive outpatient (IOP), or outpatient (OP) settings. Treatment attrition was declared at >37 days following the last recorded visit. Survival analyses and predictive modelling were used.

RESULTS

Retention was consistently 2-3 times higher following BUP initiation in OP (n = 2409) than in IP/IOP (n = 2749) settings after 2 (50% vs 25%), 6 (27% vs 9%) and 12 months (14% vs 4%). Retention was higher for females, whites (vs blacks), and those with less severe OUD, better global function, or not using non-psychotropic medications. Comorbid substance use, other psychiatric disorders, and the number of psychotropic medications were variously related to retention depending on the setting in which BUP was initiated. Predictive modelling revealed that a higher global assessment of functioning and a smaller OUD severity based on the Clinical Global Impression - Severity led to longer retentions, a higher initial BUP dose led to higher retention in a few cases, an OP setting of BUP initiation led to longer retentions, and a lower total number of psychotropic and non-psychotropic medications led to longer retentions. These were the most important parameters in the model, which identified 75.2% of patients who left BUP treatment within three months post-initiation, with a precision of 90.5%.

CONCLUSION

Of all the OUD patients who began BUP, 50-75% left treatment within three months, and most could be accurately identified. This could facilitate patient-centered management to better retain OUD patients in BUP treatment.

Successful use of buprenorphine-naloxone medication-assisted program to treat concurrent pain and opioid addiction after cancer therapy

Cancer pain is often treated with opioids, a therapeutic regimen that can become a challenge in patients with an opioid use disorder (OUD). While use of the buprenorphine-naloxone combination is an effective medication-assisted treatment (MAT) for OUD, its use in pain patients with OUD has been controversial due to concerns that co-administration of buprenorphine can reduce or block analge-sia and precipitate opioid withdrawal in those patients requiring full opioid agonists. Data on its use in cancer pain patients are lack-ing. In this case series, the authors explore the frequency of buprenorphine-naloxone use and its outcomes in patients in a Compre-hensive Care Center (CCC) Pain Registry. OUD was deduced from an International Classification of Diseases (ICD-10) diagnostic code for opioid-related disorders recorded in the electronic medical records. Of 2,320 chronic cancer pain patients, 125 patients had ICD-10 code for opioid-related disorders, and 43 had a diagnosis of opioid abuse of whom 11 received buprenorphine-naloxone combina-tions. Eight patients on 18 (6-24) mg per day of buprenorphine-naloxone remained in therapy for 4 (2-7) years without opioid abuse relapse. This assessment was based on clinician's notes, the Prescription Monitoring Program, random urine drug screening, and the absence of Urgent Care Center visits for opioid withdrawal or overdose. When short-term opioids were administered for acute pain, these patients were able to taper down and stop them quickly without an opioid abuse relapse. Buprenorphine-naloxone was effec-tive as the sole analgesic in selected patients. Given its success at the CCC, buprenorphine-naloxone should be made available and strongly considered as a treatment for patients suffering from OUD during and following cancer treatment and when cancer pain re-duces or resolves.

New directions in the treatment of opioid withdrawal

The treatment of opioid withdrawal is an important area of clinical concern when treating patients with chronic, non-cancer pain, patients with active opioid use disorder, and patients receiving medication for opioid use disorder. Current standards of care for medically supervised withdrawal include treatment with μ-opioid receptor agonists, (eg, methadone), partial agonists (eg, buprenorphine), and α2-adrenergic receptor agonists (eg, clonidine and lofexidine). Newer agents likewise exploit these pharmacological mechanisms, including tramadol (μ-opioid receptor agonism) and tizanidine (α2 agonism). Areas for future research include managing withdrawal in the context of stabilising patients with opioid use disorder to extended-release naltrexone, transitioning patients with opioid use disorder from methadone to buprenorphine, and tapering opioids in patients with chronic, non-cancer pain.

Opioid withdrawal symptoms, frequency, and pain characteristics as correlates of health risk among people who inject drugs

OBJECTIVE

Opioid withdrawal symptoms are widely understood to contribute to health risk but have rarely been measured in community samples of opioid using people who inject drugs (PWID).

METHODS

Using targeted sampling methods, 814 PWID who reported regular opioid use (at least 12 uses in the last 30 days) were recruited and interviewed about demographics, drug use, health risk, and withdrawal symptoms, frequency, and pain. Multivariable regression models were developed to examine factors associated with any opioid withdrawal, withdrawal frequency, pain severity, and two important health risks (receptive syringe sharing and non-fatal overdose).

RESULTS

Opioid withdrawal symptoms were reported by 85 % of participants in the last 6 months, with 29 % reporting at least monthly withdrawal symptoms and 35 % reporting at least weekly withdrawal symptoms. Very or extremely painful symptoms were reported by 57 %. In separate models, we found any opioid withdrawal (adjusted odds ratio [AOR] = 2.75, 95 % confidence interval [CI] = 1.52, 5.00) and weekly or more opioid withdrawal frequency (AOR = 1.94; 95 % CI = 1.26, 3.00) (as compared to less than monthly) to be independently associated with receptive syringe sharing while controlling for confounders. Any opioid withdrawal (AOR = 1.71; 95 % CI = 1.04, 2.81) was independently associated with nonfatal overdose while controlling for confounders. In a separate model, weekly or more withdrawal frequency (AOR = 1.69; 95 % CI = 1.12, 2.55) and extreme or very painful withdrawal symptoms (AOR = 1.53; 95 % CI = 1.08, 2.16) were associated with nonfatal overdose as well.

CONCLUSIONS

Withdrawal symptoms among PWID increase health risk. Treatment of withdrawal symptoms is urgently needed and should include buprenorphine dispensing.

Auricular neural stimulation as a new non-invasive treatment for opioid detoxification

The recent opioid crisis is one of the rising challenges in the history of modern health care. New and effective treatment modalities with less adverse effects to alleviate and manage this modern epidemic are critically needed. The FDA has recently approved two non-invasive electrical nerve stimulators for the adjunct treatment of symptoms of acute opioid withdrawal. These devices, placed behind the ear, stimulate certain cranial nerves with auricular projections. This neural stimulation reportedly generates a prompt effect in terms of alleviation of withdrawal symptoms resulting from acute discontinuation of opioid use. Current experimental evidence indicates that this type of non-invasive neural stimulation has excellent potential to supplement medication assisted treatment in opioid detoxification with lower side effects and increased adherence to treatment. Here, we review current findings supporting the use of non-invasive neural stimulation in detoxification from opioid use. We briefly outline the neurophysiology underlying this approach of auricular electrical neural stimulation and its role in enhancing medication assisted treatment in treating symptoms of opioid withdrawal. Considering the growing deleterious impact of addictive disorders on our society, further studies on this emerging treatment modality are warranted.

Effects of Interim Buprenorphine Treatment for opioid use disorder among emerging adults

OBJECTIVE

Although opioid maintenance is a first-line approach for treating opioid use disorder (OUD), suboptimal treatment outcomes have been reported among emerging adults (EAs; 18-25 years of age). In this secondary analysis, we compared treatment outcomes between EAs and older adults (OAs; ≥ 26 years of age) receiving low-barrier, technology-assisted Interim Buprenorphine Treatment (IBT) during waitlist delays to comprehensive opioid maintenance treatment.

METHOD

Participants were 35 individuals with OUD who received IBT consisting of 12-weeks of buprenorphine maintenance with bi-monthly clinic visits and technology-assisted monitoring. At monthly follow-up assessments, participants completed staff-observed urinalysis, the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), and Addiction Severity Index (ASI).

RESULTS

At study intake, EAs (n = 10) reported greater past-year intravenous drug use and greater employment, legal, and psychiatric severity (p's < .05) compared to OAs (n = 25). Despite these initial differences, there were no significant differences in the percentages of urine specimens testing negative for illicit opioids between EA and OA participants at Study Week 4 (90 % vs. 88 %, p = .99), Week 8 (80 % vs. 76 %, p = .99) or Week 12 (60 % vs. 68 %, p = .71). Relative to their older peers, EAs also demonstrated significantly greater improvements on the BAI, BDI-II, and ASI Employment and Legal subscales (p's < .05).

CONCLUSIONS

Despite presenting with greater past-year intravenous drug use and psychosocial severity relative to OAs, EAs responded favorably to the IBT intervention.

Canadian Guidelines on Opioid Use Disorder Among Older Adults

BACKGROUND

In Canada, rates of hospital admission from opioid overdose are higher for older adults (≥ 65) than younger adults, and opioid use disorder (OUD) is a growing concern. In response, Health Canada commissioned the Canadian Coalition of Seniors' Mental Health to create guidelines for the prevention, screening, assessment, and treatment of OUD in older adults.

METHODS

A systematic review of English language literature from 2008-2018 regarding OUD in adults was conducted. Previously published guidelines were evaluated using AGREE II, and key guidelines updated using ADAPTE method, by drawing on current literature. Recommendations were created and assessed using the GRADE method.

RESULTS

Thirty-two recommendations were created. Prevention recommendations: it is key to prioritize non-pharmacological and non-opioid strategies to treat acute and chronic noncancer pain. Assessment recommendations: a comprehensive assessment is important to help discern contributions of other medical conditions. Treatment recommendations: buprenorphine is first line for both withdrawal management and maintenance therapy, while methadone, slow-release oral morphine, or naltrexone can be used as alternatives under certain circumstances; non-pharmacological treatments should be offered as an integrated part of care.

CONCLUSION

These guidelines provide practical and timely clinical recommendations on the prevention, assessment, and treatment of OUD in older adults within the Canadian context.

Dihydrocodeine for detoxification and maintenance treatment in individuals with opiate use disorders

BACKGROUND

Medical treatment and detoxification from opiate disorders includes oral administration of opioid agonists. Dihydrocodeine (DHC) substitution treatment is typically low threshold and therefore has the capacity to reach wider groups of opiate users. Decisions to prescribe DHC to patients with less severe opiate disorders centre on its perceived safety, reduced toxicity, shorter half-life and more rapid onset of action, and potential retention of patients. This review set out to investigate the effects of DHC in comparison to other pharmaceutical opioids and placebos in the detoxification and substitution of individuals with opiate use disorders.

OBJECTIVES

To investigate the effectiveness of DHC in reducing illicit opiate use and other health-related outcomes among adults compared to other drugs or placebos used for detoxification or substitution therapy.

SEARCH METHODS

In February 2019 we searched Cochrane Drugs and Alcohol's Specialised Register, CENTRAL, PubMed, Embase and Web of Science. We also searched for ongoing and unpublished studies via ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and Trialsjournal.com. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials that evaluated the effect of DHC for detoxification and maintenance substitution therapy for adolescent (aged 15 years and older) and adult illicit opiate users. The primary outcomes were abstinence from illicit opiate use following detoxification or maintenance therapy measured by self-report or urinalysis. The secondary outcomes were treatment retention and other health and behaviour outcomes.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures that are outlined by Cochrane. This includes the GRADE approach to appraise the quality of evidence.

MAIN RESULTS

We included three trials (in five articles) with 385 opiate-using participants that measured outcomes at different follow-up periods in this review. Two studies with 150 individuals compared DHC with buprenorphine for detoxification, and one study with 235 participants compared DHC to methadone for maintenance substitution therapy. We downgraded the quality of evidence mainly due to risk of bias and imprecision. For the two studies that compared DHC to buprenorphine, we found low-quality evidence of no significant difference between DHC and buprenorphine for detoxification at six-month follow-up (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.25 to 1.39; P = 0.23) in the meta-analysis for the primary outcome of abstinence from illicit opiates. Similarly, low-quality evidence indicated no difference for treatment retention (RR 1.29, 95% CI 0.99 to 1.68; P = 0.06). In the single trial that compared DHC to methadone for maintenance substitution therapy, the evidence was also of low quality, and there may be no difference in effects between DHC and methadone for reported abstinence from illicit opiates (mean difference (MD) -0.01, 95% CI -0.31 to 0.29). For treatment retention at six months' follow-up in this single trial, the RR calculated with an intention-to-treat analysis also indicated that there may be no difference between DHC and methadone (RR 1.04, 95% CI 0.94 to 1.16). The studies that compared DHC to buprenorphine reported no serious adverse events, while the DHC versus methadone study reported one death due to methadone overdose.

AUTHORS' CONCLUSIONS

We found low-quality evidence that DHC may be no more effective than other commonly used pharmacological interventions in reducing illicit opiate use. It is therefore premature to make any conclusive statements about the effectiveness of DHC, and it is suggested that further high-quality studies are conducted, especially in low- to middle-income countries.

Hospitalization outcomes of people who use drugs: One size does not fit all

People with opioid use disorder (OUD) have worse hospital outcomes and higher healthcare costs. There are rising reports of people with OUD also using other classes of drugs, however patterns of substance use have not been evaluated for differential effects on hospital outcomes. We performed a data-analysis of the Healthcare Utilization Project's National Readmissions Database, examining the effects of patterns of substance use, age, gender, and diagnosis on the outcomes of Against Medical Advice (AMA) discharges and 30-day readmissions. About one-third of the patients with OUD who were admitted to the hospital had at least one additional substance use disorder (SUD). Thirteen percent of persons with OUD were discharged AMA, and 12% were readmitted to the hospital within 30 days of discharge. Compared to people with OUD alone, people who used stimulants had increased odds of AMA discharge (aOR 1.83 (CI 1.73, 1.96)) and 30-day readmission (aOR 1.30 (95% CI 1.23, 1.37)). Multiple concomitant substance use disorders were associated with increased odds of AMA discharge and 30-day readmission. Conclusions: People with OUD have high rates of both AMA discharges and 30 day-readmissions, and there is a layered effect of increasing co-occurring SUDs leading to worse hospitalization outcomes. The heterogeneity of drug use patterns needs to be considered when developing strategies to improve health care outcomes for people with substance use disorder.

A G protein signaling-biased agonist at the μ-opioid receptor reverses morphine tolerance while preventing morphine withdrawal

It has been demonstrated that opioid agonists that preferentially act at μ-opioid receptors to activate G protein signaling over βarrestin2 recruitment produce antinociception with less respiratory suppression. However, most of the adverse effects associated with opioid therapeutics are realized after extended dosing. Therefore, we tested the onset of tolerance and dependence, and assessed for neurochemical changes associated with prolonged treatment with the biased agonist SR-17018. When chronically administered to mice, SR-17018 does not lead to hot plate antinociceptive tolerance, receptor desensitization in periaqueductal gray, nor a super-sensitization of adenylyl cyclase in the striatum, which are hallmarks of opioid neuronal adaptations that are seen with morphine. Interestingly, substitution with SR-17018 in morphine-tolerant mice restores morphine potency and efficacy, whereas the onset of opioid withdrawal is prevented. This is in contrast to buprenorphine, which can suppress withdrawal, but produces and maintains morphine antinociceptive tolerance. Biased agonists of this nature may therefore be useful for the treatment of opioid dependence while restoring opioid antinociceptive sensitivity.

Preliminary evidence of different and clinically meaningful opioid withdrawal phenotypes

Opioid use disorder (OUD) is a public health crisis. Differences in opioid withdrawal severity that predict treatment outcome could facilitate the process of matching patients to treatments. This is a secondary analysis of a randomized controlled trial (RCT) that enrolled treatment seeking heroin-users (N = 89, males = 78) into a residential study. Participants maintained on morphine (30 mg, subcutaneous, four-times daily) underwent a naloxone (0.4 mg, IM = intramuscular) challenge session to precipitate withdrawal. Area-under-the-curve (AUC) values from self-reported withdrawal ratings during the challenge session were analyzed using K-means clustering, revealing two phenotype groups. Withdrawal and retention from the subsequent 14-day double-blind, double-dummy RCT comparing three study medications (clonidine, tramadol-ER, and buprenorphine) were evaluated as a function of phenotype. Cluster analyses suggested HIGH (N = 37; mean [SD] subjective opiate withdrawal scale [SOWS]-AUC 123.7 [65.8]) and LOW (N = 52; SOWS-AUC 68.0 [47.7]) withdrawal phenotype groups. HIGH participants were significantly more female and had lower body mass indices than LOW participants; no drug-use variables were significant. Regarding RCT outcomes, HIGH phenotype participants were less likely to be retained in the study (P = 0.02) and had higher mean self-reported withdrawal (P = 0.05) than LOW phenotype participants. A significant interaction in RCT retention was observed between phenotype (P = 0.02) and study medication (P < 0.01). Self-reported withdrawal was significant for phenotype (P = 0.02); study medication trended towards significance (P = 0.07). Results suggest patients have meaningfully different experiences of opioid withdrawal that may predict differential response to opioid pharmacotherapies during supervised withdrawal. Additional prospective research to replicate and more thoroughly evaluate withdrawal phenotype correlates and sex differences is warranted.

Buprenorphine prescribing for opioid use disorder in medical practices: can office-based out-patient care address the opiate crisis in the United States?

BACKGROUND AND AIMS

Opioid use disorder (OUD) remains a serious public health issue, and treating adults with OUD is a major priority in the United States. Little is known about trends in the diagnosis of OUD and in buprenorphine prescribing by physicians in office-based medical practices. We sought to characterize OUD diagnoses and buprenorphine prescribing among adults with OUD in the United States between 2006 and 2015.

DESIGN AND SETTINGS

We used a repeated cross-sectional design, based on data from the 2006-15 National Ambulatory Medical Care Surveys that surveyed nationally representative samples of office-based out-patient physician visits.

PARTICIPANTS

Adult patients aged 18 years or older with a diagnosis of OUD (n = 1034 unweighted) were included.

MEASUREMENTS

Buprenorphine prescribing was defined by whether visits involved buprenorphine or buprenorphine-naloxone, or not. We also examined other covariates (e.g. age, gender, race and psychiatric comorbidities).

FINDINGS

We observed an almost tripling of the diagnosis of OUD from 0.14% in 2006-10 to 0.38% in 2011-15 in office-based medical practices (P < 0.001). Among adults diagnosed with OUD, buprenorphine prescribing increased from 56.1% in 2006-10 to 73.6% in 2011-15 (P = 0.126). Adults with OUD were less likely to receive buprenorphine prescriptions if they were Hispanic [adjusted odds ratio (aOR) = 0.26; 95% confidence interval (CI) = 0.11, 0.60], had Medicaid insurance (aOR = 0.27; 95% CI = 0.10, 0.74) or were diagnosed with other psychiatric disorders (aOR = 0.45; 95% CI = 0.25, 0.83) or substance use disorders (aOR = 0.19; 95% CI = 0.09, 0.41).

CONCLUSIONS

In office-based medical practices in the United States, diagnoses for opioid use disorder and buprenorphine prescriptions for adults with opioid use disorder increased from 0.14 and 56.1%, respectively, in 2006-10 to 0.38 and 73.6% in 2011-15.

Differential adoption of opioid agonist treatments in detoxification and outpatient settings

BACKGROUND

Opioid use disorder (OUD) is a significant public health problem for which a substantial amount of treatment exists. The degree to which methadone and buprenorphine are administered in different treatment modalities is not clear but critical to understanding treatment success rates and service development strategies.

METHODS

Data from the national Treatment Episode Dataset for Admissions and Discharges (TEDS-A [N = 4,070,264] and TEDS-D [832,731], respectively) were used to determine the likelihood patients initiating detoxification and outpatient OUD treatment between 2006 and 2015 were expected to receive opioid agonist treatment. Joinpoint regression evaluated significant trends and a generalized linear model with logit link function identified characteristics associated with receiving an agonist during detoxification. TEDS-D informed the percent of patients leaving detoxification against medical advice who did/did not receive an opioid agonist.

RESULTS

Though agonist use in outpatient settings increased by 60% during 2012-2015, agonist use in detoxification was lower than outpatient treatment, decreased significantly by 26% from 2009 to 2015, and never exceeded 16% of detoxification admissions during 2006-2015. In 2015, persons who were under 25, homeless, had co-occurring psychiatric problems, utilized Medicare, Medicaid, or had no insurance, and had no prior OUD treatment or were high treatment utilizers were the least likely to receive an agonist during detoxification.

CONCLUSIONS

Efforts to expand opioid agonist access has been successful for outpatient but not detoxification settings. Improving detoxification outcomes is a potentially high impact way for the US to expand efficacious OUD treatment access in the US.

Use of Tramadol for Management of Opioid Use Disorders: Rationale and Recommendations

Opioids are one of the most common illicit psychoactive substances being used in India. In fact, opioid use disorders are the most common disorder presenting to the substance use disorder treatment centers across the country. Effective and evidence-based interventions are available for management of opioid use disorders. However, the treatment for opioid use disorders remains difficult to access for most of those in need in India. The current article presents the literature on the use of tramadol for the management of opioid use disorders. It also makes recommendations on the use of tramadol for the management of opioid use disorders. Tramadol offers a viable alternative to the existing options for the management of opioid use disorders. It has been found effective when used for this indication. It offers certain major advantages such as easy and wide availability and low abuse liability. It offers a good option to expand the treatment services for opioid use disorders across the country.

Testing a support programme for opioid reduction for people with chronic non-malignant pain: the I-WOTCH randomised controlled trial protocol

INTRODUCTION

Chronic non-malignant pain has a major impact on the well-being, mood and productivity of those affected. Opioids are increasingly prescribed to manage this type of pain, but with a risk of other disabling symptoms, when their effectiveness has been questioned. This trial is designed to implement and evaluate a patient-centred intervention targeting withdrawal of strong opioids in people with chronic pain.

METHODS AND ANALYSIS

A pragmatic, multicentre, randomised controlled trial will assess the clinical and cost-effectiveness of a group-based multicomponent intervention combined with individualised clinical facilitator led support for the management of chronic non-malignant pain against the control intervention (self-help booklet and relaxation compact disc). An embedded process evaluation will examine fidelity of delivery and investigate experiences of the intervention. The two primary outcomes are activities of daily living (measured by Patient-Reported Outcomes Measurement Information System Pain Interference Short Form (8A)) and opioid use. The secondary outcomes are pain severity, quality of life, sleep quality, self-efficacy, adverse events and National Health Service (NHS) healthcare resource use. Participants are followed up at 4, 8 and 12 months, with a primary endpoint of 12 months. Between-group differences will indicate effectiveness; we are looking for a difference of 3.5 points on our pain interference outcome (scale 40 to 77). We will undertake an NHS perspective cost-effectiveness analysis using quality adjusted life years.

ETHICS AND DISSEMINATION

Full approval was given by Yorkshire & The Humber - South Yorkshire Research Ethics Committee on 13 September, 2016 (16/YH/0325). Appropriate local approvals were sought for each area in which recruitment was undertaken. The current protocol version is 1.6 date 19 December 2018. Publication of results in peer- reviewed journals will inform the scientific and clinical community. We will disseminate results to patient participants and study facilitators in a study newsletter as well as a lay summary of results on the study website.

TRIAL REGISTRATION NUMBER

ISRCTN49470934; Pre-results.

Association of current and past opioid use disorders with health-related quality of life and employment among US adults

BACKGROUND

To examine the association of current and past Opiate Use Disorder (OUD) with measures of HRQOL and employment in a nationally representative sample of adults.

METHODS

The 2012-2013 National Epidemiological Survey on Alcohol and Related Conditions III (NESARC III) surveyed a nationally representative sample of non-institutionalized civilian adults (≥18 years) in the US (n = 36,309 unweighted). Using DSM-5 criteria, adults without history of OUD were compared to those with current and past OUD. Using the SF-12 items, standard measures of the mental and physical component scores of HRQOL and of quality-adjusted life years (QALYs) were constructed. Employment in the past year (yes/no) was also assessed. Multivariable-adjusted regression analyses were used to adjust for covariates.

RESULTS

Overall, 0.9% of the study sample, representing 2.1 of 235.4 million adults, met criteria for current OUD; 1.2%, representing 2.7 million adults, met criteria for past OUD. Adults with current or past OUD had large and moderately reduced mental component (MCS) and physical health component (PCS) summary scores compared to adults who never had OUD (p < 0.001, respectively). Current OUD was associated with lower odds of being employed compared to never experiencing OUD (Adjusted odds ratio = 0.65; 95% CI: 0.48, 0.88; p = 0.005), as was past OUD. Adjustment for potentially confounding factors reduced the independent association of OUD and HRQOL by about 40-50% but did not change employment comparisons.

CONCLUSION

Adults with current OUD are associated with large reductions in HRQOL and likelihood of not being employed, and adults with past OUD also have considerable residual impairment.

Comparison of sublingual buprenorphine and intravenous morphine in reducing bone metastases associated pain in cancer patients

Bone metastases is one of the most common causes of pain in cancer patients and have a significant effect on their quality of life. The most common symptom of bone metastases is pain that gradually develops. Morphine is used to relieve pain in these patients, but poorly accepted due to its adverse events. Therefore, the current study was aimed to compare the effect of sublingual buprenorphine, with certainly lower complications with morphine. Fourth patients were divided into 2 groups. In group A, metastatic cancer patients received 2.5 mg of intravenous morphine. Furthermore, in group B, sublingual tablet of buprenorphine (one-fourth of a 500 μg tablet) was administered sublingually. Pain was measured 15, 30, and 45 minutes after the onset of pain using visual analog scale ruler. Based on the obtained data, two groups A and B were compared using SPSS 23 software. There was a significant difference between the patient's pain intensity after 15 and 30 minutes from the onset of pain in both groups. Due to the fact that the duration of the effect of morphine is 3-4 hours and the duration of the effect of sublingual buprenorphine is 6-8 hours, morphine showed fast acting forms of opioids (P= 0.001). The required dose level on the first day was similar in both groups and there was no statistically significant difference between the two groups. While on the second and third days, the median dose in group A (morphine) was greater than group B (buprenorphine), indicating prolonged duration of action for buprenorphine compared with morphine, thus requiring lower subsequent doses. The results of this study suggested that sublingual buprenorphine is a higher effective drug compared to intravenous morphine during and after operation. With regard to easy and painless administration, it seems that its use can be useful in controlling pain due to bone metastases in cancer patients.

Impact of Substance Use Disorder Pharmacotherapy on Executive Function: A Narrative Review

Substance use disorders are chronic, relapsing, and harmful conditions characterized by executive dysfunction. While there are currently no approved pharmacotherapy options for stimulant and cannabis use disorders, there are several evidence-based options available to help reduce symptoms during detoxification and aid long-term cessation for those with tobacco, alcohol and opioid use disorders. While these medication options have shown clinical efficacy, less is known regarding their potential to enhance executive function. This narrative review aims to provide a brief overview of research that has investigated whether commonly used pharmacotherapies for these substance use disorders (nicotine, bupropion, varenicline, disulfiram, acamprosate, nalmefene, naltrexone, methadone, buprenorphine, and lofexidine) effect three core executive function components (working memory, inhibitory control and cognitive flexibility). While pharmacotherapy-induced enhancement of executive function may improve cessation outcomes in dependent populations, there are limited and inconsistent findings regarding the effects of these medications on executive function. We discuss possible reasons for the mixed findings and suggest some future avenues of work that may enhance the understanding of addiction pharmacotherapy and cognitive training interventions and lead to improved patient outcomes.

Comparison of opioid use disorder among male veterans and non-veterans: Disorder rates, socio-demographics, co-morbidities, and quality of life

BACKGROUND AND OBJECTIVES

Amidst a surging national crisis of opioid use, concern has been expressed about its impact on veterans, but no study has presented a population-based comparison of opioid use disorder (OUD) among veterans and non-veterans. We analyzed national epidemiologic data to compare rates, correlates and impacts of the opioid crisis on male veterans and non-veterans.

METHODS

Restricted data from 2012 to 2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) were used to compare veteran and non-veteran men on rates of OUD, as well as correlates of OUD including socio-demographic characteristics, psychiatric and substance use co-morbidities, and reductions in health-related quality of life (HRQOL).

RESULTS

About 2.0% of veterans and 2.7% of non-veterans, estimated at 418,000 and 2.5 million men, respectively, met criteria for life-time OUD. In both groups, OUD was associated with younger age, lower income levels, and fewer years of education. OUD was associated minority race among veterans, but with non-Hispanic white race among non-veterans. Both veteran and non-veteran adults with OUD were at least five times more likely than their peers to have both psychiatric and substance use co-morbidities (p < .001) and they experienced strongly reduced HRQOL scores (Cohen's d = -.50 to -.93).

DISCUSSION AND CONCLUSION

Veterans and non-veterans experience similar risk of OUD, similar correlates and adverse HRQOL impacts suggesting that similar treatment approaches may be effective for both groups.

SCIENTIFIC SIGNIFICANCE

Our findings highlight comparable vulnerability of veterans to non-veterans in both the risk of OUD and adverse effects on HRQOL. (Am J Addict 2018;XX:1-9).

Utilizing resources of neuropsychopharmacology to address the opioid overdose crisis

BACKGROUND

North America is facing a severe public health crisis in the form of excessive numbers of deaths due to overdose from self-administration of opioids by individuals who are dependent on these substances.

AIMS

There are many factors that must be addressed in order to gain control over this tragedy. Of particular relevance to neuropsychopharmacology is the fact that the problem is due in part to misuse of pharmaceuticals and especially the illicit production of the powerful synthetic opioids, fentanyl, and carfentanil.

METHOD

The development and adoption of appropriate pharmacotherapies are of critical importance. We discuss specific options to deal effectively with both withdrawal from opioid dependence and substitution of clinically approved drugs in place of illicit substances.

CONCLUSION

Hopefully, this crisis will reinvigorate both basic and clinical neuropsychopharmacological research leading to the develop new and more effective options for dealing with the many and varied elements of the current opioid crisis as described in the present commentary.

Assessing the validity and reliability of the Turkish versions of craving beliefs and beliefs about substance use questionnaire in patients with heroin use disorder: demonstrating valid tools to assess cognition-emotion interplay

Background

Cognitions associated with craving and substance use are important contributors for the psychological theories of Substance use disorders (SUD), as they may affect the course and treatment. In this study, we aimed to validate Turkish version of two major scales ‘Beliefs About Substance Use’(BSU) and ‘Craving Beliefs Questionnaire’(CBQ) in patients with heroin use disorder and define the interaction of these beliefs with patient profile, depression and anxiety symptoms, with an aim to use these thoughts as targets for treatment.

Methods

One hundred seventy-six inpatients diagnosed with heroin use disorder and 120 participants in the healthy comparison group were evaluated with CBQ, BSU, Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI) and sociodemographic data questionnaire. Patient group was also evaluated with Addiction Profile Index. Reliability and validity analysis for scales were conducted. Linear regression analysis was conducted to evaluate the determinants of BSU and CBQ scores.

Results

Cronbach alpha level was 0.93 for BSU and 0.94 for CBQ. Patient group showed significantly higher CBQ, BSU, BAI and BDI scores (p < 0.001). BSU score significantly correlated with API-substance use profile score, API-diagnosis, BAI, BDI and CBQ (p < 0.005), whereas CBQ scores significantly correlated with API-diagnosis, API-impact on life, API-craving, API-total score, BSU, BAI, BDI and amount of cigarette smoking (p < 0.002). Number of previous treatments and age of onset for substance use were not correlated with either BSU or CBQ. BAI and BDI scores significantly predicted BSU score, however only BDI score predicted CBQ score (p < 0.003).

Conclusions

Craving beliefs were highly correlated with addiction profile. Anxiety and depression are significant modulators for patients’ beliefs about substance use and depression is a modulator for craving and maladaptive beliefs, validating emotion-cognition interplay in addiction.

Sex/gender reporting and analysis in Campbell and Cochrane systematic reviews: a cross-sectional methods study

BACKGROUND

The importance of sex and gender considerations in research is being increasingly recognized. Evidence indicates that sex and gender can influence intervention effectiveness. We assessed the extent to which sex/gender is reported and analyzed in Campbell and Cochrane systematic reviews.

METHODS

We screened all the systematic reviews in the Campbell Library (n = 137) and a sample of systematic reviews from 2016 to 2017 in the Cochrane Library (n = 674). We documented the frequency of sex/gender terms used in each section of the reviews.

RESULTS

We excluded 5 Cochrane reviews because they were withdrawn or published and updated within the same time period as well as 4 Campbell reviews and 114 Cochrane reviews which only included studies focused on a single sex. Our analysis includes 133 Campbell reviews and 555 Cochrane reviews. We assessed reporting of sex/gender considerations for each section of the systematic review (Abstract, Background, Methods, Results, Discussion). In the methods section, 83% of Cochrane reviews (95% CI 80-86%) and 51% of Campbell reviews (95% CI 42-59%) reported on sex/gender. In the results section, less than 30% of reviews reported on sex/gender. Of these, 37% (95% CI 29-45%) of Campbell and 75% (95% CI 68-82%) of Cochrane reviews provided a descriptive report of sex/gender and 63% (95% CI 55-71%) of Campbell reviews and 25% (95% CI 18-32%) of Cochrane reviews reported analytic approaches for exploring sex/gender, such as subgroup analyses, exploring heterogeneity, or presenting disaggregated data by sex/gender.

CONCLUSION

Our study indicates that sex/gender reporting in Campbell and Cochrane reviews is inadequate.

Opioid Use Disorders: Perioperative Management of a Special Population

Opioid-related overdose deaths have reached epidemic levels within the last decade. The efforts to prevent, identify, and treat opioid use disorders (OUDs) mostly focus on the outpatient setting. Despite their frequent overrepresentation, less is known about the inpatient management of patients with OUDs. Specifically, the perioperative phase is a very vulnerable time for patients with OUDs, and little has been studied on the optimal management of acute pain in these patients. The preoperative evaluation should aim to identify those with OUDs and assess factors that may interfere with OUD treatment and pain management. Efforts should be made to provide education and assistance to patients and their support systems. For those who are actively struggling with opioid use, the perioperative phase can be an opportunity for engagement and to initiate treatment. Buprenorphine, methadone, and naltrexone medication treatment for OUD and opioid tolerance complicate perioperative pain management. A multidisciplinary team approach is crucial to provide clinically balanced pain relief without jeopardizing the patient's recovery. This article reviews the existing literature on the perioperative management of patients with OUDs and provides clinical suggestions for the optimal care of this patient population.

Opioid substitution therapy: Legal challenges

Drug dependence syndrome is a medical condition classified as a multifactorial health disorder that often follows the course of a relapsing and remitting chronic disease. Opioid substitution therapy (OST) is one of the established standard treatments for opioid dependence syndrome. OST, a process in which opioid-dependent injecting drug users, is provided with long-acting opioid agonist medications for a long period under medical supervision along with psychosocial interventions. OST service provider may have to deal with issues of license/registration/recognition/permission under various legislations such as the Drugs and Cosmetic Act, 1940; Narcotic Drugs and Psychotropic Substances Act, 1985; Rights of person with disability Act, 2016 and Mental Healthcare Act, 2017 depending on the drug prescribed, type of services provided, procuring, transportation, storage, and prescribing these narcotics and psychotropic medicines. The narcotics and psychotropic drugs are administered through various ministries and departments causing huge confusion, lack of coordination, overlapping roles and responsibilities, and various laws/rules and gives an opportunity for the abdication of the responsibilities. The "public mental health issue," where the number of opioid users in the country is approximately two million and opioid dependence syndrome is approximately 0.5 million. The number of beds in the public governed deaddiction centers is abysmally low, number of psychiatrist, or trained medical practitioners in OST are also few in number to face this humongous challenge. Against this background, this article focuses on the legal issues surrounding the OST.

Opioid misuse in gastroenterology and non-opioid management of abdominal pain

Opioids were one of the earliest classes of medications used for pain across a variety of conditions, but morbidity and mortality have been increasingly associated with their chronic use. Despite these negative consequences, chronic opioid use is increasing worldwide, with the USA and Canada having the highest rates. Chronic opioid use for noncancer pain can have particularly negative effects in the gastrointestinal and central nervous systems, including opioid-induced constipation, narcotic bowel syndrome, worsening psychopathology and addiction. This Review summarizes the evidence of opioid misuse in gastroenterology, including the lack of evidence of a benefit from these drugs, as well as the risk of harm and negative consequences of opioid use relative to the brain-gut axis. Guidelines for opioid management and alternative pharmacological and nonpharmacological strategies for pain management in patients with gastrointestinal disorders are also discussed. As chronic pain is complex and involves emotional and social factors, a multimodal approach targeting both pain intensity and quality of life is best.

Buprenorphine in Neonatal Abstinence Syndrome

Infants exposed in utero to opioids will demonstrate a withdrawal syndrome known as neonatal abstinence syndrome (NAS). Buprenorphine is a long-acting opioid with therapeutic use in medication-assisted treatment of opioid dependency in adults and adolescents. Emerging data from clinical trials and treatment cohorts demonstrate the efficacy and safety of sublingual buprenorphine for those infants with NAS who require pharmacologic treatment. Pharmacometric modeling will assist in defining the exposure-response relationships and facilitate dose optimization.

Buprenorphine for the Treatment of the Neonatal Abstinence Syndrome

BACKGROUND

Current pharmacologic treatment of the neonatal abstinence syndrome with morphine is associated with a lengthy duration of therapy and hospitalization. Buprenorphine may be more effective than morphine for this indication.

METHODS

In this single-site, double-blind, double-dummy clinical trial, we randomly assigned 63 term infants (≥37 weeks of gestation) who had been exposed to opioids in utero and who had signs of the neonatal abstinence syndrome to receive either sublingual buprenorphine or oral morphine. Infants with symptoms that were not controlled with the maximum dose of opioid were treated with adjunctive phenobarbital. The primary end point was the duration of treatment for symptoms of neonatal opioid withdrawal. Secondary clinical end points were the length of hospital stay, the percentage of infants who required supplemental treatment with phenobarbital, and safety.

RESULTS

The median duration of treatment was significantly shorter with buprenorphine than with morphine (15 days vs. 28 days), as was the median length of hospital stay (21 days vs. 33 days) (P<0.001 for both comparisons). Adjunctive phenobarbital was administered in 5 of 33 infants (15%) in the buprenorphine group and in 7 of 30 infants (23%) in the morphine group (P=0.36). Rates of adverse events were similar in the two groups.

CONCLUSIONS

Among infants with the neonatal abstinence syndrome, treatment with sublingual buprenorphine resulted in a shorter duration of treatment and shorter length of hospital stay than treatment with oral morphine, with similar rates of adverse events. (Funded by the National Institute on Drug Abuse; BBORN ClinicalTrials.gov number, NCT01452789 .).

Opioid antagonists with minimal sedation for opioid withdrawal

BACKGROUND

Managed withdrawal is a necessary step prior to drug-free treatment or as the endpoint of long-term substitution treatment.

OBJECTIVES

To assess the effects of opioid antagonists plus minimal sedation for opioid withdrawal. Comparators were placebo as well as more established approaches to detoxification, such as tapered doses of methadone, adrenergic agonists, buprenorphine and symptomatic medications.

SEARCH METHODS

We updated our searches of the following databases to December 2016: CENTRAL, MEDLINE, Embase, PsycINFO and Web of Science. We also searched two trials registers and checked the reference lists of included studies for further references to relevant studies.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled clinical trials along with prospective controlled cohort studies comparing opioid antagonists plus minimal sedation versus other approaches or different opioid antagonist regimens for withdrawal in opioid-dependent participants.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Ten studies (6 randomised controlled trials and 4 prospective cohort studies, involving 955 participants) met the inclusion criteria for the review. We considered 7 of the 10 studies to be at high risk of bias in at least one of the domains we assessed.Nine studies compared an opioid antagonist-adrenergic agonist combination versus a treatment regimen based primarily on an alpha2-adrenergic agonist (clonidine or lofexidine). Other comparisons (placebo, tapered doses of methadone, buprenorphine) made by included studies were too diverse for any meaningful analysis. This review therefore focuses on the nine studies comparing an opioid antagonist (naltrexone or naloxone) plus clonidine or lofexidine versus treatment primarily based on clonidine or lofexidine.Five studies took place in an inpatient setting, two studies were in outpatients with day care, two used day care only for the first day of opioid antagonist administration, and one study described the setting as outpatient without indicating the level of care provided.The included studies were heterogeneous in terms of the type of opioid antagonist treatment regimen, the comparator, the outcome measures assessed, and the means of assessing outcomes. As a result, the validity of any estimates of overall effect is doubtful, therefore we did not calculate pooled results for any of the analyses.The quality of the evidence for treatment with an opioid antagonist-adrenergic agonist combination versus an alpha2-adrenergic agonist is very low. Two studies reported data on peak withdrawal severity, and four studies reported data on the average severity over the period of withdrawal. Peak withdrawal induced by opioid antagonists in combination with an adrenergic agonist appears to be more severe than withdrawal managed with clonidine or lofexidine alone, but the average severity over the withdrawal period is less. In some situations antagonist-induced withdrawal may be associated with significantly higher rates of treatment completion compared to withdrawal managed with adrenergic agonists. However, this result was not consistent across studies, and the extent of any benefit is highly uncertain.We could not extract any data on the occurrence of adverse events, but two studies reported delirium or confusion following the first dose of naltrexone. Delirium may be more likely with higher initial doses and with naltrexone rather than naloxone (which has a shorter half-life), but we could not confirm this from the available evidence.Insufficient data were available to make any conclusions on the best duration of treatment.

AUTHORS' CONCLUSIONS

Using opioid antagonists plus alpha2-adrenergic agonists is a feasible approach for managing opioid withdrawal. However, it is unclear whether this approach reduces the duration of withdrawal or facilitates transfer to naltrexone treatment to a greater extent than withdrawal managed primarily with an adrenergic agonist.A high level of monitoring and support is desirable for several hours following administration of opioid antagonists because of the possibility of vomiting, diarrhoea and delirium.Using opioid antagonists to induce and accelerate opioid withdrawal is not currently an active area of research or clinical practice, and the research community should give greater priority to investigating approaches, such as those based on buprenorphine, that facilitate the transition to sustained-release preparations of naltrexone.

Treatment of opioid use disorder with ibogaine: detoxification and drug use outcomes

BACKGROUND

Ibogaine is a monoterpene indole alkaloid used in medical and nonmedical settings for the treatment of opioid use disorder. Its mechanism of action is apparently novel. There are no published prospective studies of drug use outcomes with ibogaine.

OBJECTIVES

To study outcomes following opioid detoxification with ibogaine.

METHODS

In this observational study, 30 subjects with DSM-IV Opioid Dependence (25 males, 5 females) received a mean total dose of 1,540 ± 920 mg ibogaine HCl. Subjects used oxycodone (n = 21; 70%) and/or heroin (n = 18; 60%) in respective amounts of 250 ± 180 mg/day and 1.3 ± 0.94 g/day, and averaged 3.1 ± 2.6 previous episodes of treatment for opioid dependence. Detoxification and follow-up outcomes at 1, 3, 6, 9, and 12 months were evaluated utilizing the Subjective Opioid Withdrawal Scale (SOWS) and Addiction Severity Index Composite (ASIC) scores, respectively.

RESULTS

SOWS scores decreased from 31.0 ± 11.6 pretreatment to 14.0 ± 9.8 at 76.5 ± 30 hours posttreatment (t = 7.07, df = 26, p < 0.001). At 1-month posttreatment follow-up, 15 subjects (50%) reported no opioid use during the previous 30 days. ASIC Drug Use and Legal and Family/Social Status scores were improved relative to pretreatment baseline at all posttreatment time points (p < .001). Improvement in Drug Use scores was maximal at 1 month, and subsequently sustained from 3 to 12 months at levels that did not reach equivalence to the effect at 1 month.

CONCLUSION

Ibogaine was associated with substantive effects on opioid withdrawal symptoms and drug use in subjects for whom other treatments had been unsuccessful, and may provide a useful prototype for discovery and development of innovative pharmacotherapy of addiction.