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Irwin M, Gunther W, Keefer P, Saul D, Singh SA, Wright J, Smith MA. Buprenorphine for Chronic Pain in a Pediatric Patient With Sickle-Cell Disease. J Pain Symptom Manage 2021; 62:1086-1091. [PMID: 33864846 DOI: 10.1016/j.jpainsymman.2021.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/29/2021] [Accepted: 04/05/2021] [Indexed: 12/23/2022]
Affiliation(s)
- Madison Irwin
- University of Michigan College of Pharmacy, Ann Arbor, Michigan; Michigan Medicine, Department of Pharmacy Services, Ann Arbor, Michigan
| | - William Gunther
- University of Michigan Medical School, Department of Geriatric and Palliative Medicine, Ann Arbor, Michigan
| | - Patricia Keefer
- University of Michigan Medical School, Department of Internal Medicine and Pediatrics, Ann Arbor, Michigan
| | - D'Anna Saul
- University of Michigan Medical School, Department of Internal Medicine and Pediatrics, Ann Arbor, Michigan
| | - Sharon A Singh
- University of Michigan Medical School, Department of Hematology/Oncology, and Pediatrics, Ann Arbor, Michigan
| | - Jennifer Wright
- Michigan Medicine, Pediatric Palliative Care Service, Ann Arbor, Michigan
| | - Michael A Smith
- University of Michigan College of Pharmacy, Ann Arbor, Michigan; Michigan Medicine, Department of Pharmacy Services, Ann Arbor, Michigan.
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Kunzler NM, Wightman RS, Nelson LS. Opioid Withdrawal Precipitated by Long-Acting Antagonists. J Emerg Med 2020; 58:245-253. [PMID: 32005608 DOI: 10.1016/j.jemermed.2019.12.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 12/05/2019] [Accepted: 12/09/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Precipitated opioid withdrawal (POW) after opioid antagonist administration can be challenging to manage in the emergency department (ED), particularly if caused by a long-acting opioid antagonist such as naltrexone. There are no evidence-based guidelines to assist in safely and efficiently managing patients with this syndrome. OBJECTIVE OF REVIEW To review current practice on the treatment of long-acting antagonist POW and make recommendations on the treatment of this complex disease process. METHODS A literature search of opioid withdrawal cases precipitated by naltrexone was done using PubMed. One of the authors screened all the results of this search by title and abstract, leading to a final count of 27 articles that were reviewed in full by all authors. English language cases that involved precipitated opioid withdrawal from a long-acting opioid antagonist were included. Data were extracted, including the precipitant involved and dose, severity of opioid withdrawal, treatments rendered, and response to treatment. In all cases where symptoms and signs were described, a Clinical Opiate Withdrawal Scale score was calculated based on the information available. RESULTS Twenty-seven papers were included. Naltrexone alone was the primary antagonist reported in 19 of the papers, extended-release naltrexone in two, naltrexone-morphine combination in two, and nalmefene in four. Treatment most commonly included fluid replacement, benzodiazepines, antiemetics, and clonidine. Full opioid agonist treatment, although often suggested, was poorly described. Buprenorphine successfully reduced the severity and duration of withdrawal in several cases. No standardized response scale was used, and response to treatment ranged from 3 to 48 h prior to resolution of clinical effects. CONCLUSIONS Management of POW from long-acting antagonists is a complex problem with little formal evaluation of treatment options. There is not currently a sufficiently robust body of literature to support an evidence-based guideline. However, use of intravenous fluids, antiemetics, and benzodiazepines is commonly reported as successful and seems to be a reasonable approach until this process is better studied. A treatment strategy using partial agonists such as buprenorphine is emerging and may represent a safe and effective treatment pathway for these patients.
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Affiliation(s)
- Nathan M Kunzler
- Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts
| | - Rachel S Wightman
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers University, Newark, New Jersey
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López-Pelayo H, Zuluaga P, Caballeria E, Van den Brink W, Mann K, Gual A. Safety of nalmefene for the treatment of alcohol use disorder: an update. Expert Opin Drug Saf 2019; 19:9-17. [PMID: 31868031 DOI: 10.1080/14740338.2020.1707802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Reduced drinking has been debated as a treatment goal for heavy drinking alcohol-dependent patients, in whom treatment based on abstinence is not always an option. Nalmefene was the first drug approved by the European Medicines Agency (2013) with the indication of reduced drinking in high drinking risk level alcohol-dependent patients. Six years after its introduction in Europe, data from clinical experience can be compared with those from preclinical studies and pivotal registration studies to evaluate what nalmefene has added to the treatment of AUD.Areas covered: Systematic review of efficacy and safety data of nalmefene use in humans from preclinical, phase III and phase IV studies, including systematic reviews, meta-analyses, cost-effectiveness analyses, and other secondary analyses.Expert opinion: Nalmefene introduces a paradigm change in the treatment of AUD that makes it appealing to patients that are reluctant to embrace abstinence, and facilitate patient-centered care in heavy users. However, information regarding safety data in special populations (e.g., patients with alcohol-related diseases, pregnancy, psychiatric disease), and direct comparisons with other potential drugs for alcohol reduction are further needed. Despite the promising role of nalmefene, there are still some factors that limit its wide prescription further than in specialized settings.
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Affiliation(s)
- Hugo López-Pelayo
- Grup Recerca Addiccions Clínic (GRAC-GRE), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic Barcelona, Barcelona, Spain
| | - Paola Zuluaga
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Elsa Caballeria
- Grup Recerca Addiccions Clínic (GRAC-GRE), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic Barcelona, Barcelona, Spain
| | - Wim Van den Brink
- Department of Psychiatry, Amsterdam University Medical Centres, Location AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Karl Mann
- Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany
| | - Antoni Gual
- Grup Recerca Addiccions Clínic (GRAC-GRE), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic Barcelona, Barcelona, Spain
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Stuart Bradley E, Liss D, Pepper Carreiro S, Brush DE, Babu K. Potential uses of naltrexone in emergency department patients with opioid use disorder. Clin Toxicol (Phila) 2019; 57:753-759. [PMID: 30831039 PMCID: PMC6908461 DOI: 10.1080/15563650.2019.1583342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 01/21/2019] [Accepted: 01/25/2019] [Indexed: 10/27/2022]
Abstract
Introduction: Despite widespread recognition of the opioid crisis, opioid overdose remains a common reason for Emergency Department (ED) utilization. Treatment for these patients after stabilization often involves the provision of information for outpatient treatment options. Ideally, an ED visit for overdose would present an opportunity to start treatment for opioid use disorder (OUD) immediately. Although widely recognized as effective, opioid agonist therapy with methadone and buprenorphine commonly referred to as "medication-assisted therapy" but more correctly as "medication for addiction treatment" (MAT), can be difficult to access even for motivated individuals due to shortages of prescribers and treatment programs. Moreover, opioid agonist therapy may not be appropriate for all patients, as many patients who present after overdose are not opioid dependent. More treatment options are required to successfully match patients with diverse needs to an optimal treatment plan in order to avoid relapse. Naltrexone, a long-acting opioid antagonist, available orally and as a monthly extended-release intramuscular injection, may represent another treatment option. Methods: We conducted a literature search of MEDLINE and PubMed. We aimed to capture references related to naltrexone and is use as MAT for OUD, as well as manuscripts that discussed naltrexone in comparison toother agents used for MAT, opioid detoxification, and naltrexone metabolism. Our initial search logic returned a total of 618 articles. Following individual evaluation for relevance, we selected 65 for in-depthreview. Manuscripts meeting criteria were examined for citations meriting further review, leading to the addition of 30 manuscripts Conclusions: Here, we review the pharmacology of naltrexone as it relates to OUD, its history of use, and highlight recent studies and new approaches for use of the drug as MAT including its potential initiation after ED visit for opioid overdose.
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Affiliation(s)
- Evan Stuart Bradley
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
| | - David Liss
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Stephanie Pepper Carreiro
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
| | - David Eric Brush
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
| | - Kavita Babu
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
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Yéléhé-Okouma M, Martini H, Lemarié J, Labroca P, Petitpain N, Gibaja V, Paille F, Gillet P. Opioid substitution therapy or hidden opioids are a minefield for nalmefene: an atypical case series of 11 patients in Lorraine. Fundam Clin Pharmacol 2017; 31:574-579. [DOI: 10.1111/fcp.12286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 03/07/2017] [Accepted: 03/16/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Melissa Yéléhé-Okouma
- Centre Régional de Pharmacovigilance de Lorraine; Laboratoire de Pharmacologie Clinique et de Toxicologie; CHRU de Nancy; Hôpital Central; 29 avenue du Maréchal de Lattre de Tassigny, CO 60034 54035 Nancy cedex France
| | - Hervé Martini
- Service de Médecine L / Addictologie CHRU de Nancy; Hôpitaux de Brabois - Bâtiment Philippe Canton; Rue du Morvan 54500 Vandœuvre-lès-Nancy France
| | - Jérémie Lemarié
- Service de Réanimation Médicale; CHRU de Nancy; Hôpital Central; 29 avenue du Maréchal de Lattre de Tassigny, CO 60034 54035 Nancy cedex France
| | - Pierre Labroca
- Service de Réanimation Médicale; Hôpital de Mercy; CHR Metz-Thionville; 1, allée du château, CS 45001 57085 Metz cedex 03 France
| | - Nadine Petitpain
- Centre Régional de Pharmacovigilance de Lorraine; Laboratoire de Pharmacologie Clinique et de Toxicologie; CHRU de Nancy; Hôpital Central; 29 avenue du Maréchal de Lattre de Tassigny, CO 60034 54035 Nancy cedex France
| | - Valérie Gibaja
- Centre d'Addictovigilance de Nancy; Hôpital Central; Pavillon Bruillatre-Balbatre, 29, avenue du Maréchal de Lattre de Tassigny, CO 60034 54035 NANCY Cedex France
| | - François Paille
- Service de Médecine L / Addictologie CHRU de Nancy; Hôpitaux de Brabois - Bâtiment Philippe Canton; Rue du Morvan 54500 Vandœuvre-lès-Nancy France
| | - Pierre Gillet
- Centre Régional de Pharmacovigilance de Lorraine; Laboratoire de Pharmacologie Clinique et de Toxicologie; CHRU de Nancy; Hôpital Central; 29 avenue du Maréchal de Lattre de Tassigny, CO 60034 54035 Nancy cedex France
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Naltrexone- or Nalmefene-Related Buprenorphine Withdrawal: Treat It With… More Buprenorphine. J Clin Psychopharmacol 2017; 37:631-633. [PMID: 28806388 DOI: 10.1097/jcp.0000000000000763] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Franchitto N, Jullian B, Salles J, Pelissier F, Rolland B. Management of precipitated opiate withdrawal syndrome induced by nalmefene mistakenly prescribed in opiate-dependent patients: a review for clinicians. Expert Opin Drug Metab Toxicol 2017; 13:669-677. [DOI: 10.1080/17425255.2017.1312340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Nicolas Franchitto
- Service d’Addictologie, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
- Centre Antipoison et de Toxicovigilance, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale (INSERM) UMR 1027, Université Paul Sabatier, Toulouse, France
| | - Benedicte Jullian
- Service d’Addictologie, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
| | - Juliette Salles
- Service d’Addictologie, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
| | - Fanny Pelissier
- Centre Antipoison et de Toxicovigilance, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
| | - Benjamin Rolland
- Département de Psychiatrie et d'Addictologie, Centre Hospitalo-Universitaire Lille, Lille, France
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Mann K, Torup L, Sørensen P, Gual A, Swift R, Walker B, van den Brink W. Nalmefene for the management of alcohol dependence: review on its pharmacology, mechanism of action and meta-analysis on its clinical efficacy. Eur Neuropsychopharmacol 2016; 26:1941-1949. [PMID: 27842940 DOI: 10.1016/j.euroneuro.2016.10.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 10/05/2016] [Accepted: 10/29/2016] [Indexed: 12/20/2022]
Abstract
Nalmefene, a mu- and delta-opioid receptor (MOR, DOR) antagonist and a partial kappa-opioid receptor (KOR) agonist, is approved in the European Union and other countries for the reduction of alcohol consumption in alcohol dependent patients with a high drinking risk level according to WHO ("target population"). This review presents an overview of nalmefene׳s pharmacology, its mechanisms of action and a meta-analysis on its efficacy in reducing alcohol consumption. The review was based on a systematic search of the literature. Random effects meta-analyses were performed on published and unpublished trials directed at drinking reduction using the changes in heavy drinking days (HDDs) and daily total alcohol consumption (TAC) from baseline to the primary endpoint. For each included study and each dose, Hedges' g was used as an unbiased estimator of the standardised mean differences between nalmefene and placebo. Preclinical data suggests that nalmefene counters alcohol-induced dysregulations of the MOR/endorphine and the KOR/dynorphin system. Evidence further suggests that reduced alcohol consumption is an effective treatment strategy that appeals to patients not ready for abstinence. Finally, meta-analyses confirmed the efficacy of 20mg nalmefene for reducing HDDs in the ITT population (Hedge׳s g=-0.20; 95% CI -0.30 to -0.09) and the target population (Hedge׳s g=-0.33; 95% CI -0.48 to -0.18). Similar results were seen for TAC. Several meta-analyses, including this new meta-analysis, support nalmefene׳s efficacy in reducing alcohol consumption. In conclusion, because it does not require abstinence, this treatment has the potential to motivate more patients for treatment and thus helps to address a major public health concern.
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Affiliation(s)
- Karl Mann
- Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Germany.
| | - Lars Torup
- Novo Nordisk Foundation, Copenhagen, Denmark
| | | | - Antoni Gual
- Neurosciences Institute, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Robert Swift
- Center for Alcohol and Addiction Studies, Brown University, and the Providence VA Medical Center, Providence, RI, USA
| | - Brendan Walker
- Laboratory of Alcoholism and Addictions Neuroscience, Washington State University, WA, USA
| | - Wim van den Brink
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Nalmefene and opioids: A contra-indication to remember. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2016. [DOI: 10.1016/j.toxac.2016.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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10
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Nalmefene Mistakenly Prescribed to Reduce Alcohol Consumption in Patients Under Buprenorphine Substitution Therapy Resulting in Acute Opioid Withdrawal: Management in an Emergency Setting. J Clin Psychopharmacol 2016; 36:100-3. [PMID: 26658085 DOI: 10.1097/jcp.0000000000000448] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Withdrawal syndrome after co-medication of opioid maintenance therapy with nalmefene: unrecognized interaction. Eur J Clin Pharmacol 2015; 71:1539-40. [DOI: 10.1007/s00228-015-1931-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 08/23/2015] [Indexed: 10/23/2022]
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