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Aapro M, Fogli S, Morlion B, Danesi R. Opioid metabolism and drug-drug interaction in cancer. Oncologist 2024:oyae094. [PMID: 38780124 DOI: 10.1093/oncolo/oyae094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/11/2024] [Indexed: 05/25/2024] Open
Abstract
Concomitant use of multiple drugs in most patients with cancer may result in drug-drug interactions (DDIs), potentially causing serious adverse effects. These patients often experience unrelieved cancer-related pain (CRP) during and after cancer treatment, which can lead to a reduced quality of life. Opioids can be used as part of a multimodal pain management strategy when non-opioid analgesics are not providing adequate pain relief, not tolerated, or are contraindicated. However, due to their narrow therapeutic window, opioids are more susceptible to adverse events when a DDI occurs. Clinically relevant DDIs with opioids are usually pharmacokinetic, mainly occurring via metabolism by cytochrome P450 (CYP). This article aims to provide an overview of potential DDIs with opioids often used in the treatment of moderate-to-severe CRP and commonly used anticancer drugs such as chemotherapeutics, tyrosine kinase inhibitors (TKIs), or biologics. A DDI-checker tool was used to contextualize the tool-informed DDI assessment outcomes with clinical implications and practice. The findings were compared to observations from a literature search conducted in Embase and PubMed to identify clinical evidence for these potential DDIs. The limited results mainly included case studies and retrospective reviews. Some potential DDIs on the DDI-checker were aligned with literature findings, while others were contradictory. In conclusion, while DDI-checkers are useful tools in identifying potential DDIs, it is necessary to incorporate literature verification and comprehensive clinical assessment of the patient before implementing tool-informed decisions in clinical practice.
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Affiliation(s)
- Matti Aapro
- Genolier Cancer Centre, Clinique de Genolier, 1272 Genolier, Switzerland
| | - Stefano Fogli
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa PI, Italy
| | - Bart Morlion
- Department of Cardiovascular Sciences, Section Anesthesiology and Algology, University of Leuven, 3000 Leuven, Belgium
| | - Romano Danesi
- Department of Oncology and Hemato-Oncology, University of Milano, 20122 Milano MI, Italy
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2
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Golubnitschaja O, Polivka J, Potuznik P, Pesta M, Stetkarova I, Mazurakova A, Lackova L, Kubatka P, Kropp M, Thumann G, Erb C, Fröhlich H, Wang W, Baban B, Kapalla M, Shapira N, Richter K, Karabatsiakis A, Smokovski I, Schmeel LC, Gkika E, Paul F, Parini P, Polivka J. The paradigm change from reactive medical services to 3PM in ischemic stroke: a holistic approach utilising tear fluid multi-omics, mitochondria as a vital biosensor and AI-based multi-professional data interpretation. EPMA J 2024; 15:1-23. [PMID: 38463624 PMCID: PMC10923756 DOI: 10.1007/s13167-024-00356-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 03/12/2024]
Abstract
Worldwide stroke is the second leading cause of death and the third leading cause of death and disability combined. The estimated global economic burden by stroke is over US$891 billion per year. Within three decades (1990-2019), the incidence increased by 70%, deaths by 43%, prevalence by 102%, and DALYs by 143%. Of over 100 million people affected by stroke, about 76% are ischemic stroke (IS) patients recorded worldwide. Contextually, ischemic stroke moves into particular focus of multi-professional groups including researchers, healthcare industry, economists, and policy-makers. Risk factors of ischemic stroke demonstrate sufficient space for cost-effective prevention interventions in primary (suboptimal health) and secondary (clinically manifested collateral disorders contributing to stroke risks) care. These risks are interrelated. For example, sedentary lifestyle and toxic environment both cause mitochondrial stress, systemic low-grade inflammation and accelerated ageing; inflammageing is a low-grade inflammation associated with accelerated ageing and poor stroke outcomes. Stress overload, decreased mitochondrial bioenergetics and hypomagnesaemia are associated with systemic vasospasm and ischemic lesions in heart and brain of all age groups including teenagers. Imbalanced dietary patterns poor in folate but rich in red and processed meat, refined grains, and sugary beverages are associated with hyperhomocysteinaemia, systemic inflammation, small vessel disease, and increased IS risks. Ongoing 3PM research towards vulnerable groups in the population promoted by the European Association for Predictive, Preventive and Personalised Medicine (EPMA) demonstrates promising results for the holistic patient-friendly non-invasive approach utilising tear fluid-based health risk assessment, mitochondria as a vital biosensor and AI-based multi-professional data interpretation as reported here by the EPMA expert group. Collected data demonstrate that IS-relevant risks and corresponding molecular pathways are interrelated. For examples, there is an evident overlap between molecular patterns involved in IS and diabetic retinopathy as an early indicator of IS risk in diabetic patients. Just to exemplify some of them such as the 5-aminolevulinic acid/pathway, which are also characteristic for an altered mitophagy patterns, insomnia, stress regulation and modulation of microbiota-gut-brain crosstalk. Further, ceramides are considered mediators of oxidative stress and inflammation in cardiometabolic disease, negatively affecting mitochondrial respiratory chain function and fission/fusion activity, altered sleep-wake behaviour, vascular stiffness and remodelling. Xanthine/pathway regulation is involved in mitochondrial homeostasis and stress-driven anxiety-like behaviour as well as molecular mechanisms of arterial stiffness. In order to assess individual health risks, an application of machine learning (AI tool) is essential for an accurate data interpretation performed by the multiparametric analysis. Aspects presented in the paper include the needs of young populations and elderly, personalised risk assessment in primary and secondary care, cost-efficacy, application of innovative technologies and screening programmes, advanced education measures for professionals and general population-all are essential pillars for the paradigm change from reactive medical services to 3PM in the overall IS management promoted by the EPMA.
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Affiliation(s)
- Olga Golubnitschaja
- Predictive, Preventive and Personalised (3P) Medicine, Department of Radiation Oncology, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany
| | - Jiri Polivka
- Department of Histology and Embryology, Faculty of Medicine in Plzen, Charles University, Prague, Czech Republic
- Biomedical Centre, Faculty of Medicine in Plzen, Charles University, Prague, Czech Republic
| | - Pavel Potuznik
- Department of Neurology, University Hospital Plzen and Faculty of Medicine in Plzen, Charles University, Prague, Czech Republic
| | - Martin Pesta
- Department of Biology, Faculty of Medicine in Plzen, Charles University, Prague, Czech Republic
| | - Ivana Stetkarova
- Department of Neurology, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Alena Mazurakova
- Department of Anatomy, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia
| | - Lenka Lackova
- Department of Histology and Embryology, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia
| | - Peter Kubatka
- Department of Histology and Embryology, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia
| | - Martina Kropp
- Experimental Ophthalmology, University of Geneva, 1205 Geneva, Switzerland
- Ophthalmology Department, University Hospitals of Geneva, 1205 Geneva, Switzerland
| | - Gabriele Thumann
- Experimental Ophthalmology, University of Geneva, 1205 Geneva, Switzerland
- Ophthalmology Department, University Hospitals of Geneva, 1205 Geneva, Switzerland
| | - Carl Erb
- Private Institute of Applied Ophthalmology, Berlin, Germany
| | - Holger Fröhlich
- Artificial Intelligence & Data Science Group, Fraunhofer SCAI, Sankt Augustin, Germany
- Bonn-Aachen International Center for IT (B-It), University of Bonn, 53115 Bonn, Germany
| | - Wei Wang
- Edith Cowan University, Perth, Australia
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing, China
| | - Babak Baban
- The Dental College of Georgia, Departments of Neurology and Surgery, The Medical College of Georgia, Augusta University, Augusta, USA
| | - Marko Kapalla
- Negentropic Systems, Ružomberok, Slovakia
- PPPM Centre, s.r.o., Ruzomberok, Slovakia
| | - Niva Shapira
- Department of Nutrition, School of Health Sciences, Ashkelon Academic College, Ashkelon, Israel
| | - Kneginja Richter
- CuraMed Tagesklinik Nürnberg GmbH, Nuremberg, Germany
- Technische Hochschule Nürnberg GSO, Nuremberg, Germany
- University Clinic for Psychiatry and Psychotherapy, Paracelsus Medical University, Nuremberg, Germany
| | - Alexander Karabatsiakis
- Department of Psychology, Clinical Psychology II, University of Innsbruck, Innsbruck, Austria
| | - Ivica Smokovski
- University Clinic of Endocrinology, Diabetes and Metabolic Disorders Skopje, University Goce Delcev, Faculty of Medical Sciences, Stip, North Macedonia
| | - Leonard Christopher Schmeel
- Department of Radiation Oncology, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany
| | | | - Paolo Parini
- Cardio Metabolic Unit, Department of Medicine Huddinge, and Department of Laboratory Medicine, Karolinska Institutet, and Medicine Unit of Endocrinology, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden
| | - Jiri Polivka
- Department of Neurology, University Hospital Plzen and Faculty of Medicine in Plzen, Charles University, Prague, Czech Republic
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3
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Ouchi R, Nagao M, Suzuki S, Yamagata T, Chiba M, Kurata N, Usui K, Watanabe T, Koyama K, Okada K. A case with a trend of QT interval prolongation due to the introduction of methadone to a pancreatic cancer patient on levofloxacin. J Pharm Health Care Sci 2024; 10:4. [PMID: 38167143 PMCID: PMC10763223 DOI: 10.1186/s40780-023-00322-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/24/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND As methadone can prevent the development of opioid resistance, it has application in alleviating cancer-related pain that proves challenging to manage with other opioids. QT interval prolongation is a serious side effect of methadone treatment, with some reported deaths. In particular, owing to the increased risk of QT interval prolongation, caution should be exercised when using it in combination with drugs that also prolong the QT interval. CASE PRESENTATION This study presents a case in which methadone was introduced to a patient (a man in his 60s) already using levofloxacin, which could prolong the QT interval-a serious side effect of methadone treatment-and whose QTc value tended to increase. Given that levofloxacin can increase the risk of QT interval prolongation, we considered switching to other antibacterial agents before introducing methadone. However, because the neurosurgeon judged that controlling a brain abscess was a priority, low-dose methadone was introduced with continuing levofloxacin. Owing to the risks, we performed frequent electrocardiograms. Consequently, we responded before the QTc increased enough to meet the diagnostic criteria for QT interval prolongation. Consequently, we prevented the occurrence of drug-induced long QT syndrome. CONCLUSIONS When considering the use of methadone for intractable cancer pain, it is important to eliminate possible risk factors for QT interval prolongation. However, as it may be difficult to discontinue concomitant drugs owing to comorbidities, there could be cases in which the risk of QT interval prolongation could increase, even with the introduction of low-dose methadone. In such cases, frequent monitoring, even with simple measurements such as those used in this case, is likely to prevent progression to more serious conditions.
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Affiliation(s)
- Ryusuke Ouchi
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan.
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan.
| | - Munenori Nagao
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Shinju Suzuki
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Toshihiro Yamagata
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Mie Chiba
- Department of Nursing, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Naoko Kurata
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Kensuke Usui
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Takashi Watanabe
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Kaori Koyama
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Kouji Okada
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
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Hirai R, Uesawa Y. Analysis of Opioid-Related Adverse Events in Japan Using FAERS Database. Pharmaceuticals (Basel) 2023; 16:1541. [PMID: 38004407 PMCID: PMC10675800 DOI: 10.3390/ph16111541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/20/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023] Open
Abstract
Adverse events associated with opioid use in palliative care have been extensively studied. However, predicting the occurrence of adverse events based on the specific opioid used remains difficult. This study aimed to comprehensively analyze the adverse events related to µ-opioid receptor stimulation of opioids approved in Japan and investigate the tendencies of adverse event occurrence among different opioids. We utilized the FDA Adverse Event Reporting System database to extract reported adverse events for opioids approved in Japan. Cluster analysis was performed on reporting odds ratios (RORs) of adverse event names among opioids to visualize relationships between opioids and adverse events, facilitating a comparative study of their classifications. We calculated the RORs of adverse events for the target opioids. Cluster analysis based on these RORs resulted in five broad clusters based on the reported adverse events: i.e., strong opioids, weak opioids, loperamide, tapentadol, and remifentanil. This study provides a comprehensive classification of the association between μ-opioid-receptor-stimulating opioids and adverse events.
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Affiliation(s)
| | - Yoshihiro Uesawa
- Department of Medical Molecular Informatics, Meiji Pharmaceutical University, Tokyo 204-8588, Japan
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Remmington C, Liew V, Hanks F, Camporota L, Stubbs O, Sousa A, Barrett NA. Methadone as an opioid and sedative weaning strategy in adults receiving extracorporeal membrane oxygenation. Perfusion 2023:2676591231195303. [PMID: 37606232 DOI: 10.1177/02676591231195303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Affiliation(s)
- Christopher Remmington
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science and Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine King's College London, London, UK
| | - Victor Liew
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Fraser Hanks
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science and Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine King's College London, London, UK
| | - Luigi Camporota
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science and Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine King's College London, London, UK
| | - Oliver Stubbs
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Angelo Sousa
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas A Barrett
- Departments of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science and Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine King's College London, London, UK
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6
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Isaza C, Castaño-Ramírez OM, Vélez JP, Henao J, Beltrán-Angarita L, Sepúlveda-Arias JC. Influence of CYP2B6 Genotype on Methadone Dosage in Patients from the Methadone Maintenance Treatment (MMT) Program in Pereira, Colombia. Life (Basel) 2023; 13:life13041038. [PMID: 37109567 PMCID: PMC10145268 DOI: 10.3390/life13041038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/05/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Methadone treatment reduces the use of heroin and withdrawal symptoms; however, methadone is an expensive medication with a narrow safety margin. We compared the retention rates, persistence of heroin use, and quality of life of a group of patients undergoing conventional Methadone Maintenance Treatment (MMT) with a group for whom the CYP2B6 516G>T polymorphism was used in addition to the MMT to calculate the required methadone dose. Over 12 weeks, the retention rate, heroin usage, and quality of life of patients under conventional treatment (n = 34) were compared with those of patients for whom we used genetic markers to calculate methadone dosage (n = 38). At the end of the study, 26.4% of patients abandoned the program, and neither demographic nor clinical variables were associated with treatment adherence. Of the remaining patients, 16% of the control group and 8% of patients in the pharmacogenetic group reported heroin use, while both groups showed a 64% reduction in the use of cocaine/crack (no significant differences between the groups were found). Starting in the second week, the methadone dosage was lower among the patients for whom methadone was prescribed based on genotype. Although there were six individuals in the control group and three in the pharmacogenetic group with QTc intervals > 450 ms (a threshold that is considered dangerous), we did not find a relationship between the QTc interval and methadone dosage. There were no differences in the perception of quality of life between the two groups. The results of this pilot study suggest that concerning methadone therapy, the CYP2B6 genotype contributes to reduced effective doses and treatment costs.
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Affiliation(s)
- Carlos Isaza
- Facultad de Ciencias de la Salud, Universidad Tecnológica de Pereira, Pereira 660003, Colombia
| | | | | | - Julieta Henao
- Facultad de Ciencias de la Salud, Universidad Tecnológica de Pereira, Pereira 660003, Colombia
| | | | - Juan Carlos Sepúlveda-Arias
- Grupo Infección e Inmunidad, Facultad de Ciencias de la Salud, Universidad Tecnológica de Pereira, Pereira 660003, Colombia
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7
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Feng H, Elladki R, Jiang J, Wei GW. Machine-learning analysis of opioid use disorder informed by MOR, DOR, KOR, NOR and ZOR-based interactome networks. Comput Biol Med 2023; 157:106745. [PMID: 36924727 DOI: 10.1016/j.compbiomed.2023.106745] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/11/2023] [Accepted: 03/04/2023] [Indexed: 03/17/2023]
Abstract
Opioid use disorder (OUD) continuously poses major public health challenges and social implications worldwide with dramatic rise of opioid dependence leading to potential abuse. Despite that a few pharmacological agents have been approved for OUD treatment, the efficacy of said agents for OUD requires further improvement in order to provide safer and more effective pharmacological and psychosocial treatments. Proteins including mu, delta, kappa, nociceptin, and zeta opioid receptors are the direct targets of opioids and play critical roles in therapeutic treatments. The protein-protein interaction (PPI) networks of the these receptors increase the complexity in the drug development process for an effective opioid addiction treatment. The report below presents a PPI-network informed machine-learning study of OUD. We have examined more than 500 proteins in the five opioid receptor networks and subsequently collected 74 inhibitor datasets. Machine learning models were constructed by pairing gradient boosting decision tree (GBDT) algorithm with two advanced natural language processing (NLP)-based autoencoder and Transformer fingerprints for molecules. With these models, we systematically carried out evaluations of screening and repurposing potential of more than 120,000 drug candidates for four opioid receptors. In addition, absorption, distribution, metabolism, excretion, and toxicity (ADMET) properties were also considered in the screening of potential drug candidates. Our machine-learning tools determined a few inhibitor compounds with desired potency and ADMET properties for nociceptin opioid receptors. Our approach offers a valuable and promising tool for the pharmacological development of OUD treatments.
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Affiliation(s)
- Hongsong Feng
- Department of Mathematics, Michigan State University, MI 48824, USA
| | - Rana Elladki
- Department of Mathematics, Michigan State University, MI 48824, USA
| | - Jian Jiang
- Research Center of Nonlinear Science, School of Mathematical and Physical Sciences, Wuhan Textile University, Wuhan, 430200, PR China
| | - Guo-Wei Wei
- Department of Mathematics, Michigan State University, MI 48824, USA; Department of Electrical and Computer Engineering, Michigan State University, MI 48824, USA; Department of Biochemistry and Molecular Biology, Michigan State University, MI 48824, USA.
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8
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Larney S, Jones NR, Hickman M, Nielsen S, Ali R, Degenhardt L. Does opioid agonist treatment reduce overdose mortality risk in people who are older or have physical comorbidities? Cohort study using linked administrative health data in New South Wales, Australia, 2002-17. Addiction 2023. [PMID: 36843415 DOI: 10.1111/add.16178] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 02/07/2023] [Indexed: 02/28/2023]
Abstract
AIMS To quantify the association between opioid agonist treatment (OAT) and overdose death by age group; test the hypothesis that across different age groups, opioid overdose mortality is lowest during OAT with buprenorphine compared with time out of treatment or OAT with methadone; and test associations between OAT and opioid overdose mortality in the presence of chronic circulatory, respiratory, liver and kidney diseases. DESIGN Retrospective observational cohort study using linked administrative data. SETTING New South Wales, Australia. PARTICIPANTS A total of 37 764 people prescribed OAT, 1 August 2002 and 31 December 2017. MEASUREMENTS OAT exposure, opioid overdose mortality and key confounders were measured using linked population data sets on OAT entry and exit, hospitalization, mental health care, incarceration and mortality. ICD-10 codes were used to define opioid overdose mortality and chronic disease groups of interest. FINDINGS Relative to time out of treatment, time in OAT was associated with a lower risk of opioid overdose death across all age groups and chronic diseases. Among people aged 50 years and older, there was weak evidence that buprenorphine may be associated with greater protection against opioid overdose death than methadone [generalized estimating equation (GEE) adjusted incident rate ratio (aIRR) = 0.47; 95% confidence interval (CI) = 0.21, 1.02; marginal structural models (MSM) aIRR = 0.49; 95% CI = 0.17, 1.41]. Buprenorphine was associated with greater protection against overdose death than methadone for clients with circulatory (MSM aIRR = 0.27; 95% CI = 0.11, 0.67) or respiratory (MSM aIRR = 0.26; 95% CI = 0.07, 0.94) diseases, but not liver (MSM aIRR = 0.59; 95% CI = 0.14, 2.43) or kidney (MSM aIRR = 1.16; 95% CI = 0.31, 4.36) diseases. CONCLUSIONS Opioid agonist treatment (OAT) appears to reduce mortality risk in people with opioid use disorder who are older or who have physical comorbidities. Opioid overdose mortality during OAT with buprenorphine appears to be lower and reduced in clients with circulatory and respiratory diseases compared with OAT with methadone.
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Affiliation(s)
- Sarah Larney
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Montreal, Canada
- Department of Family Medicine and Emergency Medicine, University of Montreal, Montreal, Canada
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Nicola R Jones
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | | | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Clayton, Australia
| | - Robert Ali
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
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9
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Rubel SK, Eisenstat M, Wolff J, Calevski M, Mital S. Scope of, Motivations for, and Outcomes Associated with Buprenorphine Diversion in the United States: A Scoping Review. Subst Use Misuse 2023; 58:685-697. [PMID: 36803159 PMCID: PMC10961708 DOI: 10.1080/10826084.2023.2177972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Expanding access to medications to treat opioid use disorder (OUD), such as buprenorphine, is an evidence-based response to the mounting drug overdose crisis. However, concerns about buprenorphine diversion persist and contribute to limited access. METHODS To inform decisions about expanding access, a scoping review was conducted on publications describing the scope of, motivations for, and outcomes associated with diverted buprenorphine in the U.S. RESULTS In the 57 included studies, definitions for diversion were inconsistent. Most studied use of illicitly-obtained buprenorphine. Across studies, the scope of buprenorphine diversion ranged from 0% to 100%, varying by sample type and recall period. Among samples of people receiving buprenorphine for OUD treatment, diversion peaked at 4.8%. Motivations for using diverted buprenorphine were self-treatment, management of drug use, to get high, and when drug of choice was unavailable. Associated outcomes examined trended toward positive or neutral, including improved attitudes toward and retention in MOUD. CONCLUSIONS Despite inconsistent definitions of diversion, studies reported a low scope of diversion among people receiving MOUD, with inability to access treatment as a motivating factor for using diverted buprenorphine, and increased retention in MOUD as an outcome associated with use of diverted buprenorphine. Future research should explore reasons for diverted buprenorphine use in the context of expanded treatment availability to address persistent barriers to evidence-based treatment for OUD.
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Affiliation(s)
- Stephanie K Rubel
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Matthew Eisenstat
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jessica Wolff
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michael Calevski
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sasha Mital
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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10
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Townsend EA, Blough BE, Epstein DH, Negus SS, Shaham Y, Banks ML. Effect of TRV130 and methadone on fentanyl-vs.-food choice and somatic withdrawal signs in opioid-dependent and post-opioid-dependent rats. Neuropsychopharmacology 2022; 47:2132-2139. [PMID: 35906489 PMCID: PMC9556538 DOI: 10.1038/s41386-022-01393-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/14/2022] [Accepted: 07/14/2022] [Indexed: 01/26/2023]
Abstract
The high efficacy mu-opioid receptor (MOR) agonist methadone is an effective opioid use disorder (OUD) medication used exclusively in opioid-dependent patients. However, methadone has undesirable effects that limit its clinical efficacy. Intermediate efficacy MOR agonists may treat OUD with fewer undesirable effects. We compared the effects of methadone with the intermediate efficacy MOR agonist TRV130 (oliceridine) on fentanyl-vs.-food choice and somatic withdrawal signs in opioid-dependent and post-opioid-dependent rats. Male rats (n = 20) were trained under a fentanyl-vs.-food choice procedure. Rats were then provided extended fentanyl (3.2 µg/kg/infusion) access (6 p.m.-6 a.m.) for 10 days to produce opioid dependence/withdrawal. Rats were treated with vehicle (n = 7), TRV130 (3.2 mg/kg; n = 8), or methadone (3.2 mg/kg; n = 5) three times per day after each extended-access session (8:30 a.m., 11 a.m., 1:30 p.m.). Withdrawal sign scoring (1:55 p.m.) and choice tests (2-4 p.m.) were conducted daily. Vehicle, TRV130, and methadone effects on fentanyl choice were redetermined in post-opioid-dependent rats. Vehicle-, TRV130-, and methadone-treated rats had similar fentanyl intakes during extended access. Vehicle-treated rats exhibited increased withdrawal signs and decreased bodyweights. Both methadone and TRV130 decreased these withdrawal signs. TRV130 was less effective than methadone to decrease fentanyl choice and increase food choice in opioid-dependent rats. Neither methadone nor TRV130 decreased fentanyl choice in post-opioid-dependent rats. Results suggest that higher MOR activation is required to reduce fentanyl choice than withdrawal signs in fentanyl-dependent rats. Additionally, given that TRV130 did not precipitate withdrawal in opioid-dependent rats, intermediate efficacy MOR agonists like TRV130 may facilitate the transition of patients with OUD from methadone to lower efficacy treatments like buprenorphine.
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Affiliation(s)
- E Andrew Townsend
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA.
| | - Bruce E Blough
- Center for Drug Discovery, RTI International, Research Triangle Park, Durham, NC, USA
| | | | - S Stevens Negus
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Yavin Shaham
- Intramural Research Program, NIDA, NIH, Baltimore, MD, USA
| | - Matthew L Banks
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
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11
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Lai G, Aroke EN, Zhang SJ. Rediscovery of Methadone to Improve Outcomes in Pain Management. J Perianesth Nurs 2022; 37:425-434. [PMID: 35396188 DOI: 10.1016/j.jopan.2021.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 08/09/2021] [Accepted: 08/28/2021] [Indexed: 11/29/2022]
Abstract
Clinically, methadone is most known for its use in the treatment of opioid maintenance therapy. However, methadone's pharmacological profile makes it an excellent analgesic that can enhance acute and chronic pain management. It is a potent μ-receptor agonist with a longer elimination half-life than most clinically used opioids. In addition, methadone inhibits serotonin and norepinephrine uptake, and it is an N-methyl-D-aspartate antagonist. These distinct analgesic pathways mediate hyperalgesic, allodynic, and neuropathic pain. Its unique analgesic properties provide several essential benefits in perioperative use, neuropathic pain, cancer, and noncancer pain. Despite these proven clinical utilities, methadone has not been used widely to treat acute and chronic pain in opioid naïve patients. This article describes the unique pharmacology of methadone and provides emerging evidence to support its application in acute and chronic pain management. Pain management options and guidelines for surgical patients on methadone are discussed as well.
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Affiliation(s)
- Gloria Lai
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA
| | - Edwin N Aroke
- Nurse Anesthesia Program, School of Nursing, University of Alabama at Birmingham, Birmingham, AL
| | - Sarah Jingying Zhang
- Nurse Anesthesiology Program, School of Nursing, University of South Florida, Tampa, CA; Nurse Anesthesia Program, School of Nursing, Samuel Merritt University, Oakland, CA.
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12
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Dufort A, Samaan Z. Problematic Opioid Use Among Older Adults: Epidemiology, Adverse Outcomes and Treatment Considerations. Drugs Aging 2021; 38:1043-1053. [PMID: 34490542 PMCID: PMC8421190 DOI: 10.1007/s40266-021-00893-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2021] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Alexander Dufort
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph's Healthcare Hamilton, McMaster University, West 5th Campus, Administration-B3, 100 West 5th, Hamilton, ON, L8N 3K7, Canada.
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph's Healthcare Hamilton, McMaster University, West 5th Campus, Administration-B3, 100 West 5th, Hamilton, ON, L8N 3K7, Canada.,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
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13
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Cardiovascular Complications of Opioid Use: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:205-223. [PMID: 33446314 DOI: 10.1016/j.jacc.2020.11.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 12/29/2022]
Abstract
Opioids are the most potent of all analgesics. Although traditionally used solely for acute self-limited conditions and palliation of severe cancer-associated pain, a movement to promote subjective pain (scale, 0 to 10) to the status of a "fifth vital sign" bolstered widespread prescribing for chronic, noncancer pain. This, coupled with rising misuse, initiated a surge in unintentional deaths, increased drug-associated acute coronary syndrome, and endocarditis. In response, the American College of Cardiology issued a call to action for cardiovascular care teams. Opioid toxicity is primarily mediated via potent μ-receptor agonism resulting in ventilatory depression. However, both overdose and opioid withdrawal can trigger major adverse cardiovascular events resulting from hemodynamic, vascular, and proarrhythmic/electrophysiological consequences. Although natural opioid analogues are devoid of repolarization effects, synthetic agents may be proarrhythmic. This perspective explores cardiovascular consequences of opioids, the contributions of off-target electrophysiologic properties to mortality, and provides practical safety recommendations.
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14
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Solhjoo S, Punjabi NM, Ivanescu AE, Crainiceanu C, Gaynanova I, Wicken C, Buckenmaier C, Haigney MC. Methadone Destabilizes Cardiac Repolarization During Sleep. Clin Pharmacol Ther 2021; 110:1066-1074. [PMID: 34287835 DOI: 10.1002/cpt.2368] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/06/2021] [Indexed: 11/09/2022]
Abstract
Methadone, a widely prescribed medication for chronic pain and opioid addiction, is associated with respiratory depression and increased predisposition for torsades de pointes, a potentially fatal arrhythmia. Most methadone-related deaths occur during sleep. The objective of this study was to determine whether methadone's arrhythmogenic effects increase during sleep, with a focus on cardiac repolarization instability using QT variability index (QTVI), a measure shown to predict arrhythmias and mortality. Sleep study data of 24 patients on chronic methadone therapy referred to a tertiary clinic for overnight polysomnography were compared with two matched groups not on methadone: 24 patients referred for overnight polysomnography to the same clinic (clinic group), and 24 volunteers who had overnight polysomnography at home (community group). Despite similar values for heart rate, heart rate variability, corrected QT interval, QTVI, and oxygen saturation (SpO2 ) when awake, patients on methadone had larger QTVI (P = 0.015 vs. clinic, P < 0.001 vs. community) and lower SpO2 (P = 0.008 vs. clinic, P = 0.013 vs. community) during sleep, and the increase in their QTVI during sleep vs. wakefulness correlated with the decrease in SpO2 (r = -0.54, P = 0.013). QTVI positively correlated with methadone dose during sleep (r = 0.51, P = 0.012) and wakefulness (r = 0.73, P < 0.001). High-density ectopy (> 1,000 premature beats per median sleep period), a precursor for torsades de pointes, was uncommon but more frequent in patients on methadone (P = 0.039). This study demonstrates that chronic methadone use is associated with increased cardiac repolarization instability. Methadone's pro-arrhythmic impact may be mediated by sleep-related hypoxemia, which could explain the increased nocturnal mortality associated with this opioid.
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Affiliation(s)
- Soroosh Solhjoo
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Naresh M Punjabi
- Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | | | | | - Cassie Wicken
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Mark C Haigney
- F. Edward Hébert School of Medicine, Bethesda, Maryland, USA.,Military Cardiovascular Outcomes Research (MiCOR), Bethesda, Maryland, USA
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15
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Ickowicz S, McLean M. Case report: rapid inpatient methadone titration during pregnancy. JOURNAL OF SUBSTANCE USE 2021. [DOI: 10.1080/14659891.2021.1953167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Sarah Ickowicz
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark McLean
- Department of Family Medicine, University of British Columbia, Vancouer, British Columbia, Canada
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16
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Giorgetti A, Natanti A, Giorgetti R, Buscemi L. Long-lasting agony and failure to provide assistance in a case of mixed methadone-prescription drugs acute intoxication. Leg Med (Tokyo) 2021; 52:101911. [PMID: 34087652 DOI: 10.1016/j.legalmed.2021.101911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 05/03/2021] [Accepted: 05/22/2021] [Indexed: 11/29/2022]
Abstract
Methadone overdoses are usually considered "slow" and avoidable deaths. Despite being frequently witnessed, the type and duration of the agonal time are rarely documented and challenging to be reconstructed. Here we report a case in which a young male was found dead in a parked car, shortly after discharge from a compulsory psychiatric treatment. Death scene investigation, clinical records collection, analysis of video recordings from surveillance cameras and private videos, post-mortem examination, GC-MS and LC-MS/MS toxicological analyses were performed and allowed to assess an acute fatal intoxication by methadone and prescription drugs. The case here-in reported is a rare example of a witnessed and recorded prolonged agonal phase due to methadone and drug intoxication, which lasted at least 12 hours. The loss of consciousness and a worsening pattern of respiratory depression, including gasping, were reported by the friends of the victim, but no one called for help, arising the suspect of failure to provide assistance. The possibility of a long-lasting agony with respiratory gasping should be considered in the evaluation of similar intoxication cases.
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Affiliation(s)
- Arianna Giorgetti
- Department of Medical and Surgical Sciences DIMEC, University of Bologna, Italy
| | - Alice Natanti
- Section of Legal Medicine, Department of Excellence SBSP, Università Politecnica delle Marche of Ancona, Italy
| | - Raffaele Giorgetti
- Section of Legal Medicine, Department of Excellence SBSP, Università Politecnica delle Marche of Ancona, Italy
| | - Loredana Buscemi
- Section of Legal Medicine, Department of Excellence SBSP, Università Politecnica delle Marche of Ancona, Italy.
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17
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Sheibani M, Mirfallah Nassiri AA, Abedtash A, McDonald R, Zamani N, Hassanian-Moghaddam H. Troponin, A Predictor of Mortality in Methadone Exposure: An Observational Prospective Study. J Am Heart Assoc 2021; 10:e018899. [PMID: 33821671 PMCID: PMC8174177 DOI: 10.1161/jaha.120.018899] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Methadone poisoning/overdose is a global public health problem. We aimed to determine whether methadone poisoning increased cardiac troponin and whether high‐sensitivity cardiac troponin I (hs‐cTnI) levels predicted the need for intensive care unit admission, intubation, and mortality. Methods and Results This observational, prospective single‐center study was done at Loghman‐Hakim Hospital (Tehran, Iran) from June 2018 until February 2019. Patients aged >14 years admitted with a diagnosis of methadone exposure were included. Patients were excluded if they had coexisting conditions associated with elevated hs‐cTnI levels. An ECG and hs‐cTnI levels were obtained on emergency department presentation. Patients were followed up on their need for intubation, intensive care unit admission, and in‐hospital mortality. Of 245 included patients (186 [75.9%] men; median age, 33 years), most referred to loss of consciousness (210 cases, 89%). Nineteen (7.7%) patients had hs‐cTnI levels of >0.1 ng/mL (positive), and 41 (16.7%) had borderline levels of 0.019 to 0.1 ng/mL. Twenty‐three (9.3%) cases were admitted to the intensive care unit, 21 (8.5%) needed intubation, and 5 (2%) died during hospitalization. An hs‐cTnI cutoff value of 0.019 ng/mL independently predicted mortality. For optimal concomitant sensitivity and specificity, receiver operating characteristic curve analysis was conducted and showed that hs‐cTnI had an independent significant association with mortality, with a cutoff value of 0.0365 ng/mL (odds ratio, 38.1; 95% CI, 2.3–641.9; P<0.001). Conclusions Methadone exposure/toxicity is a newly identified cause of elevated hs‐cTnI. Values >0.019 ng/mL, and particularly >0.0365 ng/mL, of hs‐cTnI predicted mortality in our sample. Future studies should measure troponin levels in methadone maintenance treatment clients to assess the risk of myocardial injury from long‐term exposure.
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Affiliation(s)
- Mehdi Sheibani
- Cardiovascular Research CenterShahid Beheshti University of Medical Sciences Tehran Iran.,Clinical Research Development Center of Loghman Hakim HospitalShahid Beheshti University of Medical Sciences Tehran Iran
| | | | - Amirhossein Abedtash
- Department of Internal Medicine School of Medicine Shahid Beheshti University of Medical Sciences Tehran Iran
| | - Rebecca McDonald
- King's College London National Addiction CentreInstitute of Psychiatry, Psychology and Neuroscience London United Kingdom
| | - Nasim Zamani
- Social Determinants of Health Research CenterShahid Beheshti University of Medical Sciences Tehran Iran.,Department of Clinical Toxicology Loghman-Hakim HospitalSchool of MedicineShahid Beheshti University of Medical Sciences Tehran Iran
| | - Hossein Hassanian-Moghaddam
- Social Determinants of Health Research CenterShahid Beheshti University of Medical Sciences Tehran Iran.,Department of Clinical Toxicology Loghman-Hakim HospitalSchool of MedicineShahid Beheshti University of Medical Sciences Tehran Iran
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18
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Giorgetti A, Pascali J, Montisci M, Amico I, Bonvicini B, Fais P, Viero A, Giorgetti R, Cecchetto G, Viel G. The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis. Metabolites 2021; 11:metabo11030189. [PMID: 33810163 PMCID: PMC8004630 DOI: 10.3390/metabo11030189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/16/2022] Open
Abstract
Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p < 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (<600 ng/mL) might lead to death in the presence of the above conditions/diseases.
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Affiliation(s)
- Arianna Giorgetti
- DIMEC, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (A.G.); (P.F.)
| | - Jennifer Pascali
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Massimo Montisci
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Irene Amico
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Barbara Bonvicini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Paolo Fais
- DIMEC, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (A.G.); (P.F.)
| | - Alessia Viero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Raffaele Giorgetti
- Department of Excellence of Biomedical Sciences and Public Health, University “Politecnica delle Marche” of Ancona, via Conca 71, 60126 Ancona, Italy;
| | - Giovanni Cecchetto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Guido Viel
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
- Correspondence:
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19
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Dezfulian C, Orkin AM, Maron BA, Elmer J, Girotra S, Gladwin MT, Merchant RM, Panchal AR, Perman SM, Starks MA, van Diepen S, Lavonas EJ. Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e836-e870. [PMID: 33682423 DOI: 10.1161/cir.0000000000000958] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.
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20
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Rapid Methadone and Concurrent Slow-Release Oral Morphine Titration in a Pregnant Fentanyl User. CANADIAN JOURNAL OF ADDICTION 2021. [DOI: 10.1097/cxa.0000000000000105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Kokubun H, Takigawa C, Chihara S, Hara S, Uezono Y. Population Pharmacokinetics of Methadone after Oral Administration in Japanese Patients with Cancer-Related Pain. J Pain Palliat Care Pharmacother 2020; 34:203-210. [PMID: 32870067 DOI: 10.1080/15360288.2020.1785070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Methadone tablets were approved for use in Japan in March 2013. The metabolism of methadone is complex and executed mainly by the cytochromes, CYP3A4 and CYP2B6. The aim of this study was to evaluate the pharmacokinetics of methadone upon oral administration in Japanese patients who experienced cancer-related pain. The concentration of the drug in blood samples was measured in 25 patients undergoing methadone therapy, and the factors leading to variations were investigated. A population pharmacokinetic analysis was evaluated using the Phoenix® NLMETM software. Based on this, the ALBI (albumin-bilirubin) score was identified as a significant factor that could be used to assess variations in the serum concentration of methadone, which was then incorporated into the following final model formula: clearance (L/h) = 5.38 × (ALBI score/-2.139)1.88. The results of these pharmacokinetic parameters suggested that, in clinical use, the dose of methadone should be reduced if liver function declined in patients with cancer-related pain.
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22
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Chawar C, Hillmer A, Sanger S, D’Elia A, Panesar B, Guan L, Xie DX, Bansal N, Abdullah A, Kapczinski F, Pare G, Thabane L, Samaan Z. GWAS-identified genetic variants associated with medication-assisted treatment outcomes in patients with opioid use disorder: a systematic review and meta-analysis protocol. Syst Rev 2020; 9:200. [PMID: 32873330 PMCID: PMC7466496 DOI: 10.1186/s13643-020-01461-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The burden of opioid use disorder (OUD) has been increasing in North America. Administration of medication-assisted treatments (MATs) for OUD on an individual-dose basis has been shown to affect patient responses to treatment, proving to be, on occasion, dangerous. A genetic basis has been identified for some MAT responses in a candidate gene context, but consensus has not been reached for any genome-wide significant associations. This systematic review aims to identify and assess any genetic variants associated with MAT patient outcomes at genome-wide significance. METHODS The databases searched by the authors will be: MEDLINE, Web of Science, EMBASE, CINAHL and Pre-CINAHL, GWAS Catalog, GWAS Central, and NIH Database of Genotypes and Phenotypes. A title and abstract screening, full-text screening, data extraction, and quality assessment will be completed in duplicate for each study via Covidence. Treatment outcomes of interest include continued opioid use or abstinence during treatment or at follow-up, time to relapse, treatment retention rates, opioid overdose, other substance use, comorbid psychiatric disorders, risk taking behaviors, MAT plasma concentrations, and mortality rates. Analysis methods applied, if appropriate, will include random effects meta-analysis with pooled odds ratios for all outcomes. Subgroup analyses will also be implemented, when possible. DISCUSSION This systematic review can hopefully inform the direction of future research, aiding in the development of a safer and more patient-centered treatment. It will be able to highlight genome-wide significant variants that are replicable and associated with MAT patient outcomes. SYSTEMATIC REVIEW REGISTRATION This systematic review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration ID CRD42020169121).
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Affiliation(s)
- Caroul Chawar
- Neuroscience Graduate Program, McMaster University, Hamilton, ON Canada
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Alannah Hillmer
- Neuroscience Graduate Program, McMaster University, Hamilton, ON Canada
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Stephanie Sanger
- Health Sciences Library, McMaster University, Hamilton, ON Canada
| | - Alessia D’Elia
- Neuroscience Graduate Program, McMaster University, Hamilton, ON Canada
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Balpreet Panesar
- Neuroscience Graduate Program, McMaster University, Hamilton, ON Canada
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Lucy Guan
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Health Sciences Program, McMaster University, Hamilton, ON Canada
| | - Dave Xiaofei Xie
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Health Sciences Program, McMaster University, Hamilton, ON Canada
| | - Nandini Bansal
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Health Sciences Program, McMaster University, Hamilton, ON Canada
| | - Aamna Abdullah
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Health Sciences Program, McMaster University, Hamilton, ON Canada
| | - Flavio Kapczinski
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Guillaume Pare
- Population Health Research Institute, Hamilton, ON Canada
- Department of Health Research Method, Evidence, and Impact, McMaster University, Hamilton, ON Canada
| | - Lehana Thabane
- Population Health Research Institute, Hamilton, ON Canada
- Department of Health Research Method, Evidence, and Impact, McMaster University, Hamilton, ON Canada
- Father Sean O’Sullivan Research Centre, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
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Mehrpour O, Hoyte C, Amirabadizadeh A, Brent J. Clinical characteristics and time trends of hospitalized methadone exposures in the United States based on the Toxicology Investigators Consortium (ToxIC) case registry: 2010-2017. BMC Pharmacol Toxicol 2020; 21:53. [PMID: 32698849 PMCID: PMC7376634 DOI: 10.1186/s40360-020-00435-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 07/16/2020] [Indexed: 11/24/2022] Open
Abstract
Background Methadone is well known for its long duration of action and propensity for mortality after an overdose. The present research was aimed at evaluating the clinical manifestations and time trends of methadone exposure in patients in US hospitals. Methods We queried the American College of Medical Toxicology’s Toxicology Investigators Consortium case registry for all cases of methadone exposure between January 1, 2010, and December 31, 2017. The collected information included demographic features, clinical presentations, therapeutic interventions, poisoning type (acute, chronic, or acute on chronic), and the reason(s) for exposure. Descriptive data and relative frequencies were used to investigate the participants’ characteristics. Our data analysis was performed using SPSS version 19 and Prism software. The trends and clinical manifestations of methadone poisoning over the time period of the study were specifically investigated. Results Nine hundred and seventy-three patients who met our inclusion criteria, with a mean age of 41.9 ± 16.6 years (range: 11 months-78 years) were analyzed. Five hundred eighty-two (60.2%) were male. The highest rate of methadone poisoning was observed in 2013. There was an increasing rate of methadone exposures in 2010–2013, followed by a decline in 2014–2017. The most common clinical manifestations in methadone-poisoned patients were coma (48.6%) and respiratory depression (33.6%). The in-hospital mortality rate of methadone poisoning was 1.4%. Conclusion ToxIC Registry data showed that inpatient methadone exposures enhanced from 2010 to 2013, after which a reduction occurred in the years 2014 to 2017.
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Affiliation(s)
- Omid Mehrpour
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 1391 Speer Blvd, 777 Bannock St. MC 0180, Denver, CO, 80204, USA. .,Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of of Medical Sciences, Birjand, Iran.
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 1391 Speer Blvd, 777 Bannock St. MC 0180, Denver, CO, 80204, USA.,Department of Emergency Medicine and Medical Toxicology, University of Colorado Anschutz Medical Campus, University Hospital, Aurora, CO, USA
| | - Alireza Amirabadizadeh
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of of Medical Sciences, Birjand, Iran.,Cardiovascular Diseases Research Center Birjand University of Medical Sciences, Birjand, Iran
| | - Jeffrey Brent
- School of medicine, University of Colorado, Aurora, CO, USA
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COPD and asthma in patients with opioid dependency: a cross-sectional study in primary care. NPJ Prim Care Respir Med 2020; 30:4. [PMID: 31937808 PMCID: PMC6959319 DOI: 10.1038/s41533-019-0161-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 11/29/2019] [Indexed: 11/15/2022] Open
Abstract
Patients treated for drug addiction have high asthma and COPD prevalence rates. The relative contributions of cigarette smoking, smoking intensity and possible smoking of other substances has not been described. We aimed to describe the prevalence and determinants of asthma and COPD in patients prescribed methadone as opioid substitution therapy (OST). In a cross-sectional study of an anonymised patient-level primary care dataset of UK inner-city general practices (n = 46), 321,395 patients aged ≥18 years were identified. A total of 676 (0.21%) had a record of a methadone ever issued in primary care. The association between respiratory disease and methadone prescribing was examined using logistic regression. Models were adjusted for potential effects of clustering by practice. A total of 97.3% of patients prescribed methadone were cigarette smokers, either current (81.2%) or ex-smokers (16.1%). The prevalences of asthma and COPD were higher in methadone patients (14.2% and 12.4%, respectively) compared to non-methadone patients (4.4% and 1.1%, respectively). Methadone was an independent determinant of asthma, adjusting for smoking status (OR 3.21; 95% CI: 2.52, 4.10) or for smoking intensity (3.08; 2.27, 4.19), and of COPD, adjusting for smoking status (6.00; 4.61, 7.80) or for smoking intensity (5.80; 4.12, 8.17). COPD and asthma prevalence were substantially higher in those prescribed methadone compared to those never prescribed methadone. Prescription of methadone was an independent predictor for both COPD and asthma, even after adjustment for smoking status and smoking intensity. Possible explanations include confounding by association with smoking of heroin or crack cocaine, both of which may have a causal association with COPD and asthma.
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25
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Maina G, Crizzle A, Maposa S, Fournier B. Sociodemographic Profiles and Clinical Outcomes for Clients on Methadone Maintenance Treatment in a Western Canadian Clinic: Implications for Practice. JOURNAL OF FORENSIC NURSING 2019; 15:231-241. [PMID: 31764527 DOI: 10.1097/jfn.0000000000000246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Clients on methadone maintenance treatment (MMT) have high attrition rates that are attributed to personal and system-related factors. To develop supportive interventions for these clients, it is imperative to understand social demographic characteristics and challenges that clients in the MMT program face. OBJECTIVES This article aims to describe (a) the sociodemographic characteristics and clinical profiles of clients in a MMT program, (b) factors that impact their positive clinical outcomes, and (c) the study's implications for practice. METHODS A retrospective review of 101 randomly selected electronic medical records representing one third of all the records were examined for sociodemographic characteristics, clinical profiles, and outcomes. Descriptive statistics were used to analyze these variables. Interviews with 18 healthcare providers focusing on their experiences of caring for clients in the MMT program were analyzed thematically. RESULTS The average age of clients on MMT is 35.5 years. Clients had early exposure to alcohol and drugs, and at the time of enrollment to the program, they presented with complex healthcare needs, borne from chronic use, and exposure to adverse traumatic events. Personal and systemic factors impact clients' recovery. These include poverty, homelessness, and inadequate healthcare services. Understanding sociodemographic characteristics, clinical profiles, and clients' challenges is central to the development of supportive interventions that enhance retention to care and recovery.
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Affiliation(s)
- Geoffrey Maina
- Author Affiliations: College of Nursing, University of Saskatchewan
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26
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Brezel ER, Powell T, Fox AD. An ethical analysis of medication treatment for opioid use disorder (MOUD) for persons who are incarcerated. Subst Abus 2019; 41:150-154. [PMID: 31800376 DOI: 10.1080/08897077.2019.1695706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Opioid use disorder (OUD) is highly prevalent among persons who are incarcerated. Medication treatment for opioid use disorder (MOUD), methadone, buprenorphine, and naltrexone, is widely used to treat OUD in the community. Despite MOUD's well-documented effectiveness in improving health and social outcomes, its use in American jails and prisons is limited.Several factors are used to justify limited access to MOUD in jails and prisons including: "uncertainty" of MOUD's effectiveness during incarceration, security concerns, risk of overdose from MOUD, lack of resources and institutional infrastructure, and the inability of people with OUD to provide informed consent. Stigma regarding MOUD also likely plays a role. While these factors are relevant to the creation and implementation of addiction treatment policies in incarcerated settings, their ethicality remains underexplored.Using ethical principles of beneficence/non-maleficence, justice, and autonomy, in addition to public health ethics, we evaluate the ethicality of the above list of factors. There is a two-fold ethical imperative to provide MOUD in jails and prisons. Firstly, persons who are incarcerated have the right to evidence-based medical care for OUD. Secondly, because jails and prisons are government institutions, they have an obligation to provide that evidence-based treatment. Additionally, jails and prisons must address the systematic barriers that prevent them from fulfilling that responsibility. According to widely accepted ethical principles, strong evidence supporting the health benefits of MOUD cannot be subordinated to stigma or inaccurate assessments of security, cost, and feasibility. We conclude that making MOUD inaccessible in jails and prisons is ethically impermissible.
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Affiliation(s)
- Emma R Brezel
- Department of Pediatrics, Montefiore Medical Center, New York, New York, USA
| | - Tia Powell
- Montefiore-Einstein Center for Bioethics, Montefiore Medical Center, New York, New York, USA
| | - Aaron D Fox
- Department of Internal Medicine, Montefiore Medical Center, New York, New York, USA
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Walley AY, Bernson D, Larochelle MR, Green TC, Young L, Land T. The Contribution of Prescribed and Illicit Opioids to Fatal Overdoses in Massachusetts, 2013-2015. Public Health Rep 2019; 134:667-674. [PMID: 31577519 PMCID: PMC6832088 DOI: 10.1177/0033354919878429] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES Opioid-related overdoses are commonly attributed to prescription opioids. We examined data on opioid-related overdose decedents in Massachusetts. For each decedent, we determined which opioid medications had been prescribed and dispensed and which opioids were detected in postmortem medical examiner toxicology specimens. METHODS Among opioid-related overdose decedents in Massachusetts during 2013-2015, we analyzed individually linked postmortem opioid toxicology reports and prescription drug monitoring program records to determine instances of overdose in which a decedent had a prescription active on the date of death for the opioid(s) detected in the toxicology report. We also calculated the proportion of overdoses for which prescribed opioid medications were not detected in decedents' toxicology reports. RESULTS Of 2916 decedents with complete toxicology reports, 1789 (61.4%) had heroin and 1322 (45.3%) had fentanyl detected in postmortem toxicology reports. Of the 491 (16.8%) decedents with ≥1 opioid prescription active on the date of death, prescribed opioids were commonly not detected in toxicology reports, specifically: buprenorphine (56 of 97; 57.7%), oxycodone (93 of 176; 52.8%), and methadone prescribed for opioid use disorder (36 of 112; 32.1%). Only 39 (1.3%) decedents had an active prescription for each opioid detected in toxicology reports on the date of death. CONCLUSION Linking overdose toxicology reports to prescription drug monitoring program records can help attribute overdoses to prescribed opioids, diverted prescription opioids, heroin, and illicitly made fentanyl.
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Affiliation(s)
- Alexander Y. Walley
- Department of Medicine, Clinical Addiction Research and Education
Unit, Section of General Internal Medicine, Boston University School of Medicine
& Boston Medical Center, Boston, MA, USA
- Massachusetts Department of Public Health, Boston, MA, USA
| | - Dana Bernson
- Massachusetts Department of Public Health, Boston, MA, USA
| | - Marc R. Larochelle
- Department of Medicine, Clinical Addiction Research and Education
Unit, Section of General Internal Medicine, Boston University School of Medicine
& Boston Medical Center, Boston, MA, USA
| | - Traci C. Green
- Department of Emergency Medicine, Injury Prevention Center, Boston
University School of Medicine & Boston Medical Center, Boston, MA, USA
| | - Leonard Young
- Massachusetts Department of Public Health, Boston, MA, USA
| | - Thomas Land
- Department of Medicine, University of Massachusetts Medical School,
Worcester, MA, USA
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28
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Weingarten TN, Taenzer AH, Elkassabany NM, Le Wendling L, Nin O, Kent ML. Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps. PAIN MEDICINE 2019; 19:2296-2315. [PMID: 29727003 DOI: 10.1093/pm/pny079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting Expert commentary. Methods Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andreas H Taenzer
- Departments of Anesthesiology.,Pediatrics, The Dartmouth Institute, Dartmouth Hitchcock Medical Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda Le Wendling
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Olga Nin
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Michael L Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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Abstract
Goals consist of determining 5-year prevalence and recurrence of methadone-related delirium (MRD), along with causes, treatments, and outcomes. Sample comprised 81 patients in methadone maintenance treatment. Criteria for MRD encompassed delirium with high methadone serum levels plus alleviation of delirium upon lowering methadone serum levels. MRD occurred in 14 cases who had 25 episodes. MRD precipitants included physician prescribing (i.e., excessive methadone or medications slowing methadone metabolism), drug misuse, and renal-fluid alterations. Social affiliation (housing with family, intimate partner) reduced MRD; employment increased MRD. Recovery occurred in 23/25 episodes of MRD; two episodes progressed to dementia. Obtaining serum methadone levels fostered prompt recognition.
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Initiation and Rapid Titration of Methadone in an Acute Care Setting for the Treatment of Opioid Use Disorder: A Case Report. J Addict Med 2019; 13:408-411. [PMID: 30741835 DOI: 10.1097/adm.0000000000000507] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although methadone is an effective treatment for opioid use disorder, its initiation requires prescribing at a subtherapeutic dose with subsequent titration to a therapeutic dose over many weeks. Accordingly, the methadone induction period can be a challenging one for individuals and can be associated with an increased risk for ongoing illicit drug use and consequently overdose. Given its capacity for regular clinical assessments, acute care settings may offer a unique opportunity to reduce the duration of the induction period for methadone maintenance therapy. CASE SUMMARY We report a case of an individual who successfully completed initiation and rapid methadone titration for treatment of opioid use disorder in an acute care setting. DISCUSSION Utilizing divided dosing intervals and regular monitoring for toxicity, the patient received a cumulative methadone dose of 130 mg total within the first 48 hours of admission with continuation of a similar dose subsequently. No adverse events occurred over a 9-day follow-up period. The case report described here highlights the potential acute care settings may offer for the successful initiation and rapid titration of methadone for the treatment of opioid use disorder. Such an approach could significantly reduce the induction period associated with methadone maintenance therapy and its associated negative outcomes including ongoing illicit substance use and risk for overdose.
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31
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Baughman M, Tossone K, Singer MI, Flannery DJ. Evaluation of Treatment and Other Factors That Lead to Drug Court Success, Substance Use Reduction, and Mental Health Symptomatology Reduction Over Time. INTERNATIONAL JOURNAL OF OFFENDER THERAPY AND COMPARATIVE CRIMINOLOGY 2019; 63:257-275. [PMID: 30058416 DOI: 10.1177/0306624x18789832] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Adults presenting with substance use and mental health disorders in the criminal justice system is well documented. While studies have examined drug courts and medication-assisted treatment (MAT), few have examined social and behavioral health indicators, and even fewer have multiple study periods. This study employed a comprehensive approach to studying the MAT contribution to drug court success; reduce substance use, mental health symptoms, and risky behaviors; and the role that violence or trauma plays in mental health symptomatology. Using three time points, our findings indicated that MAT did not play a significant role in the reduction of substance use, risky behaviors, or mental health symptoms or increasing the odds of successful court graduation. However, there was an overall improvement from intake to termination in reduction of substance use, risky behaviors, and mental health symptomatology. Other factors, including social support, may play a role in drug court graduation. Policy implications are discussed.
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Affiliation(s)
| | | | - Mark I Singer
- 1 Case Western Reserve University, Cleveland, OH, USA
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32
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Zolezzi M, Cheung L. A literature-based algorithm for the assessment, management, and monitoring of drug-induced QTc prolongation in the psychiatric population. Neuropsychiatr Dis Treat 2019; 15:105-114. [PMID: 30636876 PMCID: PMC6309020 DOI: 10.2147/ndt.s186474] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Certain psychotropics and a number of other medications used to treat medical conditions in psychiatric patients can increase the risk of prolonging the corrected QT (QTc) interval on the electrocardiogram, which puts patients at risk of life-threatening ventricular arrhythmias such as torsades de pointes. Pharmacists are often consulted about medications which are known to prolong the QTc interval. Although this information is often accessible, advising how to identify, assess, manage, and refer psychiatric patients at risk for drug-induced QTc prolongation is more challenging. OBJECTIVES The objective of this project was first to review the literature, which describes guidelines and recommendations for the assessment and management of drug-induced QTc prolongation, and then to design an algorithm to be used by pharmacists working closely with mental health professionals or who provide care to psychiatric patients. METHODS A review of the literature was undertaken. Predefined keywords were used to perform the database search in MEDLINE, EMBASE, and International Pharmaceutical Abstracts to identify reviews, reports and guidelines on the assessment, prevention and monitoring of drug-induced QTc prolongation with an emphasis on psychotropic medications and management in the psychiatric population. RESULTS The electronic database search retrieved 637 relevant citations. These were initially screened by title and all duplicates were removed. The abstracts were then reviewed for relevancy based on the inclusion/exclusion criteria. Additional citations were retrieved from the bibliography of the articles identified in the initial search. A total of 79 articles describing QTc prolongation in the psychiatric population were thoroughly examined, but only 31 articles were selected to guide the development of the algorithm. CONCLUSION The literature-based algorithm developed provides a stepped-based approach for the assessment, monitoring, and management of drug-induced QTc prolongation in the psychiatric population. The algorithm may assist mental health clinicians in the decision-making process when psychiatric patients are prescribed medications known to increase the QTc interval.
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Affiliation(s)
- M Zolezzi
- Division of Clinical Pharmacy and Practice, College of Pharmacy, Qatar University, Doha, Qatar,
| | - L Cheung
- Pharmacy Department, Grey Nuns Community Hospital, Edmonton, AB, Canada
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Fischer B, Jones W, Varatharajan T, Malta M, Kurdyak P. Correlations between population-levels of prescription opioid dispensing and related deaths in Ontario (Canada), 2005-2016. Prev Med 2018; 116:112-118. [PMID: 30217407 DOI: 10.1016/j.ypmed.2018.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/24/2018] [Accepted: 09/11/2018] [Indexed: 01/17/2023]
Abstract
Canada is experiencing an ongoing opioid-related public health crisis, including persistently rising opioid (e.g., poisoning) mortality. Previous research has documented marked correlations between population-levels of opioid dispensing and deaths. We examined possible correlations between annual population-level dispensing of specific opioid formulations and related poisoning deaths in Ontario (Canada), for the period 2005-2016. Annual coroner statistics-based numbers of poisoning deaths associated with six main opioid formulations (codeine, fentanyl, hydromorphone, methadone, morphine, and oxycodone) for Ontario were converted into annual death rates (per 100,000 population). Annual dispensing data for the opioid formulations under study were based on commercial retail-sales data from a representative, stratified sample of community pharmacies (IMSQuintiles/IQVIA CompuScript), converted into Defined Daily Doses (DDD/1,000 population/day). Possible relationships between the annual death and dispensing rates were assessed by Pearson's correlation coefficient analyses. Death rates increased for almost all, while dispensing rates increased for half of the opioid categories. A significant positive correlation between death and dispensing rates was found for hydromorphone (r = 0.97, 95% CI: 0.88-0.99) and oxycodone (r = 0.90, 95% CI: 0.68-0.97) formulations; a significant negative correlation was found for codeine (r = -0.78, 95% CI: -0.93 to -0.37). No significant correlations were detected for fentanyl, methadone, and morphine related deaths. Strong correlations between levels of dispensing and deaths for select opioid formulations were found. For select others, extrinsic factors - e.g., increasing involvement of non-medical opioid products (e.g., fentanyl) in overdose deaths - likely confounded underlying correlation effects. Opioid dispensing levels continue to influence population-level mortality levels, and need to be addressed by prevention strategies.
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Affiliation(s)
- Benedikt Fischer
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Institute of Medical Science (IMS), University of Toronto, Toronto, Canada; Centre for Criminology & Sociolegal Studies, University of Toronto, Toronto, Canada; Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.
| | - Wayne Jones
- Centre for Applied Research in Mental Health and Addictions, Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| | - Thepikaa Varatharajan
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
| | - Monica Malta
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Paul Kurdyak
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Mental Health & Addictions Research Program, Institute for Clinical Evaluative Sciences, Toronto, Canada
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Ahmad-Molaei L, Hassanian-Moghaddam H, Farnaghi F, Tomaz C, Haghparast A. Delay-Dependent Impairments in Memory and Motor Functions After Acute Methadone Overdose in Rats. Front Pharmacol 2018; 9:1023. [PMID: 30250433 PMCID: PMC6139438 DOI: 10.3389/fphar.2018.01023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 08/23/2018] [Indexed: 11/21/2022] Open
Abstract
Methadone is used as a substitution drug for the treatment of opioid dependence and chronic pain. Despite its widespread use and availability, there is a serious concern with respect to the relative safety of methadone. The purpose of this study was to characterize how acute methadone overdose affects the cognitive and motor performance of naïve healthy rats. The methadone overdose was induced by administering an acute toxic dose of methadone (15 mg/kg; ip; the equivalent dose of 80% of LD50) to adolescent rats. Resuscitation using a ventilator pump along with a single dose of naloxone (2 mg/kg; ip) was administered following the occurrence of apnea. The animals which were successfully resuscitated divided randomly into three apnea groups that evaluated either on day 1, 5, or 10 post-resuscitation (M/N-Day 1, M/N-Day 5, and M/N-Day 10 groups) in the Y-maze and novel object memory recognition tasks as well as pole and rotarod tests. The data revealed that a single toxic dose of methadone had an adverse effect on spontaneous behavior. In addition, Recognition memory impairment was observed in the M/N-Day 1, 5, and 10 groups after methadone-induced apnea. Further, descending time in the M/N-Day 5 group increased significantly in comparison with its respective Saline control group. The overall results indicate that acute methadone-overdose-induced apnea produced delay-dependent cognitive and motor impairment. We suggest that methadone poisoning should be considered as a possible cause of delayed neurological disorders, which might be transient, in some types of memory or motor performance in naïve healthy rats.
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Affiliation(s)
- Leila Ahmad-Molaei
- Neuroscience Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Hassanian-Moghaddam
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fariba Farnaghi
- Department of Pediatric Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Carlos Tomaz
- Neuroscience Research Program, CEUMA University, São Luís, Brazil
| | - Abbas Haghparast
- Neuroscience Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Elwell-Cuddy T, Li M, KuKanich B, Lin Z. The construction and application of a population physiologically based pharmacokinetic model for methadone in Beagles and Greyhounds. J Vet Pharmacol Ther 2018; 41:670-683. [DOI: 10.1111/jvp.12676] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/30/2018] [Accepted: 05/18/2018] [Indexed: 01/18/2023]
Affiliation(s)
- Trevor Elwell-Cuddy
- Institute of Computational Comparative Medicine (ICCM); Department of Anatomy and Physiology; College of Veterinary Medicine; Kansas State University; Manhattan Kansas
| | - Miao Li
- Institute of Computational Comparative Medicine (ICCM); Department of Anatomy and Physiology; College of Veterinary Medicine; Kansas State University; Manhattan Kansas
| | - Butch KuKanich
- Institute of Computational Comparative Medicine (ICCM); Department of Anatomy and Physiology; College of Veterinary Medicine; Kansas State University; Manhattan Kansas
| | - Zhoumeng Lin
- Institute of Computational Comparative Medicine (ICCM); Department of Anatomy and Physiology; College of Veterinary Medicine; Kansas State University; Manhattan Kansas
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Parpouchi M, Moniruzzaman A, Rezansoff SN, Russolillo A, Somers JM. The effect of Housing First on adherence to methadone maintenance treatment. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 56:73-80. [DOI: 10.1016/j.drugpo.2018.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/08/2018] [Accepted: 03/13/2018] [Indexed: 11/28/2022]
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37
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Treating Opioid Dependence with Buprenorphine in the Safety Net: Critical Learning from Clinical Data. J Behav Health Serv Res 2018; 44:351-363. [PMID: 28488155 DOI: 10.1007/s11414-017-9553-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Research has examined the safety, efficacy, feasibility, and cost-effectiveness of buprenorphine for the treatment of opioid dependence, but few studies have examined patient and provider experiences, especially in community health centers. Using de-identified electronic health record system (EHRS) data from 70 OCHIN community health centers (n = 1825), this cross-sectional analysis compared the demographics, comorbidities, and service utilization of patients receiving buprenorphine to those not receiving medication-assisted treatment (MAT). Compared to non-MAT patients, buprenorphine patients were younger and less likely to be Hispanic or live in poverty. Buprenorphine patients were less likely to have Medicaid insurance coverage, more likely to self-pay, and have private insurance coverage. Buprenorphine patients were less likely to have problem medical comorbidities or be coprescribed high-risk medications. It is important for providers, clinic administrators, and patients to understand the clinical application of medications for opioid dependence to ensure safe and effective care within safety net clinics.
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Abraham AJ, Andrews CM, Grogan CM, Pollack HA, D'Aunno T, Humphreys K, Friedmann PD. State-Targeted Funding and Technical Assistance to Increase Access to Medication Treatment for Opioid Use Disorder. Psychiatr Serv 2018; 69:448-455. [PMID: 29241428 PMCID: PMC6703818 DOI: 10.1176/appi.ps.201700196] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE As the United States grapples with an opioid epidemic, expanding access to effective treatment for opioid use disorder is a major public health priority. Identifying effective policy tools that can be used to expand access to care is critically important. This article examines the relationship between state-targeted funding and technical assistance and adoption of three medications for treating opioid use disorder: oral naltrexone, injectable naltrexone, and buprenorphine. METHODS This study draws from the 2013-2014 wave of the National Drug Abuse Treatment System Survey, a nationally representative, longitudinal study of substance use disorder treatment programs. The sample includes data from 695 treatment programs (85.5% response rate) and representatives from single-state agencies in 49 states and Washington, D.C. (98% response rate). Logistic regression was used to examine the relationships of single-state agency targeted funding and technical assistance to availability of opioid use disorder medications among treatment programs. RESULTS State-targeted funding was associated with increased program-level adoption of oral naltrexone (adjusted odds ratio [AOR]=3.14, 95% confidence interval [CI]=1.49-6.60, p=.004) and buprenorphine (AOR=2.47, 95% CI=1.31-4.67, p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR=1.18, 95% CI=1.00-1.39, p=.049). CONCLUSIONS State-targeted funding for medications may be a viable policy lever for increasing access to opioid use disorder medications. Given the historically low rates of opioid use disorder medication adoption in treatment programs, single-state agency targeted funding is a potentially important tool to reduce mortality and morbidity associated with opioid disorders and misuse.
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Affiliation(s)
- Amanda J Abraham
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
| | - Christina M Andrews
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
| | - Colleen M Grogan
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
| | - Harold A Pollack
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
| | - Thomas D'Aunno
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
| | - Keith Humphreys
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
| | - Peter D Friedmann
- Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts
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Abstract
Supplemental Digital Content is Available in the Text. This descriptive case series among adults documents that pain can return temporarily at healed, previously pain-free injury sites during acute opioid withdrawal. Withdrawal pain can be a barrier to opioid cessation. Yet, little is known about old injury site pain in this context. We conducted an exploratory mixed-methods descriptive case series using a web-based survey and in-person interviews with adults recruited from pain and addiction treatment and research settings. We included individuals who self-reported a past significant injury that was healed and pain-free before the initiation of opioids, which then became temporarily painful upon opioid cessation—a phenomenon we have named withdrawal-associated injury site pain (WISP). Screening identified WISP in 47 people, of whom 34 (72%) completed the descriptive survey, including 21 who completed qualitative interviews. Recalled pain severity scores for WISP were typically high (median: 8/10; interquartile range [IQR]: 2), emotionally and physically aversive, and took approximately 2 weeks to resolve (median: 14; IQR: 24 days). Withdrawal-associated injury site pain intensity was typically slightly less than participants' original injury pain (median: 10/10; IQR: 3), and more painful than other generalized withdrawal symptoms which also lasted approximately 2 weeks (median: 13; IQR: 25 days). Fifteen surveyed participants (44%) reported returning to opioid use because of WISP in the past. Participants developed theories about the etiology of WISP, including that the pain is the brain's way of communicating a desire for opioids. This research represents the first known documentation that previously healed, and pain-free injury sites can temporarily become painful again during opioid withdrawal, an experience which may be a barrier to opioid cessation, and a contributor to opioid reinitiation.
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Faul M, Bohm M, Alexander C. Methadone Prescribing and Overdose and the Association with Medicaid Preferred Drug List Policies - United States, 2007-2014. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2017; 66:320-323. [PMID: 28358791 PMCID: PMC5657959 DOI: 10.15585/mmwr.mm6612a2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Pfeiffer PN, Bowersox N, Birgenheir D, Burgess J, Forman J, Valenstein M. Preferences and Barriers to Care Following Psychiatric Hospitalization at Two Veterans Affairs Medical Centers: A Mixed Methods Study. J Behav Health Serv Res 2017; 43:88-103. [PMID: 25779387 DOI: 10.1007/s11414-015-9460-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient preferences and barriers to care may impact receipt of adequate mental health treatment following psychiatric hospitalization and could inform quality improvement initiatives. This study assessed preferences for a broad range of post-hospital services and barriers to counseling by surveying 291 patients and interviewing 25 patients who had recently been discharged from an inpatient psychiatric stay at one of the two Veterans Affairs Medical Centers. Individual counseling was the most frequently reported service that survey respondents preferred, but did not receive; whereas, open-ended survey responses and interviews also identified telephone follow-up "check-in" calls as a frequently preferred service. Difficulty with transportation was the most commonly cited barrier to counseling among survey respondents and in interviews; however, patients strongly preferred in-person counseling to telephone or internet-video alternatives. Increasing support from family and support from an individual Veteran peer were also perceived to be helpful in the majority of survey respondents.
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Affiliation(s)
- Paul N Pfeiffer
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, MI, USA. .,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA. .,North Campus Research Complex, 2800 Plymouth Rd, Building 14, Ann Arbor, MI, 48109, USA.
| | - Nicholas Bowersox
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Denis Birgenheir
- Department of Veterans Affairs, VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Jennifer Burgess
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Jane Forman
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Marcia Valenstein
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
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Khoubnasabjafari M, Ansarin K, Jouyban-Gharamaleki V, Panahi-Azar V, Hamidi S, Azarmir Z, Jouyban A. Methadone Concentrations in Exhaled Breath Condensate, Serum and Urine of Patients Under Maintenance Treatment. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2017; 16:1621-1630. [PMID: 29552071 PMCID: PMC5843324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Drug abuse is a serious problem causing health, economical and psycho-social negative outcomes. Methadone is commonly used drug for management of drug addiction. Exhaled breath condensate (EBC) is a promising non-invasive biological sample which attracted more attention in recent years. This work aimed to extend the applicability of a developed preconcentration - liquid chromatographic method for analysis of methadone in serum and urine samples. Drug concentrations in EBC, serum and urine are also investigated for dose-concentration and their inter-correlations. Biological samples were collected from 53 patients receiving methadone and the concentrations were determined using a validated analytical method after a pre-concentration step. Methadone measured in all samples and there are correlations between administered dose of methadone and its serum and urine concentrations. A weak correlation is observed between dose and EBC concentration. Wider variations in EBC concentrations of methadone could be justified concerning a number of affecting parameters such as relative humidity of the collection area and further investigations are required for standardization of EBC as a non-invasive biological sample to be used in clinical practice.
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Affiliation(s)
- Maryam Khoubnasabjafari
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz 51664, Iran.
| | - Khalil Ansarin
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz 51664, Iran.
| | - Vahid Jouyban-Gharamaleki
- Department of Mechatronic Engineering, International Campus, University of Tabriz, Tabriz 51664, Iran.
| | - Vahid Panahi-Azar
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz 51664, Iran.
| | - Samin Hamidi
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz 51664, Iran.
| | - Zhila Azarmir
- Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz 51664, Iran.
| | - Abolghasem Jouyban
- Pharmaceutical Analysis Research Center and Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz 51664, Iran.,Kimia Idea Pardaz Azarbayjan (KIPA) Science Based Company, Tabriz University of Medical Sciences, Tabriz 51664, Iran.,Corresponding author: E-mail:
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Alinejad S, Ghaemi K, Abdollahi M, Mehrpour O. Nephrotoxicity of methadone: a systematic review. SPRINGERPLUS 2016; 5:2087. [PMID: 28018795 PMCID: PMC5148752 DOI: 10.1186/s40064-016-3757-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 11/29/2016] [Indexed: 12/18/2022]
Abstract
Background Methadone is commonly administered for chronic pain relief and treatment of opioid dependence. Concurrent with its increased consumption, toxicities and fatalities have increased. One of the adverse effects of opioid analgesics, including methadone, is that of nephrotoxicity. Opioids can have an effect on renal function through several different mechanisms. Methods We searched common bibliographical databases for the terms methadone, toxicity, poisoning, kidney, renal, and nephrotoxicity and summarize our findings in this review. Results Methadone can have both direct and indirect effects on the kidney. These effects include rhabdomyolysis (leading to acute kidney injury), volumetric changes, renal lipidosis and amyloidosis, kidney growth during pregnancy, and kidney transplant rejection. Conclusion Improved understanding of the effects of methadone on kidney function can promote safer and more confident use of the drug.
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Affiliation(s)
- Samira Alinejad
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Moallem Avenue, Birjand, 9713643138 Iran
| | - Kazem Ghaemi
- Atherosclerosis and Coronary Artery Research Centre, Birjand University of Medical Sciences, Birjand, Iran ; Department of Neurosurgery, Birjand University of Medical Science, Birjand, Iran
| | - Mohammad Abdollahi
- Toxicology and Diseases Group, Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Moallem Avenue, Birjand, 9713643138 Iran
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Ventilation and the Response to Hypercapnia after Morphine in Opioid-naive and Opioid-tolerant Rats. Anesthesiology 2016; 124:945-57. [PMID: 26734964 DOI: 10.1097/aln.0000000000000997] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Opioid-related deaths are a leading cause of accidental death, with most occurring in patients receiving chronic pain therapy. Respiratory arrest is the usual cause of death, but mechanisms increasing that risk with increased length of treatment remain unclear. Repeated administration produces tolerance to opioid analgesia, prompting increased dosing, but depression of ventilation may not gain tolerance to the same degree. This study addresses differences in the degree to which chronic morphine (1) produces tolerance to ventilatory depression versus analgesia and (2) alters the magnitude and time course of ventilatory depression. METHODS Juvenile rats received subcutaneous morphine for 3 days (n = 116) or vehicle control (n = 119) and were then tested on day 4 following one of a range of morphine doses for (a) analgesia by paw withdraw from heat or (b) respiratory parameters by plethysmography-respirometry. RESULTS Rats receiving chronic morphine showed significant tolerance to morphine sedation and analgesia (five times increased ED50). When sedation was achieved for all animals in a dose group (lowest effective doses: opioid-tolerant, 15 mg/kg; opioid-naive, 3 mg/kg), the opioid-tolerant showed similar magnitudes of depressed ventilation (-41.4 ± 7.0%, mean ± SD) and hypercapnic response (-80.9 ± 15.7%) as found for morphine-naive (-35.5 ± 16.9% and -67.7 ± 15.1%, respectively). Ventilation recovered due to tidal volume without recovery of respiratory rate or hypercapnic sensitivity and more slowly in morphine-tolerant. CONCLUSIONS In rats, gaining tolerance to morphine analgesia does not reduce ventilatory depression effects when sedated and may inhibit recovery of ventilation.
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Drug-induced deaths in Southern Spain: profiles and associated characteristics. JOURNAL OF SUBSTANCE USE 2016. [DOI: 10.1080/14659891.2016.1190412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Johnson J, Sheth S. Methadone for Pain Relief. J Pain Palliat Care Pharmacother 2016; 30:146-7. [DOI: 10.3109/15360288.2016.1167806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Roy DN, Goswami R. Drugs of abuse and addiction: A slippery slope toward liver injury. Chem Biol Interact 2015; 255:92-105. [PMID: 26409324 DOI: 10.1016/j.cbi.2015.09.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/14/2015] [Accepted: 09/18/2015] [Indexed: 02/08/2023]
Abstract
Substances of abuse induce alteration in neurobehavioral symptoms, which can lead to simultaneous exacerbation of liver injury. The biochemical changes of liver are significantly observed in the abused group of people using illicit drugs or drugs that are abused. A huge amount of work has been carried out by scientists for validation experiments using animal models to assess hepatotoxicity in cases of drugs of abuse. The risk of hepatotoxicity from these psychostimulants has been determined by different research groups. Hepatotoxicity of these drugs has been recently highlighted and isolated case reports always have been documented in relation to misuse of the drugs. These drugs induce liver toxicity on acute or chronic dose dependent process, which ultimately lead to liver damage, acute fatty infiltration, cholestatic jaundice, liver granulomas, hepatitis, liver cirrhosis etc. Considering the importance of drug-induced hepatotoxicity as a major cause of liver damage, this review emphasizes on various drugs of abuse and addiction which induce hepatotoxicity along with their mechanism of liver damage in clinical aspect as well as in vitro and in vivo approach. However, the mechanisms of drug-induced hepatotoxicity is dependent on reactive metabolite formation via metabolism, modification of covalent bonding between cellular components with drug and its metabolites, reactive oxygen species generation inside and outside of hepatocytes, activation of signal transduction pathways that alter cell death or survival mechanism, and cellular mitochondrial damage, which leads to alteration in ATP generation have been notified here. Moreover, how the cytokines are modulated by these drugs has been mentioned here.
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Affiliation(s)
- Dijendra Nath Roy
- Department of Bio Engineering, National Institute of Technology (NIT)-Agartala, West Tripura, Tripura 799046, India.
| | - Ritobrata Goswami
- Institute of Life Sciences, Ahmedabad University, Ahmedabad 380009, Gujarat, India
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Hassanian-Moghaddam H, Soltaninejad K, Shadnia S, Kabir A, Movahedi M, Mirafzal A. Risk Factors for Mortality and Endotracheal Intubation after Methadone Intoxication. Basic Clin Pharmacol Toxicol 2015; 118:231-7. [PMID: 26301535 DOI: 10.1111/bcpt.12476] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 08/13/2015] [Indexed: 11/29/2022]
Abstract
This was a retrospective chart review to evaluate various risk factors associated with in-hospital mortality and intubation risk in acute methadone overdose. All patients admitted to an academic hospital in Tehran, Iran, during a 10-year period (2000-2009) constituted the study sample. Exclusion criteria were significant comorbidities and age under 18 years. Outcome variables were in-hospital mortality and being intubated during admission. A total of 802 patients were enrolled in the study. There were 15 (1.8%) deaths due to methadone overdose or its complications. The number of yearly admissions was 15 patients in 2000, 16 in 2001, 16 in 2002, 18 in 2003, 23 in 2004, 38 in 2005, 59 in 2006, 110 in 2007, 206 in 2008 and 301 in 2009. Based on logistic regression analysis, the most important independent variable predicting mortality was length of admission in toxicology ward [OR (95% CI): 1.6 (1.1-2.3)]. For the prediction of intubation, independent variables were Glasgow Coma Scale (GCS) score of 5-9 [OR (95% CI): 356.5 (9.8-12907.4)] in the emergency department (ED), miosis in the ED [356.9 (1.4-87872.5)] and respiratory rate in the ED [1.5 (1.1-2.1)]. Linear regression model for length of hospitalization showed patient age as the most important variable for prediction of this outcome. Despite a relatively low mortality rate, the increasing number of methadone-poisoned patients requires special attention to this common intoxication. Careful disposition of patients from ED to ordinary wards or intensive care units and also from higher to lower levels of care should be considered in methadone overdose.
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Affiliation(s)
- Hossein Hassanian-Moghaddam
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid-Beheshti University of Medical Sciences, Tehran, Iran.,Excellence Center of Clinical Toxicology, Iranian Ministry of Health, Tehran, Iran
| | - Kambiz Soltaninejad
- Department of Forensic Toxicology, Legal Medicine Research Center, Legal Medicine Organization of Iran, Tehran, Iran
| | - Shahin Shadnia
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid-Beheshti University of Medical Sciences, Tehran, Iran.,Excellence Center of Clinical Toxicology, Iranian Ministry of Health, Tehran, Iran
| | - Ali Kabir
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran.,Department of Epidemiology, School of Public Health, Shahid-Beheshti University of Medical Sciences, Tehran, Iran
| | - Mitra Movahedi
- Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Amirhossein Mirafzal
- Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran
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Davis C, Boddington D. Teenage cardiac arrest following abuse of synthetic cannabis. Heart Lung Circ 2015; 24:e162-3. [PMID: 26256565 DOI: 10.1016/j.hlc.2015.04.176] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 03/25/2015] [Accepted: 04/14/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The cardiac effects of many illegal substances (cocaine, methadone) have previously been well described [1,2]. However the association between synthetic cannabis and cardiac arrest is less well documented. Here we describe an out-of-hospital cardiac arrest in a previously healthy 16-year-old female associated with the use of inhaled synthetic cannabis. METHODS An electronic systematic search of online databases PubMed and Embase was performed using keywords, "synthetic cannabis death" and "cardiac arrest". RESULTS In this case study a previously healthy 16-year-old had a cardiac arrest after synthetic cannabis use. Despite extensive investigations no other cause for her arrest was found. To the best of our knowledge there has been one previous case report of cardiac arrest following synthetic cannabis use in a 56-year-old man [3]. CONCLUSIONS This case report augments the relationship between synthetic cannabis and cardiac arrest in the medical community. More awareness surrounding the risk of synthetic cannabinoids is warranted.
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Affiliation(s)
- C Davis
- Tauranga Hospital, New Zealand.
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