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Nahata R, Mancino MJ, Thostenson J, Oliveto AH. Survey of Treatment Preferences for Opioid Use Disorder. JACOBS JOURNAL OF ADDICTION AND THERAPY 2018; 5:30. [PMID: 31131330 PMCID: PMC6530927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES This study gathered preliminary information on the initial feasibility of using injection Naltrexone (NTX) therapy in opioid users. METHODS One hundred opioid users (36% female, 8% minorities, mean age 34.5±11.4 yrs.) undergoing a health screen to determine initial eligibility for an ongoing study completed the survey. RESULTS Of the 100 respondents, 26, 16, 16, 1 and 0 reported prior treatment episodes of opioid detoxification, buprenorphine (BUP), methadone (MTD), oral NTX and injection NTX, respectively. Ninety and 71% were interested in participating in a study involving oral and/or injection NTX treatment, respectively. Reasons for not wanting to try injection NTX included fear of needles (n=13), side effects (n=7), lack of pain relief (n=12) and cost (n=3). A significantly higher percentage of those interested in injection NTX had episodes of prior opioid agonist maintenance treatment relative to those uninterested (32.4% vs 10.3%; Chi2=5.2, p<0.03). Those preferring injection NTX therapy showed a higher level of interest in this therapy (3.08±1.01 vs 1.62±1.35; Rank Sum p<0.0001) and a lower degree of interest in BUP treatment (2.96±0.93 vs 3.38±0.90; Rank Sum p< 0.03) than those not preferring injection NTX. CONCLUSIONS These preliminary results suggest that those with prior, failed experience with opioid agonist maintenance treatment are more likely to consider injection NTX therapy, suggesting it may be optimal as a second-line treatment for OUD.
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Affiliation(s)
- Ravi Nahata
- Division of Mental Health Service, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, Bldg. 170, Rm. 3L 105, North Little Rock, AR 72114
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham Street, Little Rock, AR 72205, USA
| | - Michael J. Mancino
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham Street, Little Rock, AR 72205, USA
| | - Jeff Thostenson
- Department of Biostatistics, University of Arkansas for Medical Sciences, 4301 W Markham Street, Little Rock, AR 72205, USA
| | - Alison H. Oliveto
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham Street, Little Rock, AR 72205, USA
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2
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Dunn KE, Tompkins DA, Bigelow GE, Strain EC. Efficacy of Tramadol Extended-Release for Opioid Withdrawal: A Randomized Clinical Trial. JAMA Psychiatry 2017; 74:885-893. [PMID: 28700791 PMCID: PMC5710234 DOI: 10.1001/jamapsychiatry.2017.1838] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Opioid use disorder (OUD) is a significant public health problem. Supervised withdrawal (ie, detoxification) from opioids using clonidine or buprenorphine hydrochloride is a widely used treatment. OBJECTIVE To evaluate whether tramadol hydrochloride extended-release (ER), an approved analgesic with opioid and nonopioid mechanisms of action and low abuse potential, is effective for use in supervised withdrawal settings. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial was conducted in a residential research setting with 103 participants with OUD. Participants' treatment was stabilized with morphine, 30 mg, administered subcutaneously 4 times daily. A 7-day taper using clonidine (n = 36), tramadol ER (n = 36), or buprenorphine (n = 31) was then instituted, and patients were crossed-over to double-blind placebo during a post-taper period. The study was conducted from October 25, 2010, to June 23, 2015. MAIN OUTCOMES AND MEASURES Retention, withdrawal symptom management, concomitant medication utilization, and naltrexone induction. Results were analyzed over time and using area under the curve for the intention-to-treat and completer groups. RESULTS Of the 103 participants, 88 (85.4%) were men and 43 (41.7%) were white; mean (SD) age was 28.9 (10.4) years. Buprenorphine participants (28 [90.3%]) were significantly more likely to be retained at the end of the taper compared with clonidine participants (22 [61.1%]); tramadol ER retention was intermediate and did not differ significantly from that of the other groups (26 [72.2%]; χ2 = 8.5, P = .01). Time-course analyses of withdrawal revealed significant effects of phase (taper, post taper) for the Clinical Opiate Withdrawal Scale (COWS) score (taper mean, 5.19 [SE, .26]; post-taper mean, 3.97 [SE, .23]; F2,170 = 3.6, P = .03) and Subjective Opiate Withdrawal Scale (SOWS) score (taper mean,8.81 [SE, .40]; post-taper mean, 4.14 [SE, .30]; F2,170 = 15.7, P < .001), but no group effects or group × phase interactions. Analyses of area under the curve of SOWS total scores showed significant reductions (F2,159 = 17.7, P < .001) in withdrawal severity between the taper and post-taper periods for clonidine (taper mean, 13.1; post-taper mean, 3.2; P < .001) and tramadol ER (taper mean, 7.4; post-taper mean, 2.8; P = .03), but not buprenorphine (taper mean, 6.4; post-taper mean, 7.4). Use of concomitant medication increased significantly (F2,159 = 30.7, P < .001) from stabilization to taper in the clonidine (stabilization mean, 0.64 [SE, .05]; taper mean, 1.54 [SE, .10]; P < .001) and tramadol ER (stabilization mean, 0.53 [SE, .05]; taper mean, 1.19 [SE, .09]; P = .003) groups and from stabilization to post taper in the buprenorphine group (stabilization mean, 0.46 [SE, .05] post-taper mean, 1.17 [SE, .09]; P = .006), suggesting higher withdrawal for those groups during those periods. Naltrexone initiation was voluntary and the percentage of participants choosing naltrexone therapy within the clonidine (8 [22.2%]), tramadol ER (7 [19.4%]), or buprenorphine (3 [9.7%]) groups did not differ significantly (χ2 = 2.5, P = .29). CONCLUSIONS AND RELEVANCE The results of this trial suggest that tramadol ER is more effective than clonidine and comparable to buprenorphine in reducing opioid withdrawal symptoms during a residential tapering program. Data support further examination of tramadol ER as a method to manage opioid withdrawal symptoms. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT01188421.
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Affiliation(s)
- Kelly E. Dunn
- Behavioral Pharmacology Research Unit, Department of
Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore,
Maryland
| | - D. Andrew Tompkins
- Behavioral Pharmacology Research Unit, Department of
Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore,
Maryland
| | - George E. Bigelow
- Behavioral Pharmacology Research Unit, Department of
Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore,
Maryland
| | - Eric C. Strain
- Behavioral Pharmacology Research Unit, Department of
Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore,
Maryland
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Buprenorphine-Naloxone in the Treatment of Codeine Dependence: a Scoping Review of Clinical Case Presentations. Int J Ment Health Addict 2017. [DOI: 10.1007/s11469-016-9655-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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4
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Ayanga D, Shorter D, Kosten TR. Update on pharmacotherapy for treatment of opioid use disorder. Expert Opin Pharmacother 2016; 17:2307-2318. [PMID: 27734745 DOI: 10.1080/14656566.2016.1244529] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Opioid Use Disorder (OUD) is a significant public health concern, negatively impacting the medical, psychological, and social domains of an individual's life as well as creating substantial burdens for society. Effective treatment interventions are necessary for reduction of OUD and its consequences. Pharmacotherapy represents a central component of management. Areas covered: This review focuses on pharmacologic strategies for OUD treatment, discussing both primary as well as adjunctive therapy modalities. We will discuss both medications used during detoxification to treat withdrawal, as well as those used as maintenance therapy. Detox medications include alpha-2 adrenergic agonists, such as clonidine, as well as the μ-opioid agonist, methadone, and the μ-opioid partial agonist, buprenorphine. Opioid maintenance treatment (OMT) is also discussed, focusing on those medications meant to substitute abused opioids and includes the agonists, methadone and buprenorphine, as well as supervised intravenous heroin, and opioid antagonist, naltrexone. Expert opinion: Medication therapy for treatment of OUD has demonstrated efficacy and is of great clinical benefit. While agonist treatment with methadone or buprenorphine remains the gold standard, there is an important place for use of long-acting antagonist therapy with naltrexone. Continued investigation into treatment paradigms and behavioral platforms which optimize medication therapy is most needed.
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Affiliation(s)
- Daniel Ayanga
- a Menninger Department of Psychiatry and Behavioral Sciences , Baylor College of Medicine , Houston , TX , USA
| | - Daryl Shorter
- b Research Service Line, Michael E. DeBakey VA Medical Center, Menninger Department of Psychiatry and Behavioral Sciences , Baylor College of Medicine , Houston , TX , USA
| | - Thomas R Kosten
- c Departments of Psychiatry; Neuroscience; Pharmacology; Immunology & Pathology , Baylor College of Medicine, Michael E. DeBakey VA Medical Center , Houston , TX , USA
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Mogali S, Khan NA, Drill ES, Pavlicova M, Sullivan MA, Nunes E, Bisaga A. Baseline characteristics of patients predicting suitability for rapid naltrexone induction. Am J Addict 2016; 24:258-264. [PMID: 25907815 DOI: 10.1111/ajad.12180] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 09/19/2014] [Accepted: 10/31/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Extended-release (XR) injection naltrexone has proved promising in the treatment of opioid dependence. Induction onto naltrexone is often accomplished with a procedure known as rapid naltrexone induction. The purpose of this study was to evaluate pre-treatment patient characteristics as predictors of successful completion of a rapid naltrexone induction procedure prior to XR naltrexone treatment. METHODS A chart review of 150 consecutive research participants (N = 84 completers and N = 66 non-completers) undergoing a rapid naltrexone induction with the buprenorphone-clonidine procedure were compared on a number of baseline demographic, clinical and psychosocial factors. Logistic regression was used to identify client characteristics that may predict successful initiation of naltrexone after a rapid induction-detoxification. RESULTS Patients who failed to successfully initiate naltrexone were younger (AOR: 1.040, CI: 1.006, 1.075), and using 10 or more bags of heroin (or equivalent) per day (AOR: 0.881, CI: 0.820, 0.946). Drug use other than opioids was also predictive of failure to initiate naltrexone in simple bivariate analyses, but was no longer significant when controlling for age and opioid use level. CONCLUSIONS Younger age, and indicators of greater substance dependence severity (more current opioid use, other substance use) predict difficulty completing a rapid naltrexone induction procedure. Such patients might require a longer period of stabilization and/or more gradual detoxification prior to initiating naltrexone. SCIENTIFIC SIGNIFICANCE Our study findings identify specific characteristics of patients who responded positively to rapid naltrexone induction.
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Affiliation(s)
- Shanthi Mogali
- Division of Substance Abuse, New York State Psychiatric Institute, New York, NY
| | - Nabil A Khan
- Division of Substance Abuse, New York State Psychiatric Institute, New York, NY
| | - Esther S Drill
- Department of Biostatistics, Columbia University, New York, NY
| | | | | | - Edward Nunes
- Division of Substance Abuse, New York State Psychiatric Institute, New York, NY.,Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, NY
| | - Adam Bisaga
- Division of Substance Abuse, New York State Psychiatric Institute, New York, NY.,Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, NY
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6
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Dependence on Over the Counter (OTC) Codeine Containing Analgesics: Treatment and Recovery with Buprenorphine Naloxone. Int J Ment Health Addict 2015. [DOI: 10.1007/s11469-015-9618-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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7
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Sigmon SC, C. Meyer A, Hruska B, Ochalek T, Rose G, Badger GJ, Brooklyn JR, Heil SH, Higgins ST, Moore BA, Schwartz RP. Bridging waitlist delays with interim buprenorphine treatment: initial feasibility. Addict Behav 2015; 51:136-42. [PMID: 26256469 DOI: 10.1016/j.addbeh.2015.07.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/02/2015] [Accepted: 07/27/2015] [Indexed: 10/23/2022]
Abstract
Despite the effectiveness of agonist maintenance for opioid dependence, individuals can remain on waitlists for months, during which they are at significant risk for morbidity and mortality. Interim dosing, consisting of daily medication without counseling, can reduce these risks. In this pilot study, we examined the initial feasibility of a novel technology-assisted interim buprenorphine treatment for waitlisted opioid-dependent adults. Following buprenorphine induction during Week 1, participants (n=10) visited the clinic at Weeks 2, 4, 6, 8, 10 and 12 to ingest their medication under staff observation, provide a urine specimen and receive their remaining doses via a computerized Med-O-Wheel Secure device. They also received daily monitoring via an Interactive Voice Response (IVR) platform, as well as random call-backs for urinalysis and medication adherence checks. The primary outcome was percent of participants negative for illicit opioids at each 2-week visit, with secondary outcomes of past-month drug use, adherence and acceptability. Participants achieved high levels of illicit opioid abstinence, with 90% abstinent at the Week 2 and 4 visits and 60% at Week 12. Significant reductions were observed in self-reported past-month illicit opioid use (p<.001), opioid withdrawal (p<.001), opioid craving (p<.001) and ASI Drug composite score (p=.008). Finally, adherence with buprenorphine administration (99%), daily IVR calls (97%) and random call-backs (82%) was high. Interim buprenorphine treatment shows promise for reducing patient and societal risks during delays to conventional treatment. A larger-scale, randomized clinical trial is underway to more rigorously examine the efficacy of this treatment approach.
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8
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Nielsen S, Bruno R, Murnion B, Dunlop A, Degenhardt L, Demirkol A, Muhleisen P, Lintzeris N. Treating codeine dependence with buprenorphine: Dose requirements and induction outcomes from a retrospective case series in New South Wales, Australia. Drug Alcohol Rev 2015. [PMID: 26223631 DOI: 10.1111/dar.12315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION AND AIMS Codeine dependence is an emerging public health concern, yet no studies have specifically examined the treatment of codeine dependence. Given the lower potency of codeine it cannot be assumed that buprenorphine dose requirements for heroin dependence will generalise to codeine. This is the first study to examine buprenorphine treatment for codeine dependence. DESIGN AND METHODS Retrospective case series of 19 codeine-dependent treatment entrants who received sublingual buprenorphine maintenance treatment through six specialist inpatient and outpatient treatment centres. Baseline codeine doses and buprenorphine dose at days 7 and 28 were collected, in addition to details on general demographics, pain and mental health, substance use and outcomes after 28 days of buprenorphine treatment. RESULTS A significant linear relationship was found between initial codeine dose and dose of buprenorphine given at days 7 and 28 for the codeine dose range of 50-960 mg day-1 (mean: 564 mg; 95% confidence interval 431-696 mg). Median buprenorphine dose was 12.0 mg (interquartile range 9.5 mg, range 4-32 mg) at day 7 and 16.0 mg (interquartile range 13.5 mg, range 4-32 mg) at day 28. Buprenorphine doses received were markedly higher than estimated codeine doses based on standard dose conversion tables. DISCUSSION AND CONCLUSIONS With increasing presentations relating to codeine dependence, these findings provide important guidance to clinicians. Buprenorphine doses were consistently higher than doses estimated based on the dose of codeine consumed, and were comparable with doses used in the treatment of dependence with heroin and more potent prescription opioids. [Nielsen S, Bruno R, Murnion B, Dunlop A, Degenhardt L, Demirkol A, Muhleisen P, Lintzeris N. Treating codeine dependence with buprenorphine: Dose requirements and induction outcomes from a retrospective case series in New South Wales, Australia. Drug Alcohol Rev 2015].
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Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Centre, University of New South Wales, Sydney, Australia.,Discipline of Addiction Medicine, University of Sydney, Sydney, Australia.,Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia
| | - Raimondo Bruno
- National Drug and Alcohol Centre, University of New South Wales, Sydney, Australia.,School of Medicine, University of Tasmania, Hobart, Australia
| | - Bridin Murnion
- Discipline of Addiction Medicine, University of Sydney, Sydney, Australia
| | - Adrian Dunlop
- District Drug and Alcohol Clinical Services, Hunter New England Local Health Services, Newcastle West, Australia.,School of Medicine and Public Health (Medicine), University of Newcastle, Newcastle, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Centre, University of New South Wales, Sydney, Australia.,School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia.,Department of Global Health, School of Public Health, University of Washington, Seattle, USA
| | - Apo Demirkol
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Peter Muhleisen
- District Drug and Alcohol Clinical Services, Hunter New England Local Health Services, Newcastle West, Australia
| | - Nicholas Lintzeris
- Discipline of Addiction Medicine, University of Sydney, Sydney, Australia.,Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia
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Dunn KE, Saulsgiver KA, Miller ME, Nuzzo PA, Sigmon SC. Characterizing opioid withdrawal during double-blind buprenorphine detoxification. Drug Alcohol Depend 2015; 151:47-55. [PMID: 25823907 PMCID: PMC4447545 DOI: 10.1016/j.drugalcdep.2015.02.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/23/2015] [Accepted: 02/27/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Prescription opioid (PO) abuse has become an urgent public health issue in the United States. Detoxification is one important treatment option, yet relatively little is known about the time course and severity of opioid withdrawal during buprenorphine detoxification. METHODS This is a secondary analysis of data from a randomized, placebo-controlled, double-blind evaluation of 1, 2, and 4-week outpatient buprenorphine tapers among primary prescription opioid (PO) abusers. The aim is to characterize the time course and severity of buprenorphine withdrawal under rigorous, double-blind conditions, across multiple taper durations, and using multiple withdrawal-related measures (i.e., self-report and observer ratings, pupil diameter, ancillary medication utilization). Participants were PO-dependent adults undergoing buprenorphine detoxification and biochemically-verified to be continuously abstinent from opioids during their taper (N = 28). RESULTS Participants randomly assigned to the 4-week taper regimen experienced a relatively mild and stable course of withdrawal, with few peaks in severity. In contrast, the 1- and 2-week taper groups experienced stark increases in withdrawal severity during the week following the last buprenorphine dose, followed by declines in withdrawal severity thereafter. The 4-week taper group also reported significantly fewer disruptions in sleep compared to the other experimental groups. When predictors of withdrawal were examined, baseline ratings of "Expected Withdrawal Severity" was the most robust predictor of withdrawal experienced during the taper. CONCLUSION Data from this trial may inform clinicians about the expected time course, magnitude, and pattern of buprenorphine withdrawal and aid efforts to identify patients who may need additional clinical support during outpatient buprenorphine detoxification.
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Affiliation(s)
- Kelly E Dunn
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, MD, United States.
| | | | - Mollie E Miller
- Brown University Center for Alcohol and Addiction Studies, Providence, RI, United States
| | - Paul A Nuzzo
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, United States
| | - Stacey C Sigmon
- University of Vermont Departments of Psychiatry, Burlington, VT, United States; University of Vermont Departments of Psychology, Burlington, VT, United States
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10
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Griffin ML, Bennett HE, Fitzmaurice GM, Hill KP, Provost SE, Weiss RD. Health-related quality of life among prescription opioid-dependent patients: Results from a multi-site study. Am J Addict 2015; 24:308-14. [PMID: 25808055 DOI: 10.1111/ajad.12188] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 11/07/2014] [Accepted: 12/04/2014] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Although prescription opioid use disorder has recently increased sharply in the United States, relatively little is known about the general well-being of this population. Assessment of quality of life in patients with substance use disorders has been recommended to improve clinical care. OBJECTIVES Health-related quality of life was examined in prescription opioid-dependent patients at entry to a national multi-site clinical trial, to compare quality of life scores in the study sample to other populations; further, background variables associated with quality of life in the literature were examined. METHODS Prescription opioid-dependent patients (N = 653) were compared to general populations on the Medical Outcome Study Short Form-36 (SF-36) quality of life measure; and the association between patient background variables and quality of life was examined. RESULTS Compared to a general population, the current sample of prescription opioid-dependent patients had worse physical (-1.7 points, p < .001) and mental quality of life (-12.3 points, p < .001) as measured by the SF-36, similar to other opioid-use disorder populations. Within our sample, women showed more impairment than men in mental quality of life (-4.3 points, p < .001); older patients scored worse on physical (-5.2 points, p < .001), but not mental, quality of life. Chronic pain was associated with poorer physical quality of life (-9.0 points, p < .001). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE The growing focus on wellness underscores the importance of measuring quality of life in addition to substance use outcomes. Routine assessment of health-related quality of life can add an important dimension to overall evaluation of patients' treatment response.
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Affiliation(s)
- Margaret L Griffin
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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11
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Woodcock EA, Lundahl LH, Greenwald MK. Predictors of buprenorphine initial outpatient maintenance and dose taper response among non-treatment-seeking heroin dependent volunteers. Drug Alcohol Depend 2015; 146:89-96. [PMID: 25479914 PMCID: PMC4272885 DOI: 10.1016/j.drugalcdep.2014.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/17/2014] [Accepted: 11/18/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Buprenorphine (BUP) is effective for treating opioid use disorder. Individuals' heroin-use characteristics may predict their responses to BUP, which could differ during maintenance and dose-taper phases. If so, treatment providers could use pre-treatment characteristics to personalize level of individual care and possibly improve treatment outcomes. METHODS Non-treatment-seeking heroin-dependent volunteers (N=34) initiated outpatient BUP maintenance (8-mg/day) and submitted urine samples thrice weekly tested for opioids (non-contingent result). After completing three programmatically-related inpatient behavioral pharmacology experiments (while maintained on 8-mg/day BUP), participants were discharged and underwent a double-blind BUP dose taper (4-mg/day, 2-mg/day and 0-mg/day during weeks 1-3, respectively) with an opioid-abstinence incentive ($30 per consecutive opioid-negative urine specimen, obtained thrice weekly). RESULTS Participants who reported less pre-study (past-month) heroin use and shorter lifetime duration of heroin use were more likely to submit an opioid-negative urine sample during initial outpatient BUP maintenance. Participants who reported more lifetime heroin-quit attempts and provided any opioid-free urine sample during initial outpatient maintenance sustained longer continuous opioid-abstinence during the BUP dose taper. Participants who reported >3 lifetime quit attempts abstained from opioid use nearly one week longer (14 days vs. 8 days to opioid-lapse) and nearly half (46.7%) refrained from opioid use during dose taper. CONCLUSIONS Number of prior heroin quit attempts may predict BUP dose taper response and provide a metric for stratifying heroin-dependent individuals by relative risk for opioid lapse. This metric may inform personalized relapse prevention care and improve treatment outcomes.
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Affiliation(s)
- Eric A. Woodcock
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI 48201, USA
,Translational Neuroscience Program, Wayne State University, Detroit, MI 48201, USA
| | - Leslie H. Lundahl
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI 48201, USA
| | - Mark K. Greenwald
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI 48201, USA
,Translational Neuroscience Program, Wayne State University, Detroit, MI 48201, USA
,Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI 48201, USA
,Corresponding author at: Department of Psychiatry and Behavioral Neurosciences, Tolan Park Medical Building, Suite 2A, 3901 Chrysler Drive, Detroit, MI 48201, USA, Tel.: +1 313 993 3965; fax: +1 313 993 1372.
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12
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Nielsen S, Murnion B, Dunlop A, Degenhardt L, Demirkol A, Muhleisen P, Lintzeris N. Comparing treatment-seeking codeine users and strong opioid users: Findings from a novel case series. Drug Alcohol Rev 2014; 34:304-11. [DOI: 10.1111/dar.12224] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 09/25/2014] [Indexed: 02/05/2023]
Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
- Royal Prince Alfred Hospital; University of Sydney; Sydney Australia
- Drug and Alcohol Services; South Eastern Sydney Local Health District; Sydney Australia
| | - Bridin Murnion
- Royal Prince Alfred Hospital; University of Sydney; Sydney Australia
| | - Adrian Dunlop
- Drug and Alcohol Services; Hunter New England Local Health District; Newcastle Australia
- School of Medicine and Public Health; Faculty of Health; University of Newcastle; Newcastle Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
- School of Population and Global Health; University of Melbourne; Melbourne Australia
- Murdoch Children's Research Institute; Royal Children's Hospital; Melbourne Australia
- Department of Global Health; School of Public Health; University of Washington; Seattle USA
| | - Apo Demirkol
- Drug and Alcohol Services; South Eastern Sydney Local Health District; Sydney Australia
- School of Public Health and Community Medicine; University of New South Wales; Sydney Australia
| | - Peter Muhleisen
- Drug and Alcohol Services; Hunter New England Local Health District; Newcastle Australia
| | - Nicholas Lintzeris
- Royal Prince Alfred Hospital; University of Sydney; Sydney Australia
- Drug and Alcohol Services; South Eastern Sydney Local Health District; Sydney Australia
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13
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Fischer B, Burnett C, Rehm J. Considerations towards a population health approach to reduce prescription opioid-related harms (with a primary focus on Canada). DRUGS-EDUCATION PREVENTION AND POLICY 2014. [DOI: 10.3109/09687637.2014.936827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
OBJECTIVES Dependence on prescription opioids (PO) is a growing problem. Although most research with buprenorphine has focused on heroin-dependent populations, we hypothesize that individuals dependent on PO display characteristics that may predict different outcomes in treatment, particularly in short-term taper procedures in which comorbidities such as pain conditions may complicate taper. METHODS This secondary data analysis examined differences in outcomes between PO users (n = 90) and heroin users (n = 426) after a buprenorphine taper. Data were collected in a multisite randomized clinical trial conducted by the National Drug Abuse Treatment Clinical Trials Network at 11 study sites across the United States. After a 4-week buprenorphine induction/stabilization phase, 516 opioid-dependent individuals were randomized into 1 of 2 taper lengths (7 vs 28 days) to assess the association between taper length and outcome. The primary outcome was measured by urine drug test for opioids at the end of the taper period. Craving, withdrawal, and buprenorphine dose were also examined. RESULTS After controlling for baseline demographic and drug use differences between the opioid use groups, results indicate that a higher percentage of the PO group (49%) provided an opioid-free urine drug specimen at the end of taper compared with the heroin group (36%; χ(2)(1) = 6.592, P < 0.010). CONCLUSION Short-term taper is not recommended as a stand-alone treatment; however, patients may taper from buprenorphine as part of a treatment plan. Despite greater comorbidity, PO users seem to have favorable taper outcomes compared with heroin users. Further studies are required to examine longer-term treatment outcomes.
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15
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Hillhouse M, Canamar CP, Ling W. Predictors of outcome after short-term stabilization with buprenorphine. J Subst Abuse Treat 2013; 44:336-42. [PMID: 23021099 PMCID: PMC3545105 DOI: 10.1016/j.jsat.2012.08.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 07/13/2012] [Accepted: 08/08/2012] [Indexed: 11/29/2022]
Abstract
Using buprenorphine as a medication to treat opioid dependence is becoming more prevalent as illicit opiate use increases. Identifying the characteristics of opiate dependent individuals best suited to benefit from buprenorphine would improve guidelines for its administration. This study evaluates baseline and treatment participation variables for predicting positive response to short-term stabilization with buprenorphine. Data include demographic, drug use, and other variables collected from participants undergoing stabilization over a 4-week period before being tapered off buprenorphine in a short-term detoxification process. Outcome variables include opioid use and retention. Logistic regression results indicate several characteristics associated with opioid use at the end of the stabilization period. These include being older, having no criminal history, and less opiate use. Criminal activity and opioid use in the last 30 days were significantly associated with shorter treatment stays. The benefits of identifying individual characteristics that may predict treatment response are discussed.
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Affiliation(s)
- Maureen Hillhouse
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA 90025, USA.
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16
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Mannelli P, Peindl KS, Lee T, Bhatia KS, Wu LT. Buprenorphine-mediated transition from opioid agonist to antagonist treatment: state of the art and new perspectives. ACTA ACUST UNITED AC 2012; 5:52-63. [PMID: 22280332 DOI: 10.2174/1874473711205010052] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 10/14/2011] [Accepted: 11/28/2011] [Indexed: 11/22/2022]
Abstract
Constant refinement of opioid dependence (OD) therapies is a condition to promote treatment access and delivery. Among other applications, the partial opioid agonist buprenorphine has been studied to improve evidence-based interventions for the transfer of patients from opioid agonist to antagonist medications. This paper summarizes PubMed-searched clinical investigations and conference papers on the transition from methadone maintenance to buprenorphine and from buprenorphine to naltrexone, discussing challenges and advances. The majority of the 26 studies we examined were uncontrolled investigations. Many small clinical trials have demonstrated the feasibility of in- or outpatient transfer to buprenorphine from low to moderate methadone doses (up to 60-70 mg). Results on the conversion from higher methadone doses, on the other hand, indicate significant withdrawal discomfort, and need for ancillary medications and inpatient treatment. Tapering high methadone doses before the transfer to buprenorphine is not without discomfort and the risk of relapse. The transition buprenorphine-naltrexone has been explored in several pilot studies, and a number of treatment methods to reduce withdrawal intensity warrant further investigation, including the co-administration of buprenorphine and naltrexone. Outpatient transfer protocols using buprenorphine, and direct comparisons with other modalities of transitioning from opioid agonist to antagonist medications are limited. Given its potential salience, the information gathered should be used in larger clinical trials on short and long-term outcomes of opioid agonist-antagonist transition treatments. Future studies should also test new pharmacological mechanisms to help reduce physical dependence, and identify individualized approaches, including the use of pharmacogenetics and long-acting opioid agonist and antagonist formulations.
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Affiliation(s)
- Paolo Mannelli
- Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC 27705, USA.
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17
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Sigmon SC, Bisaga A, Nunes EV, O'Connor PG, Kosten T, Woody G. Opioid detoxification and naltrexone induction strategies: recommendations for clinical practice. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2012; 38:187-99. [PMID: 22404717 PMCID: PMC4331107 DOI: 10.3109/00952990.2011.653426] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Opioid dependence is a significant public health problem associated with high risk for relapse if treatment is not ongoing. While maintenance on opioid agonists (i.e., methadone, buprenorphine) often produces favorable outcomes, detoxification followed by treatment with the μ-opioid receptor antagonist naltrexone may offer a potentially useful alternative to agonist maintenance for some patients. METHOD Treatment approaches for making this transition are described here based on a literature review and solicitation of opinions from several expert clinicians and scientists regarding patient selection, level of care, and detoxification strategies. CONCLUSION Among the current detoxification regimens, the available clinical and scientific data suggest that the best approach may be using an initial 2-4 mg dose of buprenorphine combined with clonidine, other ancillary medications, and progressively increasing doses of oral naltrexone over 3-5 days up to the target dose of naltrexone. However, more research is needed to empirically validate the best approach for making this transition.
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Affiliation(s)
- Stacey C Sigmon
- Department of Psychiatry, University of Vermont College of Medicine, Burlington, 05401, USA.
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18
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Dunn KE, Sigmon SC, Strain EC, Heil SH, Higgins ST. The association between outpatient buprenorphine detoxification duration and clinical treatment outcomes: a review. Drug Alcohol Depend 2011; 119:1-9. [PMID: 21741781 PMCID: PMC3205338 DOI: 10.1016/j.drugalcdep.2011.05.033] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 05/24/2011] [Accepted: 05/29/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The association between buprenorphine taper duration and treatment outcomes is not well understood. This review evaluated whether duration of outpatient buprenorphine taper is significantly associated with treatment outcomes. METHODS Studies that were published in peer-reviewed journals, administered buprenorphine as an outpatient taper to opioid-dependent participants, and provided data on at least one of three primary treatment outcome measures (opioid abstinence, retention, peak withdrawal severity) were reviewed. Primary treatment outcomes were evaluated as a function of taper duration using hierarchical linear regressions with pre-taper maintenance duration as a cofactor. RESULTS Twenty-eight studies were reviewed. Taper duration significantly predicted percent of opioid-negative samples provided during treatment, however pre-taper maintenance period predicted percent participants abstinent on the final day of treatment. High rates of relapse were reported. No significant association between taper duration and retention in treatment or peak withdrawal severity was observed. CONCLUSION The data reviewed here suggest taper duration is associated with opioid abstinence achieved during detoxification but not with other markers of treatment outcome. The reviewed studies varied widely on several parameters (e.g., frequency of urinalysis testing, provision of ancillary medications) that may influence treatment outcome and thus could have interfered with the ability to identify relationships between taper duration and outcomes. Future studies evaluating opioid detoxification should utilize rigorous experimental methods and report a wider range of outcome measures in order to help advance our understanding of the association between taper duration and treatment outcomes.
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Affiliation(s)
- Kelly E. Dunn
- Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 142 West, Baltimore, MD 21224. Phone: 410-550-5370, Fax: 410-550-7495,
| | - Stacey C. Sigmon
- University of Vermont. UHC-SATC Room 1415, 1 South Prospect Street, Burlington, VT 05401,
| | - Eric C. Strain
- Johns Hopkins University. 5500 Nathan Shock Drive, Baltimore MD, 21224.
| | - Sarah H. Heil
- University of Vermont. UHC-SATC Room 1415, 1 South Prospect Street, Burlington, VT 05401,
| | - Stephen T. Higgins
- University of Vermont. UHC-SATC Room 1415, 1 South Prospect Street, Burlington, VT 05401,
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Weiss RD, Potter JS, Fiellin DA, Byrne M, Connery HS, Dickinson W, Gardin J, Griffin ML, Gourevitch MN, Haller DL, Hasson AL, Huang Z, Jacobs P, Kosinski AS, Lindblad R, McCance-Katz EF, Provost SE, Selzer J, Somoza EC, Sonne SC, Ling W. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. ARCHIVES OF GENERAL PSYCHIATRY 2011; 68:1238-46. [PMID: 22065255 PMCID: PMC3470422 DOI: 10.1001/archgenpsychiatry.2011.121] [Citation(s) in RCA: 383] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT No randomized trials have examined treatments for prescription opioid dependence, despite its increasing prevalence. OBJECTIVE To evaluate the efficacy of brief and extended buprenorphine hydrochloride-naloxone hydrochloride treatment, with different counseling intensities, for patients dependent on prescription opioids. DESIGN Multisite, randomized clinical trial using a 2-phase adaptive treatment research design. Brief treatment (phase 1) included 2-week buprenorphine-naloxone stabilization, 2-week taper, and 8-week postmedication follow-up. Patients with successful opioid use outcomes exited the study; unsuccessful patients entered phase 2: extended (12-week) buprenorphine-naloxone treatment, 4-week taper, and 8-week postmedication follow-up. SETTING Ten US sites. Patients A total of 653 treatment-seeking outpatients dependent on prescription opioids. INTERVENTIONS In both phases, patients were randomized to standard medical management (SMM) or SMM plus opioid dependence counseling; all received buprenorphine-naloxone. MAIN OUTCOME MEASURES Predefined "successful outcome" in each phase: composite measures indicating minimal or no opioid use based on urine test-confirmed self-reports. RESULTS During phase 1, only 6.6% (43 of 653) of patients had successful outcomes, with no difference between SMM and SMM plus opioid dependence counseling. In contrast, 49.2% (177 of 360) attained successful outcomes in phase 2 during extended buprenorphine-naloxone treatment (week 12), with no difference between counseling conditions. Success rates 8 weeks after completing the buprenorphine-naloxone taper (phase 2, week 24) dropped to 8.6% (31 of 360), again with no counseling difference. In secondary analyses, successful phase 2 outcomes were more common while taking buprenorphine-naloxone than 8 weeks after taper (49.2% [177 of 360] vs 8.6% [31 of 360], P < .001). Chronic pain did not affect opioid use outcomes; a history of ever using heroin was associated with lower phase 2 success rates while taking buprenorphine-naloxone. CONCLUSIONS Prescription opioid-dependent patients are most likely to reduce opioid use during buprenorphine-naloxone treatment; if tapered off buprenorphine-naloxone, even after 12 weeks of treatment, the likelihood of an unsuccessful outcome is high, even in patients receiving counseling in addition to SMM.
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Affiliation(s)
- Roger D Weiss
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA 02478, USA.
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Subtypes of nonmedical opioid users: results from the national epidemiologic survey on alcohol and related conditions. Drug Alcohol Depend 2010; 112:69-80. [PMID: 20580168 PMCID: PMC2967592 DOI: 10.1016/j.drugalcdep.2010.05.013] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Revised: 05/19/2010] [Accepted: 05/20/2010] [Indexed: 11/21/2022]
Abstract
AIMS To identify subtypes of nonmedical opioid users, gender variations in psychiatric disorders, and quality of life in a representative sample of adults. METHODS Analyses of data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (N=43,093). Latent class analysis (LCA) and multinomial logistic regression procedures examined subtypes of nonmedical opioid users. RESULTS Approximately 5% (n=1815) of adults used nonmedical opioids. LCA identified four subtypes: opioid-marijuana users (33%), opioid-other prescription drug users (9%), opioid-marijuana-hallucinogen users (28%), and opioid-polydrug users (30%). Subtypes were distinguished by race/ethnicity, gender, familial substance abuse, personal history of substance abuse treatment, and patterns of psychiatric disorders. Whites and men had increased odds of being in the opioid-polydrug and opioid-marijuana-hallucinogen subtypes. The opioid-other prescription drug use subtype had disproportionately affected women who were characterized by high rates of mood/anxiety disorders and low quality of life. Across all subtypes, women and men had similarly problematic substance use disorders; however, women had more major depression and disability in the mental health domain. CONCLUSIONS The generally high prevalence of psychiatric disorders among nonmedical opioid users, particularly women, underscores the need for comprehensive assessment and coordinated delivery of services to match needs with treatment, as well as continued monitoring of trends in opioid use and related problems.
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Veilleux JC, Colvin PJ, Anderson J, York C, Heinz AJ. A review of opioid dependence treatment: Pharmacological and psychosocial interventions to treat opioid addiction. Clin Psychol Rev 2010; 30:155-66. [DOI: 10.1016/j.cpr.2009.10.006] [Citation(s) in RCA: 242] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2009] [Revised: 10/21/2009] [Accepted: 10/23/2009] [Indexed: 11/17/2022]
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Potter JS, Prather K, Kropp F, Byrne M, Sullivan CR, Mohamedi N, Copersino ML, Weiss RD. A method to diagnose opioid dependence resulting from heroin versus prescription opioids using the Composite International Diagnostic Interview. Contemp Clin Trials 2010; 31:185-8. [PMID: 20079463 DOI: 10.1016/j.cct.2010.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2009] [Revised: 12/31/2009] [Accepted: 01/08/2010] [Indexed: 11/30/2022]
Abstract
Treatment research with opioid-dependent populations has not traditionally distinguished between those dependent on prescription opioids versus dependent upon heroin. Evidence suggests there is a substantial subpopulation of individuals with opioid dependence resulting largely or exclusively from prescription opioid use. Because this subpopulation may respond to treatment differently from heroin users, a method for discriminating DSM-IV opioid dependence due to prescription opioid use would provide more precision when examining this population. This paper describes an innovative method using a currently available diagnostic instrument, to diagnose DSM-IV opioid dependence and distinguish between dependence resulting from prescription opioids versus dependence upon heroin.
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23
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Abstract
BACKGROUND Managed withdrawal is a necessary step prior to drug-free treatment or as the end point of substitution treatment. OBJECTIVES To assess the effectiveness of interventions involving the use of buprenorphine to manage opioid withdrawal, for withdrawal signs and symptoms, completion of withdrawal and adverse effects. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2008), MEDLINE (January 1966 to July 2008), EMBASE (January 1985 to 2008 Week 31), PsycINFO (1967 to 7 August 2008) and reference lists of articles. SELECTION CRITERIA Randomised controlled trials of interventions involving the use of buprenorphine to modify the signs and symptoms of withdrawal in participants who were primarily opioid dependent. Comparison interventions involved reducing doses of methadone, alpha(2)-adrenergic agonists, symptomatic medications or placebo, or different buprenorphine-based regimes. DATA COLLECTION AND ANALYSIS One author assessed studies for inclusion and methodological quality, and undertook data extraction. Inclusion decisions and the overall process was confirmed by consultation between all authors. MAIN RESULTS Twenty-two studies involving 1736 participants were included. The major comparisons were with methadone (5 studies) and clonidine or lofexidine (12 studies). Five studies compared different rates of buprenorphine dose reduction.Severity of withdrawal is similar for withdrawal managed with buprenorphine and withdrawal managed with methadone, but withdrawal symptoms may resolve more quickly with buprenorphine. It appears that completion of withdrawal treatment may be more likely with buprenorphine relative to methadone (RR 1.18; 95% CI 0.93 to 1.49, P = 0.18) but more studies are required to confirm this.Relative to clonidine or lofexidine, buprenorphine is more effective in ameliorating the symptoms of withdrawal, patients treated with buprenorphine stay in treatment for longer (SMD 0.92, 95% CI 0.57 to 1.27, P < 0.001), and are more likely to complete withdrawal treatment (RR 1.64; 95% CI 1.31 to 2.06, P < 0.001). At the same time there is no significant difference in the incidence of adverse effects, but drop-out due to adverse effects may be more likely with clonidine. AUTHORS' CONCLUSIONS Buprenorphine is more effective than clonidine or lofexidine for the management of opioid withdrawal. Buprenorphine may offer some advantages over methadone, at least in inpatient settings, in terms of quicker resolution of withdrawal symptoms and possibly slightly higher rates of completion of withdrawal.
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Affiliation(s)
- Linda Gowing
- Discipline of Pharmacology, University of Adelaide, Frome Road, Adelaide, South Australia, Australia, 5005
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