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Spinella S, McCarthy R. Buprenorphine for Pain: A Narrative Review and Practical Applications. Am J Med 2024; 137:406-413. [PMID: 38340973 DOI: 10.1016/j.amjmed.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
Chronic noncancer pain affects about 20% of US adults and can significantly affect function and quality of life. Current guidelines recommend multimodal pain control. Despite risks associated with long-term opioid therapy, opioids are commonly prescribed. Buprenorphine is a partial opioid agonist with an improved safety profile compared to full agonists. Some formulations are approved for chronic pain and others for opioid use disorder. Buprenorphine is an option for patients who use chronic daily opioids for pain. This review summarizes the literature on buprenorphine's efficacy and safety for chronic pain and provides recommendations to generalists on initiation, titration, and monitoring of buprenorphine-based pain treatment. We also discuss a communication approach when considering buprenorphine for pain.
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Affiliation(s)
- Sara Spinella
- Department of Medicine, University of Pittsburgh School of Medicine and VA Pittsburgh Healthcare System, Pittsburgh, Pa.
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2
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Buresh C, Kaplan R. Opioid Use Disorder, Adolescents, and the Importance of Treatment in the Emergency Department. Pediatr Emerg Care 2024; 40:51-55. [PMID: 38157394 DOI: 10.1097/pec.0000000000003104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
ABSTRACT Deaths from opiate overdoses are climbing every year, especially from fentanyl. Adolescents are particularly vulnerable to the acute and chronic harms associated with drug use, addiction, and overdose. Providers in the acute care setting have a unique opportunity to address a population of adolescents with opioid use disorder who are at the highest risk of harm and who may be more receptive to help. It is critical that providers are familiar with the tools that are available to assist and have some facility with their application.
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Affiliation(s)
| | - Ron Kaplan
- From the Associate Professor, Division of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
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Cooper RL, Edgerton RD, Watson J, Conley N, Agee WA, Wilus DM, MacMaster SA, Bell L, Patel P, Godbole A, Bass-Thomas C, Ramesh A, Tabatabai M. Meta-analysis of primary care delivered buprenorphine treatment retention outcomes. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2023; 49:756-765. [PMID: 37737714 DOI: 10.1080/00952990.2023.2251653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 08/21/2023] [Indexed: 09/23/2023]
Abstract
Background: Currently, the capacity to provide buprenorphine treatment (BT) is not sufficient to treat the growing number of people in the United States with opioid use disorder (OUD). We sought to examine participant retention in care rates of primary care delivered BT programs and to describe factors associated with retention/attrition for participants receiving BT in this setting.Objectives: A PRISMA-guided search of various databases was performed to identify the articles focusing on efficacy of BT treatment and OUD.Method: A systematic literature search identified 15 studies examining retention in care in the primary care setting between 2002 and 2020. Random effects meta-regression were used to identify retention rates across studies.Results: Retention rates decreased across time with a mean 0.52 rate at one year. Several factors were found to be related to retention, including: race, use of other drugs, receipt of counseling, and previous treatment with buprenorphine.Conclusions: While we only investigate BT through primary care, our findings indicate retention rates are equivalent to the rates reported in the specialty care literature. More work is needed to examine factors that may impact primary care delivered BT specifically and differentiate participants that may benefit from care delivered in specialty over primary care as well as the converse.
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Affiliation(s)
- Robert L Cooper
- Department of Family and Community Medicine, Meharry Medical College, Nashville, TN, USA
| | - Ryan D Edgerton
- Department of Family and Community Medicine, Meharry Medical College, Nashville, TN, USA
| | - Julia Watson
- College of Public Health, University of Kentucky, Lexington, KY, USA
| | | | - William A Agee
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Derek M Wilus
- School of Graduate Studies & Research, Meharry Medical College, Nashville, TN, USA
| | - Samuel A MacMaster
- Department of Family and Community Medicine, Meharry Medical College, Nashville, TN, USA
| | - Lisa Bell
- Department of Family and Community Medicine, Meharry Medical College, Nashville, TN, USA
| | - Parul Patel
- Department of Family and Community Medicine, Meharry Medical College, Nashville, TN, USA
| | - Amruta Godbole
- Department of Family and Community Medicine, Meharry Medical College, Nashville, TN, USA
| | - Cynthia Bass-Thomas
- Department of Family and Community Medicine, Meharry Medical College, Nashville, TN, USA
| | - Aramandla Ramesh
- Department of Biochemistry, Cancer Biology, Neuroscience & Pharmacology, Meharry Medical College, Nashville, TN, USA
| | - Mohammad Tabatabai
- School of Graduate Studies & Research, Meharry Medical College, Nashville, TN, USA
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4
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Kelly JC, Ayala NK, Holroyd L, Raghuraman N, Carter EB, Williams SA, Mills MM, Friedman H, Zhang F, Townsel C. Number of buprenorphine induction attempts impacts maternal and neonatal outcomes: a multicenter cohort study. Am J Obstet Gynecol MFM 2023; 5:100998. [PMID: 38236700 DOI: 10.1016/j.ajogmf.2023.100998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/14/2023] [Accepted: 04/27/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Buprenorphine can be used to treat maternal opioid use disorder effectively and decrease obstetrical risks. Compared with the use of other medications to treat opioid use disorder, the use of buprenorphine results in improved neonatal outcomes; however, its use is associated with higher rates of treatment attrition. Initiation of buprenorphine, termed "induction," is a high-risk time for treatment dropout and can require repeated attempts. OBJECTIVE This study aimed to evaluate the effect of multiple buprenorphine induction attempts on maternal and neonatal outcomes. STUDY DESIGN This was a retrospective cohort study of all pregnant patients who underwent sublingual buprenorphine induction for the treatment of opioid use disorder from June 18, 2018, to January 1, 2021, at 3 tertiary care centers. Patients who required only 1 attempt for successful buprenorphine induction were compared with those who required multiple attempts but ultimately were successful in the treatment initiation during pregnancy, confirmed by urine drug screening. The primary outcome was nonprescribed opioid use at the time of delivery. The secondary outcomes included obstetrical and neonatal outcomes associated with opioid use disorder. Background characteristics were compared using Fisher exact, chi-square, Mann-Whitney U, and Student t tests. The outcomes were compared using multivariable logistic regression, and time to delivery after initiation of prenatal care was compared between groups using Kaplan-Meier curves and a Cox proportional-hazards model. RESULTS Overall, 63 patients undergoing buprenorphine induction during pregnancy were included, with 38 (60.3%) patients with 1 attempt and 25 patients (39.7%) with multiple attempts. There was no statistical difference between the 2 groups in terms of background characteristics. Compared with a single successful attempt, multiple attempts at buprenorphine induction were associated with a significantly increased odds of nonprescribed opioid use at the time of delivery (76.0% vs 15.8%; adjusted odds ratio, 30.00; 95% confidence interval, 5.50-163.90), increased risk of preterm birth (48.0% vs 15.8%; adjusted hazard ratio, 3.24; 95% confidence interval, 1.17-8.95), and decreased rate of breastfeeding at both maternal discharge (24.0% vs 78.9%; adjusted odds ratio, 0.06; 95% confidence interval, 0.00-0.30) and infant discharge (24.0% vs 55.3%; adjusted odds ratio, 0.23; 95% confidence interval, 0.10-0.80). CONCLUSION Requiring multiple attempts for buprenorphine induction significantly increases the odds of nonprescribed opioid use at the time of delivery and preterm birth and decreases the odds of breastfeeding. As the buprenorphine induction process may affect obstetrical outcomes for patients induced during pregnancy, investigating the techniques that increase the likelihood of successful induction is crucially needed to improve outcomes in patients with maternal opioid use disorder.
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Affiliation(s)
- Jeannie C Kelly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Holroyd, Raghuraman, and Carter); Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Raghuraman, and Carter, Mses Williams and Mills, and Dr Zhang); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI (Dr Townsel).
| | - Nina K Ayala
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI (Dr Ayala)
| | - Lauren Holroyd
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Holroyd, Raghuraman, and Carter)
| | - Nandini Raghuraman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Holroyd, Raghuraman, and Carter); Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Raghuraman, and Carter, Mses Williams and Mills, and Dr Zhang)
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Holroyd, Raghuraman, and Carter); Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Raghuraman, and Carter, Mses Williams and Mills, and Dr Zhang)
| | - Samantha A Williams
- Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Raghuraman, and Carter, Mses Williams and Mills, and Dr Zhang)
| | - Melissa M Mills
- Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Raghuraman, and Carter, Mses Williams and Mills, and Dr Zhang)
| | - Hayley Friedman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI (Dr Ayala)
| | - Fan Zhang
- Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Raghuraman, and Carter, Mses Williams and Mills, and Dr Zhang)
| | - Courtney Townsel
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO (Dr Friedman)
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Guo CZ, D'Onofrio G, Fiellin DA, Edelman EJ, Hawk K, Herring A, McCormack R, Perrone J, Cowan E. Emergency department-initiated buprenorphine protocols: A national evaluation. J Am Coll Emerg Physicians Open 2021; 2:e12606. [PMID: 34877567 PMCID: PMC8630357 DOI: 10.1002/emp2.12606] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 10/28/2021] [Accepted: 11/02/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Emergency department-initiated buprenorphine (BUP) for opioid use disorder is an evidence-based practice, but limited data exist on BUP initiation practices in real-world settings. We sought to characterize protocols for BUP initiation among a geographically diverse sample of emergency departments (EDs). METHODS In December 2020, we reviewed prestudy clinical BUP initiation protocols from all EDs participating in CTN0099 Emergency Department-INitiated bupreNOrphine VAlidaTION (ED-INNOVATION). We abstracted information on processes for identification of treatment-eligible patients, BUP administration, and discharge care. RESULTS All participating ED-INNOVATION sites across 22 states submitted protocols; 31 protocols were analyzed. Identification of treatment-eligible patients: Most EDs 22 (71%) relied on clinician judgment to determine appropriateness of BUP treatment with only 7 (23%) requiring decision support tools or diagnosis checklists. Before BUP initiation, 27 (87%) protocols required a documented Clinical Opiate Withdrawal Scale (COWS) score; 4 (13%) required a clinical diagnosis of withdrawal with optional COWS score. Twenty-seven (87%) recommended a minimum COWS score of 8 for ED-initiated BUP. BUP administration: Initial BUP dose ranged from 2-16 mg (mode = 4). For continued withdrawal symptoms, 27 (87%) protocols recommended an interval of 30-60 minutes between first and second BUP dose. Total BUP dose in the ED ranged from 8 to 32 mg. Discharge care: Twenty-eight (90%) protocols recommended a BUP prescription (mode 16 mg daily) at discharge. Naloxone prescription and/or provision was suggested in 23 (74%) protocols. CONCLUSIONS In this geographically diverse sample of EDs, protocols for ED-initiated BUP differed between sites. Future work should evaluate the association between this variation and patient outcomes.
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Affiliation(s)
- Clara Z. Guo
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Gail D'Onofrio
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - David A. Fiellin
- Department of Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - E. Jennifer Edelman
- Department of Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Kathryn Hawk
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Andrew Herring
- Department of Emergency MedicineHighland Hospital – Alameda Health SystemUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Ryan McCormack
- Department of Emergency MedicineNew York University School of MedicineNew YorkNew YorkUSA
| | - Jeanmarie Perrone
- Department of Emergency MedicinePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ethan Cowan
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Home Induction of Buprenorphine for Treatment of Opioid Use Disorder in Pregnancy. Obstet Gynecol 2021; 138:655-659. [PMID: 34623078 DOI: 10.1097/aog.0000000000004539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022]
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Nalven T, Spillane NS, Schick MR, Weyandt LL. Diversity inclusion in United States opioid pharmacological treatment trials: A systematic review. Exp Clin Psychopharmacol 2021; 29:524-538. [PMID: 34242040 PMCID: PMC8511246 DOI: 10.1037/pha0000510] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pharmacological treatments for opioid use disorders (OUDs) may have mixed efficacy across diverse groups, i.e., sex/gender, race/ethnicity, and socioeconomic status (SES). The present systematic review aims to examine how diverse groups have been included in U.S. randomized clinical trials examining pharmacological treatments (i.e., methadone, buprenorphine, or naltrexone) for OUDs. PubMed was systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The initial search yielded 567 articles. After exclusion of ineligible articles, 50 remained for the present review. Of the included articles, 14.0% (n = 7) reported both full (i.e., accounting for all participants) sex/gender and race/ethnicity information; only two of those articles also included information about any SES indicators. Moreover, only 22.0% (n = 11) reported full sex/gender information, and 42.0% (n = 21) reported full racial/ethnic information. Furthermore, only 10.0% (n = 5) reported that their lack of subgroup analyses or diverse samples was a limitation to their studies. Particularly underrepresented were American Indian/Alaska Native (AI/AN), Asian, Native Hawaiian/Other Pacific Islander (NH/OPI), and multiracial individuals. These results also varied by medication type; Black individuals were underrepresented in buprenorphine randomized controlled trials (RCTs) but were well represented in RCTs for methadone and/or naltrexone. In conclusion, it is critical that all people receive efficacious pharmacological care for OUDs given the ongoing opioid epidemic. Findings from the present review, however, support that participants from diverse or marginalized backgrounds are underrepresented in treatment trials, despite being at increased risk for disparities related to OUDs. Suggestions for future research are advanced. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Tessa Nalven
- Department of Psychology, University of Rhode Island
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8
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The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med 2021; 14:1-91. [PMID: 32511106 DOI: 10.1097/adm.0000000000000633] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Carley JA, Oesterle T. Therapeutic Approaches to Opioid Use Disorder: What is the Current Standard of Care? Int J Gen Med 2021; 14:2305-2311. [PMID: 34113160 PMCID: PMC8184146 DOI: 10.2147/ijgm.s295461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/25/2021] [Indexed: 11/23/2022] Open
Abstract
Opioid use disorder is a frequent cause of suffering to communities worldwide. Therapeutic approaches to opioid use disorder include screening, appropriate assessment and diagnosis, consideration of level of care, acute management of overdose or withdrawal, treatment with medications, psychotherapeutic approaches, and community support. People who struggle with addiction to opioids often suffer deeply from direct and indirect consequences of use. Subsequently, it is critical that all medical providers understand the appropriate treatment options for opioid use disorder. This paper provides a comprehensive overview of the therapeutic options available for treatment of this chronic disease.
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Affiliation(s)
- Joseph A Carley
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Tyler Oesterle
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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10
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Abstract
Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.
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Affiliation(s)
- Megan Buresh
- Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert Stern
- Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Darius Rastegar
- Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Sokol R, Albanese M, Chew A, Early J, Grossman E, Roll D, Sawin G, Wu DJ, Schuman-Olivier Z. Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation. Addict Sci Clin Pract 2019; 14:47. [PMID: 31882001 PMCID: PMC6935085 DOI: 10.1186/s13722-019-0176-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Group-Based Opioid Treatment (GBOT) has recently emerged as a mechanism for treating patients with opioid use disorder (OUD) in the outpatient setting. However, the more practical "how to" components of successfully delivering GBOT has received little attention in the medical literature, potentially limiting its widespread implementation and utilization. Building on a previous case series, this paper delineates the key components to implementing GBOT by asking: (a) What are the core components to GBOT implementation, and how are they defined? (b) What are the malleable components to GBOT implementation, and what conceptual framework should providers use in determining how to apply these components for effective delivery in their unique clinical environment? METHODS To create a blueprint delineating GBOT implementation, we integrated findings from a previously conducted and separately published systematic review of existing GBOT studies, conducted additional literature review, reviewed best practice recommendations and policies related to GBOT and organizational frameworks for implementing health systems change. We triangulated this data with a qualitative thematic analysis from 5 individual interviews and 2 focus groups representing leaders from 5 different GBOT programs across our institution to identify the key components to GBOT implementation, distinguish "core" and "malleable" components, and provide a conceptual framework for considering various options for implementing the malleable components. RESULTS We identified 6 core components to GBOT implementation that optimize clinical outcomes, comply with mandatory policies and regulations, ensure patient and staff safety, and promote sustainability in delivery. These included consistent group expectations, team-based approach to care, safe and confidential space, billing compliance, regular monitoring, and regular patient participation. We identified 14 malleable components and developed a novel conceptual framework that providers can apply when deciding how to employ each malleable component that considers empirical, theoretical and practical dimensions. CONCLUSION While further research on the effectiveness of GBOT and its individual implementation components is needed, the blueprint outlined here provides an initial framework to help office-based opioid treatment sites implement a successful GBOT approach and hence potentially serve as future study sites to establish efficacy of the model. This blueprint can also be used to continuously monitor how components of GBOT influence treatment outcomes, providing an empirical framework for the ongoing process of refining implementation strategies.
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Affiliation(s)
- Randi Sokol
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Mark Albanese
- Outpatient Addiction Services, 26 Central St, Somerville, MA 02143 USA
| | - Aaronson Chew
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Jessica Early
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Ellie Grossman
- Somerville Hospital Primary Care, 236 Highland Avenue, Somerville, MA 02143 USA
| | - David Roll
- Revere Care Center, 454 Broadway, Revere, MA 02151 USA
| | - Greg Sawin
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Dominic J. Wu
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Zev Schuman-Olivier
- Center for Mindfulness and Compassion, 1035 Cambridge Street, Suite 21, Cambridge, MA 02141 USA
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Rahimi‐Movaghar A, Gholami J, Amato L, Hoseinie L, Yousefi‐Nooraie R, Amin‐Esmaeili M. Pharmacological therapies for management of opium withdrawal. Cochrane Database Syst Rev 2018; 6:CD007522. [PMID: 29929212 PMCID: PMC6513031 DOI: 10.1002/14651858.cd007522.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pharmacologic therapies for management of heroin withdrawal have been studied and reviewed widely. Opium dependence is generally associated with less severe dependence and milder withdrawal symptoms than heroin. The evidence on withdrawal management of heroin might therefore not be exactly applicable for opium. OBJECTIVES To assess the effectiveness and safety of various pharmacologic therapies for the management of the acute phase of opium withdrawal. SEARCH METHODS We searched the following sources up to September 2017: CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, regional and national databases (IMEMR, Iranmedex, and IranPsych), main electronic sources of ongoing trials, and reference lists of all relevant papers. In addition, we contacted known investigators to obtain missing data or incomplete trials. SELECTION CRITERIA Controlled clinical trials and randomised controlled trials on pharmacological therapies, compared with no intervention, placebo, other pharmacologic treatments, different doses of the same drug, and psychosocial intervention, to manage acute withdrawal from opium in a maximum duration of 30 days. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included 13 trials involving 1096 participants. No pooled analysis was possible. Studies were carried out in three countries, Iran, India, and Thailand, in outpatient and inpatient settings. The quality of the evidence was generally very low.When the mean of withdrawal symptoms was provided for several days, we mainly focused on day 3. The reason for this was that the highest severity of opium withdrawal is in the second to fourth day.Comparing different pharmacological treatments with each other, clonidine was twice as good as methadone for completion of treatment (risk ratio (RR) 2.01, 95% confidence interval (CI) 1.69 to 2.38; 361 participants, 1 study, low-quality evidence). All the other results showed no differences between the considered drugs: baclofen versus clonidine (RR 1.06, 95% CI 0.63 to 1.80; 66 participants, 1 study, very low-quality evidence); clonidine versus clonidine plus amantadine (RR 1.03, 95% CI 0.86 to 1.24; 69 participants, 1 study); clonidine versus buprenorphine in an inpatient setting (RR 1.04, 95% CI 0.90 to 1.20; 1 study, 35 participants, very low-quality evidence); methadone versus tramadol (RR 0.95, 95% CI 0.65 to 1.37; 1 study, 72 participants, very low-quality evidence); methadone versus methadone plus gabapentin (RR 1.17, 95% CI 0.96 to 1.43; 1 study, 40 participants, low-quality evidence), and tincture of opium versus methadone (1 study, 74 participants, low-quality evidence).Comparing different pharmacological treatments with each other, adding amantadine to clonidine decreased withdrawal scores rated at day 3 (mean difference (MD) -3.56, 95% CI -5.97 to -1.15; 1 study, 60 participants, very low-quality evidence). Comparing clonidine with buprenorphine in an inpatient setting, we found no difference in withdrawal symptoms rated by a physician (MD -1.40, 95% CI -2.93 to 0.13; 1 study, 34 participants, very low-quality evidence), and results in favour of buprenorpine when rated by participants (MD -11.80, 95% CI -15.56 to -8.04). Buprenorphine was superior to clonidine in controlling severe withdrawal symptoms in an outpatient setting (RR 0.35, 95% CI 0.19 to 0.64; 1 study, 76 participants). We found no difference in the comparison of methadone versus tramadol (MD 0.04, 95% CI -2.68 to 2.76; 1 study, 72 participants) and in the comparison of methadone versus methadone plus gabapentin (MD -2.20, 95% CI -6.72 to 2.32; 1 study, 40 participants).Comparing clonidine versus buprenorphine in an outpatient setting, more adverse effects were reported in the clonidine group (1 study, 76 participants). Higher numbers of participants in the clonidine group experienced hypotension at days 5 to 8, headache at days 1 to 8, sedation at days 5 to 8, dizziness and dry mouth at days 1 to 10, and nausea at days 1 to 9. Sweating was reported in a significantly higher number of participants in the buprenorphine group at days 1 to 10. We found no difference between groups for all the other comparisons considering this outcome.Comparing different dosages of the same pharmacological detoxification treatment, a high dose of clonidine (1 to 1.2 mg/day) did not differ from a low dose of clonidine (0.5 to 0.6 mg/day) in completion of treatment in an inpatient setting (RR 1.00, 95% CI 0.84 to 1.19; 1 study, 68 participants), however a higher number of participants with hypotension was reported in the high-dose group (RR 3.25, 95% CI 1.77 to 5.98). Gradual reduction of methadone was associated with more adverse effects than abrupt withdrawal of methadone (RR 2.25, 95% CI 1.02 to 4.94; 1 study, 20 participants, very low-quality evidence). AUTHORS' CONCLUSIONS Results did not support using any specific pharmacological approach for the management of opium withdrawal due to generally very low-quality evidence and small or no differences between treatments. However, it seems that opium withdrawal symptoms are significant, especially at days 2 to 4 after discontinuation of opium. All of the assessed medications might be useful in alleviating symptoms. Those who receive clonidine might experience hypotension.
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Affiliation(s)
- Afarin Rahimi‐Movaghar
- Tehran University of Medical SciencesIranian National Center for Addiction Studies (INCAS)No. 486, South Karegar Ave.TehranTehranIran1336616357
| | - Jaleh Gholami
- Tehran University of Medical SciencesIranian National Center for Addiction Studies (INCAS)No. 486, South Karegar Ave.TehranTehranIran1336616357
| | - Laura Amato
- Lazio Regional Health ServiceDepartment of EpidemiologyVia Cristoforo Colombo, 112RomeItaly00154
| | - Leila Hoseinie
- Tehran University of Medical SciencesIranian National Center for Addiction Studies (INCAS)No. 486, South Karegar Ave.TehranTehranIran1336616357
| | - Reza Yousefi‐Nooraie
- University of TorontoInstitute of Health Policy, Management and Evaluation155 College StreetTorontoONCanadaM5T 3M6
| | - Masoumeh Amin‐Esmaeili
- Tehran University of Medical SciencesIranian National Center for Addiction Studies (INCAS)No. 486, South Karegar Ave.TehranTehranIran1336616357
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Haffajee RL, Bohnert ASB, Lagisetty PA. Policy Pathways to Address Provider Workforce Barriers to Buprenorphine Treatment. Am J Prev Med 2018; 54:S230-S242. [PMID: 29779547 PMCID: PMC6330240 DOI: 10.1016/j.amepre.2017.12.022] [Citation(s) in RCA: 163] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 12/18/2017] [Accepted: 02/01/2018] [Indexed: 11/22/2022]
Abstract
At least 2.3 million people in the U.S. have an opioid use disorder, less than 40% of whom receive evidence-based treatment. Buprenorphine used as part of medication-assisted treatment has high potential to address this gap because of its approval for use in non-specialty outpatient settings, effectiveness at promoting abstinence, and cost effectiveness. However, less than 4% of licensed physicians are approved to prescribe buprenorphine for opioid use disorder, and approximately 47% of counties lack a buprenorphine-waivered physician. Existing policies contribute to workforce barriers to buprenorphine provision and access. Providers are reticent to prescribe buprenorphine because of workforce barriers, such as (1) insufficient training and education on opioid use disorder treatment, (2) lack of institutional and clinician peer support, (3) poor care coordination, (4) provider stigma, (5) inadequate reimbursement from private and public insurers, and (6) regulatory hurdles to obtain the waiver needed to prescribe buprenorphine in non-addiction specialty treatment settings. Policy pathways to addressing these provider workforce barriers going forward include providing free and easy-to-access education for providers about opioid use disorders and medication-assisted treatment, eliminating buprenorphine waiver requirements for those licensed to prescribe controlled substances, enforcing insurance parity requirements, requiring coverage of evidence-based medication-assisted treatment as essential health benefits, and providing financial incentives for care coordination across healthcare professional types-including behavioral health counselors and other non-physicians in specialty and non-specialty settings. SUPPLEMENT INFORMATION This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.
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Affiliation(s)
- Rebecca L Haffajee
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan.
| | - Amy S B Bohnert
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan; Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, Michigan
| | - Pooja A Lagisetty
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, Michigan; Division of General Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
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Bachhuber MA, Thompson C, Prybylowski A, Benitez J, Mazzella S, Barclay D. Description and outcomes of a buprenorphine maintenance treatment program integrated within Prevention Point Philadelphia, an urban syringe exchange program. Subst Abus 2018; 39:167-172. [DOI: 10.1080/08897077.2018.1443541] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Marcus A. Bachhuber
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Cole Thompson
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ann Prybylowski
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - José Benitez
- Prevention Point Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - David Barclay
- Prevention Point Philadelphia, Philadelphia, Pennsylvania, USA
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Lagisetty P, Klasa K, Bush C, Heisler M, Chopra V, Bohnert A. Primary care models for treating opioid use disorders: What actually works? A systematic review. PLoS One 2017; 12:e0186315. [PMID: 29040331 PMCID: PMC5645096 DOI: 10.1371/journal.pone.0186315] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 09/28/2017] [Indexed: 12/30/2022] Open
Abstract
Background Primary care-based models for Medication-Assisted Treatment (MAT) have been shown to reduce mortality for Opioid Use Disorder (OUD) and have equivalent efficacy to MAT in specialty substance treatment facilities. Objective The objective of this study is to systematically analyze current evidence-based, primary care OUD MAT interventions and identify program structures and processes associated with improved patient outcomes in order to guide future policy and implementation in primary care settings. Data sources PubMed, EMBASE, CINAHL, and PsychInfo. Methods We included randomized controlled or quasi experimental trials and observational studies evaluating OUD treatment in primary care settings treating adult patient populations and assessed structural domains using an established systems engineering framework. Results We included 35 interventions (10 RCTs and 25 quasi-experimental interventions) that all tested MAT, buprenorphine or methadone, in primary care settings across 8 countries. Most included interventions used joint multi-disciplinary (specialty addiction services combined with primary care) and coordinated care by physician and non-physician provider delivery models to provide MAT. Despite large variability in reported patient outcomes, processes, and tasks/tools used, similar key design factors arose among successful programs including integrated clinical teams with support staff who were often advanced practice clinicians (nurses and pharmacists) as clinical care managers, incorporating patient “agreements,” and using home inductions to make treatment more convenient for patients and providers. Conclusions The findings suggest that multidisciplinary and coordinated care delivery models are an effective strategy to implement OUD treatment and increase MAT access in primary care, but research directly comparing specific structures and processes of care models is still needed.
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Affiliation(s)
- Pooja Lagisetty
- Division of General Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, United States of America
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Katarzyna Klasa
- University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Christopher Bush
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Michele Heisler
- Division of General Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, United States of America
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Vineet Chopra
- Division of General Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, United States of America
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
| | - Amy Bohnert
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
- Division of Psychiatry, University of Michigan School of Medicine, Ann Arbor, Michigan, United States of America
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Bhatraju EP, Grossman E, Tofighi B, McNeely J, DiRocco D, Flannery M, Garment A, Goldfeld K, Gourevitch MN, Lee JD. Public sector low threshold office-based buprenorphine treatment: outcomes at year 7. Addict Sci Clin Pract 2017; 12:7. [PMID: 28245872 PMCID: PMC5331716 DOI: 10.1186/s13722-017-0072-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 02/02/2017] [Indexed: 11/28/2022] Open
Abstract
Background Buprenorphine maintenance for opioid dependence remains of limited availability among underserved populations, despite increases in US opioid misuse and overdose deaths. Low threshold primary care treatment models including the use of unobserved, “home,” buprenorphine induction may simplify initiation of care and improve access. Unobserved induction and long-term treatment outcomes have not been reported recently among large, naturalistic cohorts treated in low threshold safety net primary care settings. Methods This prospective clinical registry cohort design estimated rates of induction-related adverse events, treatment retention, and urine opioid results for opioid dependent adults offered buprenorphine maintenance in a New York City public hospital primary care office-based practice from 2006 to 2013. This clinic relied on typical ambulatory care individual provider-patient visits, prescribed unobserved induction exclusively, saw patients no more than weekly, and did not require additional psychosocial treatment. Unobserved induction consisted of an in-person screening and diagnostic visit followed by a 1-week buprenorphine written prescription, with pamphlet, and telephone support. Primary outcomes analyzed were rates of induction-related adverse events (AE), week 1 drop-out, and long-term treatment retention. Factors associated with treatment retention were examined using a Cox proportional hazard model among inductions and all patients. Secondary outcomes included overall clinic retention, buprenorphine dosages, and urine sample results. Results Of the 485 total patients in our registry, 306 were inducted, and 179 were transfers already on buprenorphine. Post-induction (n = 306), week 1 drop-out was 17%. Rates of any induction-related AE were 12%; serious adverse events, 0%; precipitated withdrawal, 3%; prolonged withdrawal, 4%. Treatment retention was a median 38 weeks (range 0–320) for inductions, compared to 110 (0–354) weeks for transfers and 57 for the entire clinic population. Older age, later years of first clinic visit (vs. 2006–2007), and baseline heroin abstinence were associated with increased treatment retention overall. Conclusions Unobserved “home” buprenorphine induction in a public sector primary care setting appeared a feasible and safe clinical practice. Post-induction treatment retention of a median 38 weeks was in line with previous naturalistic studies of real-world office-based opioid treatment. Low threshold treatment protocols, as compared to national guidelines, may compliment recently increased prescriber patient limits and expand access to buprenorphine among public sector opioid use disorder patients.
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Affiliation(s)
- Elenore Patterson Bhatraju
- Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA.,Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, New York, NY, USA
| | - Ellie Grossman
- Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, New York, NY, USA
| | - Babak Tofighi
- Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA.,Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, New York, NY, USA
| | - Jennifer McNeely
- Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA.,Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, New York, NY, USA
| | - Danae DiRocco
- Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA
| | - Mara Flannery
- Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA
| | - Ann Garment
- Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, New York, NY, USA
| | - Keith Goldfeld
- Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA
| | - Marc N Gourevitch
- Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA
| | - Joshua D Lee
- Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, New York, NY, USA. .,Department of Population Health, NYU School of Medicine, 227 East 30th St #712, New York, NY, 10016, USA.
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Evren C, Karabulut V, Can Y, Bozkurt M, Umut G, Evren B. Predictors of Outcome During a 6-Month Follow-Up Among Heroin Dependent Patients Receiving Buprenorphine/Naloxone Maintenance Treatment. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20140310072258] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Cuneyt Evren
- Bakirkoy Training and Research Hospital for Psychiatry Neurology and Neurosurgery, Alcohol and Drug Research, Treatment and Training Center (AMATEM), Istanbul - Turkey
| | - Vahap Karabulut
- Bakirkoy Training and Research Hospital for Psychiatry Neurology and Neurosurgery, Alcohol and Drug Research, Treatment and Training Center (AMATEM), Istanbul - Turkey
| | - Yesim Can
- Bakirkoy Training and Research Hospital for Psychiatry Neurology and Neurosurgery, Alcohol and Drug Research, Treatment and Training Center (AMATEM), Istanbul - Turkey
| | - Muge Bozkurt
- Bakirkoy Training and Research Hospital for Psychiatry Neurology and Neurosurgery, Alcohol and Drug Research, Treatment and Training Center (AMATEM), Istanbul - Turkey
| | - Gokhan Umut
- Bakirkoy Training and Research Hospital for Psychiatry Neurology and Neurosurgery, Alcohol and Drug Research, Treatment and Training Center (AMATEM), Istanbul - Turkey
| | - Bilge Evren
- Baltalimani Training and Research Hospital for Muskuloskeletal Disorders, Department of Psychiatry, Istanbul - Turkey
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Webster L, Hjelmström P, Sumner M, Gunderson EW. Efficacy and safety of a sublingual buprenorphine/naloxone rapidly dissolving tablet for the treatment of adults with opioid dependence: A randomized trial. J Addict Dis 2016; 35:325-338. [DOI: 10.1080/10550887.2016.1195608] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Mobile phone use patterns and preferences in safety net office-based buprenorphine patients. J Addict Med 2016; 9:217-21. [PMID: 25918966 DOI: 10.1097/adm.0000000000000121] [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 Integrating mobile phone technologies in addiction treatment is of increasing importance and may optimize patient engagement with their care and enhance the delivery of existing treatment strategies. Few studies have evaluated mobile phone and text message (TM) use patterns in persons enrolled in addiction treatment, and none have assessed the use in safety net, office-based buprenorphine practices. METHODS A 28-item, quantitative and qualitative semistructured survey was administered to opiate-dependent adults in an urban, publicly funded, office-based buprenorphine program. Survey domains included demographic characteristics, mobile phone and TM use patterns, and preferences pertaining to their recovery. RESULTS Surveyors approached 73 of the 155 eligible subjects (47%); 71 respondents completed the survey. Nearly all participants reported mobile phone ownership (93%) and TM use (93%), and most reported "very much" or "somewhat" comfort sending TM (79%). Text message contact with 12-step group sponsors, friends, family members, and counselors was also described (32%). Nearly all preferred having their providers' mobile phone number (94%), and alerting the clinic via TM in the event of a potential relapse to receive both supportive TM and a phone call from their buprenorphine provider was also well received (62%). CONCLUSIONS Mobile phone and TM use patterns and preferences among this sample of office-based buprenorphine participants highlight the potential of adopting patient-centered mobile phone-based interventions in this treatment setting.
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Abstract
BACKGROUND Unobserved, or "home" buprenorphine induction is common in some clinical practices. Patients take the initial and subsequent doses of buprenorphine after, rather than during, an office visit. This review summarizes the literature on the feasibility and acceptability, safety, effectiveness, and prevalence of unobserved induction. METHODS We searched the English language literature for studies describing unobserved buprenorphine induction and associated outcomes. Clinical studies were assessed by strength of design, bias, and internal and external validity. Surveys of provider practices and unobserved induction adoption were reviewed for prevalence data and key findings. We also examined previous review papers and international buprenorphine treatment guidelines. RESULTS N = 10 clinical studies describing unobserved induction were identified: 1 randomized controlled trial, 3 prospective cohort studies, and 6 retrospective cohort studies. The evidence supports the feasibility of unobserved induction, particularly in office-based primary care practices. Evidence is weak to moderate in support of no differences in adverse event rates between unobserved and observed inductions. There is insufficient or weak evidence in terms of any or no differences in overall effectiveness (treatment retention, medication adherence, illicit opioid abstinence, other drug use). N = 9 provider surveys assessed unobserved induction: observed induction logistics are seen as barriers to buprenorphine prescribing; unobserved induction appears widespread in specific locations. International guidelines reviewed emphasize clinician or pharmacist observed induction (the United States, the United Kingdom, France, Australia); only one (Denmark) explicitly endorses unobserved induction. CONCLUSIONS There is insufficient evidence supporting unobserved induction as more, less, or as effective as observed induction. However, the predominantly observational and naturalistic studies of unobserved induction reviewed, all of which have significant sources of bias and limited external validity, document feasibility and low rates of adverse events. Unobserved induction seems to be widely adopted in US and French regional provider surveys. Prescribers, policy makers, and patients should balance the benefits of observed induction such as maximum clinical supervision with the ease-of-use and comparable safety profile of unobserved induction.
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Transdermal Buprenorphine, Opioid Rotation to Sublingual Buprenorphine, and the Avoidance of Precipitated Withdrawal. Am J Ther 2015; 22:199-205. [DOI: 10.1097/mjt.0b013e31828bfb6e] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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D'Onofrio G, O'Connor PG, Pantalon MV, Chawarski MC, Busch SH, Owens PH, Bernstein SL, Fiellin DA. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA 2015; 313:1636-44. [PMID: 25919527 PMCID: PMC4527523 DOI: 10.1001/jama.2015.3474] [Citation(s) in RCA: 610] [Impact Index Per Article: 67.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Opioid-dependent patients often use the emergency department (ED) for medical care. OBJECTIVE To test the efficacy of 3 interventions for opioid dependence: (1) screening and referral to treatment (referral); (2) screening, brief intervention, and facilitated referral to community-based treatment services (brief intervention); and (3) screening, brief intervention, ED-initiated treatment with buprenorphine/naloxone, and referral to primary care for 10-week follow-up (buprenorphine). DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial involving 329 opioid-dependent patients who were treated at an urban teaching hospital ED from April 7, 2009, through June 25, 2013. INTERVENTIONS After screening, 104 patients were randomized to the referral group, 111 to the brief intervention group, and 114 to the buprenorphine treatment group. MAIN OUTCOMES AND MEASURES Enrollment in and receiving addiction treatment 30 days after randomization was the primary outcome. Self-reported days of illicit opioid use, urine testing for illicit opioids, human immunodeficiency virus (HIV) risk, and use of addiction treatment services were the secondary outcomes. RESULTS Seventy-eight percent of patients in the buprenorphine group (89 of 114 [95% CI, 70%-85%]) vs 37% in the referral group (38 of 102 [95% CI, 28%-47%]) and 45% in the brief intervention group (50 of 111 [95% CI, 36%-54%]) were engaged in addiction treatment on the 30th day after randomization (P < .001). The buprenorphine group reduced the number of days of illicit opioid use per week from 5.4 days (95% CI, 5.1-5.7) to 0.9 days (95% CI, 0.5-1.3) vs a reduction from 5.4 days (95% CI, 5.1-5.7) to 2.3 days (95% CI, 1.7-3.0) in the referral group and from 5.6 days (95% CI, 5.3-5.9) to 2.4 days (95% CI, 1.8-3.0) in the brief intervention group (P < .001 for both time and intervention effects; P = .02 for the interaction effect). The rates of urine samples that tested negative for opioids did not differ statistically across groups, with 53.8% (95% CI, 42%-65%) in the referral group, 42.9% (95% CI, 31%-55%) in the brief intervention group, and 57.6% (95% CI, 47%-68%) in the buprenorphine group (P = .17). There were no statistically significant differences in HIV risk across groups (P = .66). Eleven percent of patients in the buprenorphine group (95% CI, 6%-19%) used inpatient addiction treatment services, whereas 37% in the referral group (95% CI, 27%-48%) and 35% in the brief intervention group (95% CI, 25%-37%) used inpatient addiction treatment services (P < .001). CONCLUSIONS AND RELEVANCE Among opioid-dependent patients, ED-initiated buprenorphine treatment vs brief intervention and referral significantly increased engagement in addiction treatment, reduced self-reported illicit opioid use, and decreased use of inpatient addiction treatment services but did not significantly decrease the rates of urine samples that tested positive for opioids or of HIV risk. These findings require replication in other centers before widespread adoption. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00913770.
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Affiliation(s)
- Gail D'Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Patrick G O'Connor
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael V Pantalon
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Marek C Chawarski
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Susan H Busch
- Yale School of Public Health, New Haven, Connecticut
| | - Patricia H Owens
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David A Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut4Yale School of Public Health, New Haven, Connecticut
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Baxter JD, Clark RE, Samnaliev M, Aweh G, O'Connell E. Adherence to Buprenorphine Treatment Guidelines in a Medicaid Program. Subst Abus 2015; 36:174-82. [DOI: 10.1080/08897077.2014.991469] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Larance B, Carragher N, Mattick RP, Lintzeris N, Ali R, Degenhardt L. A latent class analysis of self-reported clinical indicators of psychosocial stability and adherence among opioid substitution therapy patients: do stable patients receive more unsupervised doses? Drug Alcohol Depend 2014; 142:46-55. [PMID: 25015687 DOI: 10.1016/j.drugalcdep.2014.05.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 05/21/2014] [Accepted: 05/21/2014] [Indexed: 11/15/2022]
Abstract
AIMS To develop a stability typology among opioid substitution therapy patients using a range of adherence indicators derived from clinical guidelines, and determine whether stable patients receive more unsupervised doses. METHODS An interviewer-administered cross-sectional survey was used in opioid substitution therapy programmes in three Australian jurisdictions, totalling 768 patients in their current treatment episode for ≥4 weeks. A structured questionnaire collated data from patients about their demographics, treatment characteristics, past 6-month drug use and medication adherence, psychosocial stability, comorbidity, child welfare concerns and levels of supervised dosing. Latent class analysis (LCA) was used to derive a stability typology. Linear regression models examined predictors of unsupervised dosing in the past month. RESULTS LCA identified two classes: (i) a higher-adherence group (67%) who had low-moderate probabilities of endorsing the opioid substitution therapy stability indicators and (ii) a lower-adherence group (33%) who had moderate-high probabilities of endorsing the stability indicators. There was no association between adherence profile and the number of unsupervised doses. Significant predictors of receiving larger numbers of unsupervised doses included being older, living in New South Wales or South Australia (vs. Victoria), receiving methadone (vs. mono-buprenorphine), being prescribed in private clinic or general practice (vs. public clinic), reporting a longer current treatment episode, not receiving a urine drug screen in the past month, being currently employed and not having a prison history. CONCLUSIONS This study suggested that system-level factors and observable indicators of social functioning were more strongly associated with the receipt of less supervised treatment. Future research should examine this issue using prospectively collected data.
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Affiliation(s)
- Briony Larance
- National Drug and Alcohol Research Centre, UNSW Australia, Randwick Campus, 22-32 King Street, Sydney NSW 2052, Australia.
| | - Natacha Carragher
- National Drug and Alcohol Research Centre, UNSW Australia, Randwick Campus, 22-32 King Street, Sydney NSW 2052, Australia
| | - Richard P Mattick
- National Drug and Alcohol Research Centre, UNSW Australia, Randwick Campus, 22-32 King Street, Sydney NSW 2052, Australia
| | - Nicholas Lintzeris
- The Langton Centre, South Eastern Sydney Local Health District (SESLHD), 591 South Dowling Street, Surry Hills NSW 2010, Australia; Discipline of Addiction Medicine, The University of Sydney, Drug Health Services, Royal Prince Alfred Hospital, Level 6 KGV Building, 83-117 Missenden Road, Camperdown, Sydney NSW 2050, Australia
| | - Robert Ali
- Discipline of Pharmacology, The University of Adelaide, Medical School South Building, Frome Road, Adelaide SA 5005, Australia; Drug and Alcohol Services South Australia, 161 Greenhill Road, Parkside SA 5063, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Australia, Randwick Campus, 22-32 King Street, Sydney NSW 2052, Australia; School of Population and Global Health, University of Melbourne, Australia; Murdoch Children's Research Institute, Australia; Department of Global Health, School of Public Health, University of Washington, USA
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Li X, Shorter D, Kosten TR. Buprenorphine in the treatment of opioid addiction: opportunities, challenges and strategies. Expert Opin Pharmacother 2014; 15:2263-75. [PMID: 25171726 DOI: 10.1517/14656566.2014.955469] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Buprenorphine follows the success of methadone as another milestone in the history of treatment for opioid addiction. Buprenorphine can be used in an office-based setting where it is clearly effective, highly accepted by patients and has a favorable safety profile and less abuse potential. However, the adoption of buprenorphine treatment has been slow in the USA. AREAS COVERED This article first reviews the history of medication-assisted opioid addiction treatment and the current epidemic opioid addiction, followed by a review of the efficacy, pharmacology and clinical prescription of buprenorphine in office-based care. We then explore the possible barriers in using buprenorphine and the ways to overcome these barriers, including new formulations, educational programs and policy regulations that strike a balance between accessibility and reducing diversion. EXPERT OPINION Buprenorphine can align addiction treatment with treatments for other chronic medical illnesses. However, preventing diversion will require graduate and continuing medical education and integrated care models for delivery of buprenorphine to those in need.
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Affiliation(s)
- Xiaofan Li
- Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences , One Baylor Plaza, Houston, TX 77030 , USA
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Mauger S, Fraser R, Gill K. Utilizing buprenorphine-naloxone to treat illicit and prescription-opioid dependence. Neuropsychiatr Dis Treat 2014; 10:587-98. [PMID: 24741316 PMCID: PMC3984058 DOI: 10.2147/ndt.s39692] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To review current evidence on buprenorphine-naloxone (bup/nx) for the treatment of opioid-use disorders, with a focus on strategies for clinical management and office-based patient care. QUALITY OF EVIDENCE Medline and the Cochrane Database of Systematic Reviews were searched. Consensus reports, guidelines published, and other authoritative sources were also included in this review. Apart from expert guidelines, data included in this review constitute level 1 evidence. FINDINGS Bup/nx is a partial μ-opioid agonist combined with the opioid antagonist naloxone in a 4:1 ratio. It has a lower abuse potential, carries less stigma, and allows for more flexibility than methadone. Bup/nx is indicated for both inpatient and ambulatory medically assisted withdrawal (acute detoxification) and long-term substitution treatment (maintenance) of patients who have a mild-to-moderate physical dependence. A stepwise long-term substitution treatment with regular monitoring and follow-up assessment is usually preferred, as it has better outcomes in reducing illicit opioid use, minimizing concomitant risks such as human immunodeficiency virus and hepatitis C transmission, retaining patients in treatment and improving global functioning. CONCLUSION Bup/nx is safe and effective for opioid detoxification and substitution treatment. Its unique pharmaceutical properties make it particularly suitable for office-based maintenance treatment of opioid-use disorder.
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Affiliation(s)
- Sofie Mauger
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Ronald Fraser
- Department of Psychiatry, McGill University, Montreal, QC, Canada ; Addictions Unit, McGill University Health Centre, Montreal, QC, Canada
| | - Kathryn Gill
- Department of Psychiatry, McGill University, Montreal, QC, Canada ; Addictions Unit, McGill University Health Centre, Montreal, QC, Canada
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Jenkinson J, Ravert P. Underutilization of Primary Care Providers in Treating Opiate Addiction. J Nurse Pract 2013. [DOI: 10.1016/j.nurpra.2013.05.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Haddad MS, Zelenev A, Altice FL. Integrating buprenorphine maintenance therapy into federally qualified health centers: real-world substance abuse treatment outcomes. Drug Alcohol Depend 2013; 131:127-35. [PMID: 23332439 PMCID: PMC3674170 DOI: 10.1016/j.drugalcdep.2012.12.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 12/09/2012] [Accepted: 12/10/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Few studies have examined real-world effectiveness of integrated buprenorphine maintenance treatment (BMT) programs in federally qualified health centers (FQHCs). METHODS Opioid dependent patients (N=266) inducted on buprenorphine between July 2007 and December 2008 were retrospectively assessed at Connecticut's largest FQHC network. Six-month BMT retention and opioid-free time were collected longitudinally from electronic health records; 136 (51.1%) of patients were followed for at least 12 months. RESULTS Participants had a mean age of 40.1 years, were primarily male (69.2%) and treated by family practitioners (70.3%). Co-morbidity included HCV infection (59.8%), mood disorders (71.8%) and concomitant cocaine use (59%). Retention on BMT was 56.8% at 6 months and 61.6% at 12 months for the subset observed over 1 year. Not being retained on BMT at 12 months was associated with cocaine use (AOR=2.18; 95% CI=1.35-3.50) while prescription of psychiatric medication (AOR=0.36; 95% CI 0.20-0.62) and receiving on-site substance abuse counseling (AOR=0.34; 95% CI 0.19, 0.59) improved retention. Two thirds of the participants experienced at least one BMT gap of 2 or more weeks with a mean gap length of 116.4 days. CONCLUSIONS Integrating BMT in this large FQHC network resulted in retention rates similarly reported in clinical trials and emphasizes the need for providing substance abuse counseling and screening for and treating psychiatric comorbidity.
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Affiliation(s)
| | | | - Frederick L. Altice
- Yale University School of Medicine, New Haven, CT, USA,Yale University School of Public Health, New Haven, CT, USA
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Uosukainen H, Pentikäinen H, Tacke U. The effect of an electronic medicine dispenser on diversion of buprenorphine-naloxone-experience from a medium-sized Finnish city. J Subst Abuse Treat 2013; 45:143-7. [PMID: 23433750 DOI: 10.1016/j.jsat.2013.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 01/10/2013] [Accepted: 01/18/2013] [Indexed: 10/27/2022]
Abstract
Providing unobserved opioid substitution treatment (OST) safely is a major challenge. This study examined whether electronic medicine dispensers (EMDs) can reduce diversion of take-home buprenorphine-naloxone (BNX) in a medium-sized Finnish city. All BNX treated OST patients in Kuopio received their take-home BNX in EMDs for 4months. EMDs' effect on diversion was investigated using questionnaires completed by patients (n=37) and treatment staff (n=19), by survey at the local needle exchange service and by systematic review of drug screen data from the Kuopio University Hospital. The majority of patients (n=21, 68%) and treatment staff (n=11, 58%) preferred to use EMDs for the safe storage of tablets. Five patients (16%) declared that EMDs had prevented them from diverting BNX. However, EMDs had no detectable effect on the availability or origin of illegal BNX or on the hospital-treated buprenorphine-related health problems. EMDs may improve the safety of storage of take-home BNX, but their ability to prevent diversion needs further research.
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Affiliation(s)
- Hanna Uosukainen
- University of Eastern Finland, Kuopio Campus, School of Pharmacy, Faculty of Health Sciences, P.O. Box 1627, FI-70211 Kuopio, Finland.
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Gunderson EW, Levin FR, Rombone MM, Vosburg SK, Kleber HD. Improving temporal efficiency of outpatient buprenorphine induction. Am J Addict 2011; 20:397-404. [PMID: 21838837 PMCID: PMC3156625 DOI: 10.1111/j.1521-0391.2011.00153.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Buprenorphine induction poses a barrier for physician adoption of office-based opioid dependence treatment. We conducted a retrospective chart review of the first 41 patients inducted at a newly established outpatient treatment program to examine the induction process and determine strategies associated with greater induction efficiency. Timed withdrawal scales, medication log, and notes enabled reconstruction of the initial day of buprenorphine treatment. To assess change with experience, consecutive patients were divided into three chronological groups for analyses (Phases 1-3). The time required for induction was substantial in Phase 1 (mean 5.5 hours), but temporal efficiency improved to a mean 1.5 hours spent at the program by Phase 3 (p < .001). Phase 2-3 patients arrived to the program after significantly longer opioid abstinence and were in greater withdrawal, with mean Clinical Opioid Withdrawal Scale scores of 6, 10, and 10 for Phases 1-3, respectively (p < .01). Patients in the later phases had less time delay to medication initiation, 5 minutes in Phase 3 compared to 133 minutes in Phase 1 (p < .001). The mean 7-mg buprenorphine dose administered in the office did not differ between groups, but occurred over a smaller time interval for later phases indicating more rapid titration. Patients in the later phases had more rapid withdrawal relief after buprenorphine initiation and were more likely to have used preinduction ancillary withdrawal medication. The study sheds light on the induction barrier and provides practical procedural information to inform clinical guidelines and hopefully mitigate procedural aspects of the induction barrier.
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Affiliation(s)
- Erik W Gunderson
- Department of Psychiatry and Neurobehavioral Sciences and Department of Medicine, University of Virginia, Charlottesville, VA 22908, USA.
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Fishman MJ, Wu LT, Woody GE. Buprenorphine for prescription opioid addiction in a patient with depression and alcohol dependence. Am J Psychiatry 2011; 168:675-9. [PMID: 21724673 PMCID: PMC3178807 DOI: 10.1176/appi.ajp.2010.10060879] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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