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Dunn KE, Strain EC. Establishing a research agenda for the study and assessment of opioid withdrawal. Lancet Psychiatry 2024; 11:566-572. [PMID: 38521089 DOI: 10.1016/s2215-0366(24)00068-3] [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] [Received: 01/03/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/25/2024]
Abstract
The opioid crisis is an international public health concern. Treatments for opioid use disorder centre largely on the management of opioid withdrawal, an aversive collection of signs and symptoms that contribute to opioid use disorder. Whereas in the past 50 years more than 90 medications have been developed for depression, only five medications have been developed for opioid use disorder during this period. We posit that underinvestment has occurred in part due to an underdeveloped understanding of opioid withdrawal syndrome. This Personal View summarises substantial gaps in our understanding of opioid withdrawal that are likely to continue to limit major advancements in its treatment. There is no firm consensus in the field as to how withdrawal should be precisely defined; 10-550 symptoms of withdrawal can be measured on 18 scales. The imprecise understanding of withdrawal is likely to result in overestimating or underestimating the severity of an individual's withdrawal syndrome or potential therapeutic effects of different candidate medications. The severity of the opioid crisis is not remitting, and an international research agenda for the study and assessment of opioid withdrawal is necessary to support transformational changes in withdrawal management and treatment of opioid use disorder. Nine actionable targets are delineated here: develop a consensus definition of opioid withdrawal; understand withdrawal symptomatology after exposure to different opioids (particularly fentanyl); understand precipitated opioid withdrawal; understand how co-exposure of other drugs (eg, xylazine and stimulants) influences withdrawal expression; examine individual variation in withdrawal phenotypes; precisely characterise the protracted withdrawal syndrome; identify biomarkers of opioid withdrawal severity; identify predictors of opioid withdrawal severity; and understand which symptoms are most closely associated with treatment attrition or relapse. The US Food and Drug Administration recently established a formal indication for opioid withdrawal that has invigorated interest in drug development for opioid withdrawal management. Action is now needed to support these interests and help industry identify new classes of medications so that real change can be achieved for people with opioid use disorder.
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Affiliation(s)
- Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hall OT, Vilensky M, Teater JE, Bryan C, Rood K, Niedermier J, Entrup P, Gorka S, King A, Williams DA, Phan KL. Withdrawal catastrophizing scale: initial psychometric properties and implications for the study of opioid use disorder and hyperkatifeia. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2024:1-13. [PMID: 38502911 DOI: 10.1080/00952990.2023.2298257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 12/19/2023] [Indexed: 03/21/2024]
Abstract
Background: Discovery of modifiable factors influencing subjective withdrawal experience might advance opioid use disorder (OUD) research and precision treatment. This study explores one factor - withdrawal catastrophizing - a negative cognitive and emotional orientation toward withdrawal characterized by excessive fear, worry or inability to divert attention from withdrawal symptoms.Objectives: We define a novel concept - withdrawal catastrophizing - and present an initial evaluation of the Withdrawal Catastrophizing Scale (WCS).Methods: Prospective observational study (n = 122, 48.7% women). Factor structure (exploratory factor analysis) and internal consistency (Cronbach's α) were assessed. Predictive validity was tested via correlation between WCS and next-day subjective opiate withdrawal scale (SOWS) severity. The clinical salience of WCS was evaluated by correlation between WCS and withdrawal-motivated behaviors including risk taking, OUD maintenance, OUD treatment delay, history of leaving the hospital against medical advice and buprenorphine-precipitated withdrawal.Results: WCS was found to have a two-factor structure (distortion and despair), strong internal consistency (α = .901), and predictive validity - Greater withdrawal catastrophizing was associated with next-day SOWS (rs (99) = 0.237, p = .017). Withdrawal catastrophizing was also correlated with risk-taking behavior to relieve withdrawal (rs (119) = 0.357, p < .001); withdrawal-motivated OUD treatment avoidance (rs (119) = 0.421, p < .001), history of leaving the hospital against medical advice (rs (119) = 0.373, p < .001) and buprenorphine-precipitated withdrawal (rs (119) = 0.369, p < .001).Conclusion: This study provides first evidence of withdrawal catastrophizing as a clinically important phenomenon with implications for the future study and treatment of OUD.
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Affiliation(s)
- Orman Trent Hall
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Michael Vilensky
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Julie E Teater
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Craig Bryan
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kara Rood
- Department of Obstetrics and Gynecology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Julie Niedermier
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Parker Entrup
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Stephanie Gorka
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anthony King
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - David A Williams
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - K Luan Phan
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, USA
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Goyal P, Kattula D, Rao R, Bhad R, Mishra AK, Dhawan A. Trazodone for sleep disturbance in opioid dependent patients maintained on buprenorphine: A double blind, placebo-controlled trial. Drug Alcohol Depend 2023; 250:110891. [PMID: 37478501 DOI: 10.1016/j.drugalcdep.2023.110891] [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: 06/29/2022] [Revised: 07/01/2023] [Accepted: 07/04/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Sleep disturbances are seen even in individuals on opioid agonist treatment (OAT). Established pharmacotherapy for sleep disturbances such as benzodiazepines have misuse potential and increased mortality risk in patients with OAT. No study has explored the role of trazodone on sleep disturbance in individuals maintained on buprenorphine. We aimed to assess the efficacy of trazodone in improving sleep disturbance among individuals maintained on buprenorphine. METHODS The study was a double-blind, placebo-controlled, parallel, randomised trial. Adult males (18-60 years) stabilised on buprenorphine with Pittsburgh Sleep Quality Index (PSQI) score of above five, without other psychiatric comorbidity were randomised to receive either trazodone (50-150mg per day) or placebo. Sleep-50 questionnaire, Epworth Sleepiness Scale (ESS), Brief Pain Inventory (BPI), Clinical Opiate Withdrawal Scale (COWS), Depression, Anxiety and Stress Scale (DASS)-21, Visual Analogue Scale (VAS) for opioid craving, and PSQI were assessed at baseline and at the end of six weeks. RESULTS Fifty-one patients were allocated to trazodone arm and 49 to placebo arm. Side-effects of trazodone were minimal and well-tolerated with comparable discontiuation rates between both groups. Significantly greater proportion of patients on trazodone (82%, mean dose 101.9 mg) had PSQI scores five or less than those on placebo (16%) at the end of six weeks. Sleep improvement was in various components like sleep quality, latency, efficiency, and duration of sleep. CONCLUSION Trazodone is well-tolerated and effective in improving sleep disturbances in individuals with opioid dependence maintained on buprenorphine over a six-week period.
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Affiliation(s)
- Piyush Goyal
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Dheeraj Kattula
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra Rao
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India.
| | - Roshan Bhad
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Ashwani Kumar Mishra
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Anju Dhawan
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
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Dunn KE, Finan PH, Huhn AS, Gamaldo C, Bergeria CL, Strain EC. Wireless electroencephalography (EEG) to monitor sleep among patients being withdrawn from opioids: Evidence of feasibility and utility. Exp Clin Psychopharmacol 2022; 30:1016-1023. [PMID: 34096756 PMCID: PMC8648854 DOI: 10.1037/pha0000483] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Sleep impairment is a common comorbid and debilitating symptom for persons with opioid use disorder (OUD). Research into underlying mechanisms and efficacious treatment interventions for OUD-related sleep problems requires both precise and physiologic measurements of sleep-related outcomes and impairment. This pilot examined the feasibility of a wireless sleep electroencephalography (EEG) monitor (Sleep Profiler™) to measure sleep outcomes and architecture among participants undergoing supervised opioid withdrawal. Sleep outcomes were compared to a self-reported sleep diary and opioid withdrawal ratings. Participants (n = 8, 100% male) wore the wireless EEG 85.6% of scheduled nights. Wireless EEG detected measures of sleep architecture including changes in total, NREM and REM sleep time during study phases, whereas the diary detected changes in wakefulness only. Direct comparisons of five overlapping outcomes revealed lower sleep efficiency and sleep onset latency and higher awakenings and time spent awake from the wireless EEG versus sleep diary. Associations were evident between wireless EEG and increased withdrawal severity, lower sleep efficiency, less time in REM and non-REM stages 1 and 2, and more hydroxyzine treatment; sleep diary was associated with total sleep time and withdrawal only. Data provide initial evidence that a wireless EEG is a feasible and useful tool for objective monitoring of sleep in persons experiencing acute opioid withdrawal. Data are limited by the small and exclusively male sample, but provide a foundation for using wireless EEG sleep monitors for objective evaluation of sleep-related impairment in persons with OUD in support of mechanistic and treatment intervention research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
- Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Patrick H Finan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Charlene Gamaldo
- Department of Neurology, Johns Hopkins University School of Medicine
| | - Cecilia L Bergeria
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
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Patient experiences of prescription drug monitoring programs: a qualitative analysis from an Australian pharmaceutical helpline. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 109:103847. [PMID: 36067724 DOI: 10.1016/j.drugpo.2022.103847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Prescription Drug Monitoring Programs (PDMP) are electronic databases that are used to track and monitor the prescribing and dispensing of controlled substances, such as opioid analgesics and benzodiazepines. PDMP have been used widely throughout North America and have recently been implemented in Australia. Several unintended harms have been associated with PDMP in North America, including increased stigma, discrimination, and dismissal from care for patients prescribed these medications. AIMS This study aimed to better understand how people who use prescription medications extramedically and their loved ones give meaning to their consumption and their treatment experiences and concerns in the context of a newly implemented real-time PDMP in Victoria, Australia. METHOD Nineteen audio recordings of telephone calls made to the PDMP Pharmaceutical Helpline were transcribed and thematically analysed. RESULTS Patients and their families were hopeful that PDMP would stop the extra medical use of medications. However, many were deeply concerned about how they would cope with withdrawal or life stressors without the support these medications afforded. Patients reported experiences of stigma and strained therapeutic relationships associated with PDMP implementation. CONCLUSION PDMP have the potential to both assist and harm patients whose prescription medication use has been identified as 'risky' by the PDMP. The findings from this study suggest that clear and open communication, as well as reflection on unconscious bias and stigma may assist healthcare providers to facilitate better patient experiences and outcomes in the context of prescription medication dependence.
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Huhn AS, Ellis JD, Dunn KE, Sholler DJ, Tabaschek P, Burns R, Strain EC. Patient-reported sleep outcomes in randomized-controlled trials in persons with substance use disorders: A systematic review. Drug Alcohol Depend 2022; 237:109508. [PMID: 35660223 DOI: 10.1016/j.drugalcdep.2022.109508] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Sleep disturbances and disorders are a common and sometimes recalcitrant problem in persons recovering from substance use disorders (SUDs). As such, several randomized-controlled trials (RCTs) have been conducted to address sleep disturbances in a variety of SUD subpopulations and clinical scenarios. The goal of this systematic review was to collate patient-reported sleep outcomes used in past SUD-related RCTs to provide guidance for future sleep research in persons with SUDs. METHODS This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on May 7th, 2020 (CRD42020182004). Studies were included if they were peer-reviewed manuscripts describing RCTs in an SUD population. RESULTS The initial search yielded 13,403 candidate articles, and 76 met a priori criteria and were included in this review. Thirty-five (46.1%) assessed sleep as a primary outcome (i.e., sleep improvement was the primary goal of the research) and 41 (53.9%) assessed sleep as a secondary outcome (i.e., sleep improvement was an important outcome, but not the primary outcome). The most commonly used measures included the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, and sleep diaries. However, multiple additional sleep assessments were also used, including visual analogue and Likert scales. CONCLUSIONS The field of addiction medicine would benefit from a streamlined approach in assessing patient-reported sleep in RCTs, including commonly used and validated assessments of sleep quality, inserting daily or repeated measures into RCTs, and including questionnaires that assess clinically relevant insomnia or other sleep disorders.
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Affiliation(s)
- Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA.
| | - Jennifer D Ellis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
| | - Dennis J Sholler
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
| | - Paula Tabaschek
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
| | - Rachel Burns
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
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Rodríguez-Espinosa S, Coloma-Carmona A, Pérez-Carbonell A, Román-Quiles JF, Carballo JL. Clinical and psychological factors associated with interdose opioid withdrawal in chronic pain population. J Subst Abuse Treat 2021; 129:108386. [PMID: 34080554 DOI: 10.1016/j.jsat.2021.108386] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The DSM-5 diagnostic criteria for Prescription Opioid-Use Disorder (POUD) have undergone some significant changes. One of the most controversial changes has been the elimination of the withdrawal symptoms criterion when opioid use is under appropriate medical supervision. For this reason, the goal of this study was to analyze factors associated with opioid withdrawal in patients with chronic non-cancer pain (CNCP). METHODS This cross-sectional descriptive study involved 404 patients who use prescription opioids for long-term treatment (≥90 days) of CNCP. Measures included sociodemographic and clinical characteristics, POUD, withdrawal symptoms, craving, anxiety-depressive symptoms, and pain intensity and interference. RESULTS Forty-seven percent (n = 193) of the sample reported moderate-severe withdrawal symptoms, which were associated with lower age, higher daily morphine dose and duration of treatment with opioids, moderate-severe POUD, use of psychotropic drugs, higher anxiety-depressive symptoms, and greater pain intensity and interference (p < .05). Binary logistic regression analysis showed that moderate-severe POUD (OR = 2.82), anxiety (OR = 2.21), depression (OR = 1.81), higher pain interference (OR = 1.05), and longer duration of treatment with opioids were the strongest factors associated with moderate-severe withdrawal symptoms (p < .05). CONCLUSION Psychological factors seem to play a key role in the severity of withdrawal symptoms. Since greater intensity of these symptoms increases the risk of developing POUD, knowing the factors associated with withdrawal may be useful in developing preventive psychological interventions.
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Affiliation(s)
- Sara Rodríguez-Espinosa
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, 03202 Elche, Spain
| | - Ainhoa Coloma-Carmona
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, 03202 Elche, Spain
| | - Ana Pérez-Carbonell
- University General Hospital of Elche, Camino de la Almazara, 11, 03203 Elche, Spain
| | - José F Román-Quiles
- University General Hospital of Elche, Camino de la Almazara, 11, 03203 Elche, Spain
| | - José L Carballo
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, 03202 Elche, Spain.
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Uddin O, Jenne C, Fox ME, Arakawa K, Keller A, Cramer N. Divergent profiles of fentanyl withdrawal and associated pain in mice and rats. Pharmacol Biochem Behav 2020; 200:173077. [PMID: 33316293 DOI: 10.1016/j.pbb.2020.173077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 11/25/2022]
Abstract
Opioid abuse has devastating effects on patients, their families, and society. Withdrawal symptoms are severely unpleasant, prolonged, and frequently hinder recovery or lead to relapse. The sharp increase in abuse and overdoses arising from the illicit use of potent and rapidly-acting synthetic opioids, such as fentanyl, highlights the urgency of understanding the withdrawal mechanisms related to these drugs. Progress is impeded by inconsistent reports on opioid withdrawal in different preclinical models. Here, using rats and mice of both sexes, we quantified withdrawal behaviors during spontaneous and naloxone-precipitated withdrawal, following two weeks of intermittent fentanyl exposure. We found that both mice and rats lost weight during exposure and showed increased signs of distress during spontaneous and naloxone precipitated withdrawal. However, these species differed in their expression of withdrawal associated pain, a key contributor to relapse in humans. Spontaneous or ongoing pain was preferentially expressed in rats in both withdrawal conditions, while no change was observed in mice. In contrast, withdrawal associated thermal hyperalgesia was found only in mice. These data suggest that rats and mice diverge in how they experience withdrawal and which aspects of the human condition they most accurately model. These differences highlight each species' strengths as model systems and can inform experimental design in studies of opioid withdrawal.
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Affiliation(s)
- Olivia Uddin
- Department of Anatomy and Neurobiology, Program in Neuroscience, University of Maryland School of Medicine, 20 Penn Street, Baltimore, MD 21201, United States of America
| | - Carleigh Jenne
- Department of Anatomy and Neurobiology, Program in Neuroscience, University of Maryland School of Medicine, 20 Penn Street, Baltimore, MD 21201, United States of America
| | - Megan E Fox
- Department of Anatomy and Neurobiology, Program in Neuroscience, University of Maryland School of Medicine, 20 Penn Street, Baltimore, MD 21201, United States of America
| | - Keiko Arakawa
- Department of Anatomy and Neurobiology, Program in Neuroscience, University of Maryland School of Medicine, 20 Penn Street, Baltimore, MD 21201, United States of America
| | - Asaf Keller
- Department of Anatomy and Neurobiology, Program in Neuroscience, University of Maryland School of Medicine, 20 Penn Street, Baltimore, MD 21201, United States of America
| | - Nathan Cramer
- Department of Anatomy and Neurobiology, Program in Neuroscience, University of Maryland School of Medicine, 20 Penn Street, Baltimore, MD 21201, United States of America.
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Young JR, Smani SA, Mischel NA, Kritzer MD, Appelbaum LG, Patkar AA. Non-invasive brain stimulation modalities for the treatment and prevention of opioid use disorder: a systematic review of the literature. J Addict Dis 2020; 38:186-199. [PMID: 32469286 DOI: 10.1080/10550887.2020.1736756] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The U.S. is currently facing an unprecedented epidemic of opioid-related deaths. Despite the efficacy of the current treatments for opioid use disorder (OUD), including psychosocial interventions and medication-assisted therapy (MAT), many patients remain treatment-resistant and at high risk for overdose. A potential augmentation strategy includes the use of non-invasive brain stimulation (NIBS) techniques, such as transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and auricular vagus nerve stimulation (aVNS). These approaches may have therapeutic benefits by directly or indirectly modulating the neurocircuitry affected in OUD. In this review, we evaluate the available studies on NIBS in the context of OUD withdrawal and detoxification, maintenance, and cravings, while also considering analgesia and safety concerns. In the context of opioid withdrawal and detoxification, a percutaneous form of aVNS has positive results in open-label trials, but has not yet been tested against sham. No randomized studies have reported on the safety and efficacy of NIBS specifically for maintenance treatment in OUD. TMS and tDCS have demonstrated effects on cravings, although published studies were limited by small sample sizes. NIBS may play a role in reducing exposure to opioids and the risk of developing OUD, as demonstrated by studies using tDCS in an experimental pain condition and TMS in a post-operative setting. Overall, while the preliminary evidence and safety for NIBS in the prevention and treatment of OUD appears promising, further research is needed with larger sample sizes, placebo control, and objective biomarkers as outcome measures before strong conclusions can be drawn.
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Affiliation(s)
- Jonathan R Young
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Shayan A Smani
- Trinity College of Arts and Sciences, Duke University, Durham, NC, USA
| | - Nicholas A Mischel
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Michael D Kritzer
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lawrence G Appelbaum
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Ashwin A Patkar
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
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Dunn KE, Huhn AS, Bergeria CL, Gipson CD, Weerts EM. Non-Opioid Neurotransmitter Systems that Contribute to the Opioid Withdrawal Syndrome: A Review of Preclinical and Human Evidence. J Pharmacol Exp Ther 2019; 371:422-452. [PMID: 31391211 DOI: 10.1124/jpet.119.258004] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/30/2019] [Indexed: 01/15/2023] Open
Abstract
Opioid misuse and abuse is a major international public health issue. Opioid use disorder (OUD) is largely maintained by a desire to suppress aversive opioid withdrawal symptoms. Opioid withdrawal in patients seeking abstinence from illicit or prescribed opioids is often managed by provision of a μ-opioid agonist/partial agonist in combination with concomitant medications. Concomitant medications are administered based on their ability to treat specific symptoms rather than a mechanistic understanding of the opioid withdrawal syndrome; however, their use has not been statistically associated with improved treatment outcomes. Understanding the central and/or peripheral mechanisms that underlie individual withdrawal symptom expression in humans will help promote medication development for opioid withdrawal management. To support focused examination of mechanistically supported concomitant medications, this review summarizes evidence from preclinical (N = 68) and human (N = 30) studies that administered drugs acting on the dopamine, serotonin, cannabinoid, orexin/hypocretin, and glutamate systems and reported outcomes related to opioid withdrawal. These studies provide evidence that each of these systems contribute to opioid withdrawal severity. The Food and Drug Administration has approved medications acting on these respective systems for other indications and research in this area could support the repurposing of these medications to enhance opioid withdrawal treatment. These data support a focused examination of mechanistically informed concomitant medications to help reduce opioid withdrawal severity and enhance the continuum of care available for persons with OUD.
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Affiliation(s)
- Kelly E Dunn
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, Baltimore, Maryland (K.D.E., A.S.H., C.L.B., E.M.W.); and Arizona State University, Tempe, Arizona (C.D.G.)
| | - Andrew S Huhn
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, Baltimore, Maryland (K.D.E., A.S.H., C.L.B., E.M.W.); and Arizona State University, Tempe, Arizona (C.D.G.)
| | - Cecilia L Bergeria
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, Baltimore, Maryland (K.D.E., A.S.H., C.L.B., E.M.W.); and Arizona State University, Tempe, Arizona (C.D.G.)
| | - Cassandra D Gipson
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, Baltimore, Maryland (K.D.E., A.S.H., C.L.B., E.M.W.); and Arizona State University, Tempe, Arizona (C.D.G.)
| | - Elise M Weerts
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, Baltimore, Maryland (K.D.E., A.S.H., C.L.B., E.M.W.); and Arizona State University, Tempe, Arizona (C.D.G.)
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Abstract
Opioid use disorder (OUD) is a disorder that can lead to several negative outcomes, including overdose and death. A variety of opioids can be abused by individuals including both prescribed and non-prescribed opioids. Continued opioid use can be driven by negative affective states associated with opioid withdrawal. Several treatments exist in the field including medication assisted treatments such as methadone, buprenorphine, and naltrexone. Treatments such as clonidine and lofexidine can also be used to assist with decreasing withdrawal symptoms. Increasing adherence to treatment can further improve patient outcomes and promote continuation with treatment. A variety of methods to reduce relapse can also be utilized such as opioid agonists and maintenance therapy. According to the Centers for Disease Control, opioid overdoses contributed to 67.8% of overdose deaths in 2017.
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Ziaaddini H, Heshmati S, Chegeni M, Mousavi-Ramezanzade M, Mazhari S. Comparison of Buprenorphine and Buprenorphine/naloxone in Detoxification of Opioid-dependent Men. ADDICTION & HEALTH 2019; 10:269-275. [PMID: 31263526 PMCID: PMC6593171 DOI: 10.22122/ahj.v10i4.679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background Buprenorphine sublingual tablets are now available in Iran for opioid detoxification in clinics. Aim of the present study was to compare the efficiency of buprenorphine with buprenorphine/naloxone in short-term detoxification in a group of Iranian male opioid-dependent patients. Methods A double-blind trial was carried out on a group of male opioid dependent patients in a psychiatric hospital in Kerman, Iran, during year 2017. A group of 100 men who met the diagnostic criteria for opiate dependence were included in the study from individuals who had referred for detoxification. They were allocated to the two groups receiving either buprenorphine (n = 51) or buprenorphine/naloxone (n = 49). Severity of withdrawal symptoms and signs were evaluated by Clinical Opiate Withdrawal Scale (COWS) and Adjective Rating Scale for Withdrawal (ARSW). Findings The mean scores of COWS and ARSW in the two groups treated with buprenorphine and buprenorphine/naloxone significantly reduced from the first day to the fifth day of detoxification (P < 0.050). Moreover, there was no significant difference between the two groups in terms of objective and subjective symptom reduction (P > 0.050). Conclusion Buprenorphine/naloxone is as effective as buprenorphine in controlling opiate withdrawal symptoms.
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Affiliation(s)
- Hassan Ziaaddini
- Professor, Neuroscience Research Center, Neuropharmacology Institute AND Department of Psychiatry, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Shima Heshmati
- Psychiatrist, Neuroscience Research Center, Neuropharmacology Institute AND Department of Psychiatry, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Maryam Chegeni
- PhD Student, HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Mahboobeh Mousavi-Ramezanzade
- Department of Biostatistics and Epidemiology, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Shahrzad Mazhari
- Associate Professor, Neuroscience Research Center, Neuropharmacology Institute AND Department of Psychiatry, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
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Stein MD, Conti MT, Herman DS, Anderson BJ, Bailey GL, Noppen DV, Abrantes AM. Worries About Discontinuing Buprenorphine Treatment: Scale Development and Clinical Correlates. Am J Addict 2019; 28:270-276. [PMID: 30993833 DOI: 10.1111/ajad.12884] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/06/2019] [Accepted: 03/09/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the benefits of maintenance buprenorphine treatment for opioid use disorder (OUD), many individuals report an interest in discontinuing the medication, while also expressing worries about tapering. The purpose of this study was to develop a measure of worries about buprenorphine discontinuation ("Off Bupe") and determine the demographic and clinical characteristics associated with these worries. METHODS Between May 2017 and May 2018, we surveyed adults in an outpatient primary care buprenorphine program (n = 138). Reliability and validity of the Off Bupe measure were examined. RESULTS Participants averaged 39 years of age, 54% were male, average duration of buprenorphine was 189 weeks and 85.5% reported eventually wanting to discontinue buprenorphine, although fewer than 10% were actively tapering. We derived two scales, withdrawal symptom worry (10 items, ɑ = 0.94) and relapse worry (7 items, ɑ = 0.88). Worry about symptoms was positively associated with current buprenorphine dose (P = 0.016), physical discomfort avoidance (P < 0.001), and inversely associated with self-efficacy to quit buprenorphine (P < 0.001) and distress tolerance (P < 0.001). Worry about opioid relapse was associated positively with age (P = 0.019), current buprenorphine dose (P = 0.004), physical discomfort avoidance (P < 0.001), and impulsivity (P = 0.002), and inversely associated with self-efficacy to quit buprenorphine (P < 0.001). DISCUSSION AND CONCLUSIONS Psychometric evaluation of the "Off Bupe" scale demonstrated its content and construct validity and internal reliability. SCIENTIFIC SIGNIFICANCE The scale might help individuals with OUD and their providers identify concerns about discontinuing buprenorphine. (Am J Addict 2019;28:270-276).
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Affiliation(s)
- Michael D Stein
- Department of Behavioral Medicine and Addictions Resaerch, Butler Hospital, Providence, Rhode Island.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Micah T Conti
- Department of Behavioral Medicine and Addictions Resaerch, Butler Hospital, Providence, Rhode Island
| | - Debra S Herman
- Department of Behavioral Medicine and Addictions Resaerch, Butler Hospital, Providence, Rhode Island.,Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Bradley J Anderson
- Department of Behavioral Medicine and Addictions Resaerch, Butler Hospital, Providence, Rhode Island
| | - Genie L Bailey
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Stanley Street Treatment and Resources, Inc, Fall River, Massachusetts
| | - Donnell Van Noppen
- Department of Behavioral Medicine and Addictions Resaerch, Butler Hospital, Providence, Rhode Island
| | - Ana M Abrantes
- Department of Behavioral Medicine and Addictions Resaerch, Butler Hospital, Providence, Rhode Island.,Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Weinstein ZM, Gryczynski G, Cheng DM, Quinn E, Hui D, Kim HW, Labelle C, Samet JH. Tapering off and returning to buprenorphine maintenance in a primary care Office Based Addiction Treatment (OBAT) program. Drug Alcohol Depend 2018; 189:166-171. [PMID: 29958128 PMCID: PMC6139651 DOI: 10.1016/j.drugalcdep.2018.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/13/2018] [Accepted: 05/04/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Guidelines recommend long-term treatment for opioid use disorder including the use of buprenorphine; however, many patients desire to eventually taper off. This study examines the prevalence and patient characteristics of patients that voluntarily taper off buprenorphine. METHODS This is a 12-year retrospective cohort study of adults on buprenorphine in a large urban safety-net primary care practice. The primary outcome was completion of a voluntary buprenorphine taper, which was further characterized as a medically supervised or unsupervised taper. The secondary outcome was re-engagement in care after taper. Descriptive statistics and estimated proportions of both taper completion and re-engagement in treatment were calculated using Kaplan-Meier estimates. RESULTS The study sample included 1308 patients with a median follow-up time of 316 days; 48 patients were observed to taper off buprenorphine during the study period, with an estimated proportion of 15% (95%CI: 10%-21%) based on Kaplan Meier analyses. Less than half of the tapers, 45.8% (22/48), were medically supervised. Thirteen of the 48 patients subsequently, re-engaged in buprenorphine treatment (estimated proportion 61%, 95%CI: 27%-96%), based on Kaplan-Meier analyses with median follow-up time of 490 days. DISCUSSION Despite the fact that many patients desire to discontinue buprenorphine, a minority had a documented taper. Among those who tapered, more than half did so unsupervised by the clinic and a majority of those who tapered off returned to buprenorphine treatment within two years. As many patients are unable to successfully taper off buprenorphine, the medical community must work to address any barriers to long-term maintenance.
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Affiliation(s)
- Zoe M Weinstein
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118, United States.
| | | | - Debbie M Cheng
- Boston University School of Public Health, Department of Biostatistics, 801 Massachusetts Avenue, 3rd Floor, Boston, MA, 02118, United States
| | - Emily Quinn
- Boston University School of Public Health, Biostatistics and Epidemiology Data Analytics Center, 85 East Newton St, M921, Boston, MA, 02118, United States
| | - David Hui
- Boston University School of Medicine, 72 East Concord St., Boston, MA, 02118, United States
| | - Hyunjoong W Kim
- Boston University School of Medicine, 72 East Concord St., Boston, MA, 02118, United States
| | - Colleen Labelle
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118, United States
| | - Jeffrey H Samet
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118, United States; Boston University School of Public Health, Department of Community Health Sciences, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118, United States
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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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The Prescription Opioid Addiction Treatment Study: What have we learned. Drug Alcohol Depend 2017; 173 Suppl 1:S48-S54. [PMID: 28363320 PMCID: PMC6866670 DOI: 10.1016/j.drugalcdep.2016.12.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 12/16/2016] [Accepted: 12/17/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND The multi-site Prescription Opioid Addiction Treatment Study (POATS), conducted by the National Drug Abuse Treatment Clinical Trials Network, was the largest clinical trial yet conducted with patients dependent upon prescription opioids (N=653). In addition to main trial results, the study yielded numerous secondary analyses, and included a 3.5-year follow-up study, the first of its kind with this population. This paper reviews key findings from POATS and its follow-up study. METHODS The paper summarizes the POATS design, main outcomes, predictors of outcome, subgroup analyses, the predictive power of early treatment response, and the long-term follow-up study. RESULTS POATS examined combinations of buprenorphine-naloxone of varying duration and counseling of varying intensity. The primary outcome analysis showed no overall benefit to adding drug counseling to buprenorphine-naloxone and weekly medical management. Only 7% of patients achieved a successful outcome (abstinence or near-abstinence from opioids) during a 4-week taper and 8-week follow-up; by comparison, 49% of patients achieved success while subsequently stabilized on buprenorphine-naloxone. Long-term follow-up results were more encouraging, with higher abstinence rates than in the main trial. Patients receiving opioid agonist treatment at the time of follow-up were more likely to have better outcomes, though a sizeable number of patients succeeded without agonist treatment. Some patients initiated risky use patterns, including heroin use and drug injection. A limitation of the long-term follow-up study was the low follow-up rate. CONCLUSIONS POATS was the first large-scale study of the treatment of prescription opioid dependence; its findings can influence both treatment guidelines and future studies.
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Abstract
BACKGROUND Managed withdrawal is a necessary step prior to drug-free treatment or as the endpoint of substitution treatment. OBJECTIVES To assess the effects of buprenorphine versus tapered doses of methadone, alpha2-adrenergic agonists, symptomatic medications or placebo, or different buprenorphine regimens for managing opioid withdrawal, in terms of the intensity of the withdrawal syndrome experienced, duration and completion of treatment, and adverse effects. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 11, 2016), MEDLINE (1946 to December week 1, 2016), Embase (to 22 December 2016), PsycINFO (1806 to December week 3, 2016), and the Web of Science (to 22 December 2016) and handsearched the reference lists of articles. SELECTION CRITERIA Randomised controlled trials of interventions using buprenorphine to modify the signs and symptoms of withdrawal in participants who were primarily opioid dependent. Comparison interventions involved reducing doses of methadone, alpha2-adrenergic agonists (clonidine or lofexidine), symptomatic medications or placebo, and different buprenorphine-based regimens. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 27 studies involving 3048 participants. The main comparators were clonidine or lofexidine (14 studies). Six studies compared buprenorphine versus methadone, and seven compared different rates of buprenorphine dose reduction. We assessed 12 studies as being at high risk of bias in at least one of seven domains of methodological quality. Six of these studies compared buprenorphine with clonidine or lofexidine and two with methadone; the other four studies compared different rates of buprenorphine dose reduction.For the comparison of buprenorphine and methadone in tapered doses, meta-analysis was not possible for the outcomes of intensity of withdrawal or adverse effects. However, information reported by the individual studies was suggestive of buprenorphine and methadone having similar capacity to ameliorate opioid withdrawal, without clinically significant adverse effects. The meta-analyses that were possible support a conclusion of no difference between buprenorphine and methadone in terms of average treatment duration (mean difference (MD) 1.30 days, 95% confidence interval (CI) -8.11 to 10.72; N = 82; studies = 2; low quality) or treatment completion rates (risk ratio (RR) 1.04, 95% CI 0.91 to 1.20; N = 457; studies = 5; moderate quality).Relative to clonidine or lofexidine, buprenorphine was associated with a lower average withdrawal score (indicating less severe withdrawal) during the treatment episode, with an effect size that is considered to be small to moderate (standardised mean difference (SMD) -0.43, 95% CI -0.58 to -0.28; N = 902; studies = 7; moderate quality). Patients receiving buprenorphine stayed in treatment for longer, with an effect size that is considered to be large (SMD 0.92, 95% CI 0.57 to 1.27; N = 558; studies = 5; moderate quality) and were more likely to complete withdrawal treatment (RR 1.59, 95% CI 1.23 to 2.06; N = 1264; studies = 12; moderate quality). At the same time there was no significant difference in the incidence of adverse effects, but dropout due to adverse effects may be more likely with clonidine (RR 0.20, 95% CI 0.04 to 1.15; N = 134; studies = 3; low quality). The difference in treatment completion rates translates to a number needed to treat for an additional beneficial outcome of 4 (95% CI 3 to 6), indicating that for every four people treated with buprenorphine, we can expect that one additional person will complete treatment than with clonidine or lofexidine.For studies comparing different rates of reduction of the buprenorphine dose, meta-analysis was possible only for treatment completion, with separate analyses for inpatient and outpatient settings. The results were diverse, and we assessed the quality of evidence as being very low. It remains very uncertain what effect the rate of dose taper has on treatment outcome. AUTHORS' CONCLUSIONS Buprenorphine is more effective than clonidine or lofexidine for managing opioid withdrawal in terms of severity of withdrawal, duration of withdrawal treatment, and the likelihood of treatment completion.Buprenorphine and methadone appear to be equally effective, but data are limited. It remains possible that the pattern of withdrawal experienced may differ and that withdrawal symptoms may resolve more quickly with buprenorphine.It is not possible to draw any conclusions from the available evidence on the relative effectiveness of different rates of tapering the buprenorphine dose. The divergent findings of studies included in this review suggest that there may be multiple factors affecting the response to the rate of dose taper. One such factor could be whether or not the initial treatment plan includes a transition to subsequent relapse prevention treatment with naltrexone. Indeed, the use of buprenorphine to support transition to naltrexone treatment is an aspect worthy of further research.Most participants in the studies included in this review were male. None of the studies reported outcomes on the basis of sex, preventing any exploration of differences related to this variable. Consideration of sex as a factor influencing response to withdrawal treatment would be relevant research for selecting the most appropriate type of intervention for each individual.
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Affiliation(s)
- Linda Gowing
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Robert Ali
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Jason M White
- University of South AustraliaSchool of Pharmacy and Medical SciencesGPO Box 2471AdelaideAustraliaSA 5001
| | - Dalitso Mbewe
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
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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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Zheng WH, Wakim RJ, Geary RC, Lander LR, Wen SJ, Xiao MC, Sullivan CR. Self-reported Sleep Improvement in Buprenorphine MAT (Medication Assisted Treatment) Population. AUSTIN JOURNAL OF DRUG ABUSE AND ADDICTION 2016; 3:1009. [PMID: 28133635 PMCID: PMC5270620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This is a prospective, naturalistic study to evaluate patient's report on sleep and depression in early recovery while receiving buprenorphine in Medication Assisted Treatment (MAT). 40 Subjects entering into MAT with buprenorphine/naloxonefor opioid dependence disorder were recruited. No change of concurrent treatment was made. Subjects were administered Sleep Scale from the Medical Outcomes Study (MOS-Sleep), a 5-item Supplemental Sleep Scale (SSS), and the Beck Depression Inventory II (BDI-II). The measures were administered at day 0 (baseline), 30, 60 and 90 days. The result showed that patients reported significant progressive improvements in three MOS-Sleep subscales: sleep disturbance, sleep indices I and II. The mean scores of SLPD4 (Sleep disturbance) at day 0, 30, 60, 90 were 62.4, 53.2, 53.3, and 48.4 respectively (p=0.0029). Similarly, subscores of SLP6 (Sleep Problem Index I) and SLP 9 (Sleep Problem Index II) were also significantly decreased over time (P=0.038 for SLP6 and p=0.007 for SLP9). BDI-II depression scores improved from "Moderate depression" at baseline to "Mild depression". The mean BDI score decreased from 24.2 to 17.0 after 90 days of treatment. Findings suggest that subjects reported improvement in both sleep and depression after initiating MAT with buprenorphine/naloxone.
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Affiliation(s)
- W H Zheng
- Department of Behavioral Medicine and Psychiatry, West Virginia University, USA
| | - R J Wakim
- Department of Behavioral Medicine and Psychiatry, West Virginia University, USA
| | - R C Geary
- Department of Behavioral Medicine and Psychiatry, West Virginia University, USA
| | - L R Lander
- Department of Behavioral Medicine and Psychiatry, West Virginia University, USA
| | - S J Wen
- Department of Biostatistics, West Virginia University, USA
| | - M C Xiao
- Department of Biostatistics, West Virginia University, USA
| | - C R Sullivan
- Department of Behavioral Medicine and Psychiatry, West Virginia University, USA
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Angarita GA, Emadi N, Hodges S, Morgan PT. Sleep abnormalities associated with alcohol, cannabis, cocaine, and opiate use: a comprehensive review. Addict Sci Clin Pract 2016; 11:9. [PMID: 27117064 PMCID: PMC4845302 DOI: 10.1186/s13722-016-0056-7] [Citation(s) in RCA: 192] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 04/08/2016] [Indexed: 01/27/2023] Open
Abstract
Sleep abnormalities are associated with acute and chronic use of addictive substances. Although sleep complaints associated with use and abstinence from addictive substances are widely recognized, familiarity with the underlying sleep abnormalities is often lacking, despite evidence that these sleep abnormalities may be recalcitrant and impede good outcomes. Substantial research has now characterized the abnormalities associated with acute and chronic use of alcohol, cannabis, cocaine, and opiates. This review summarizes this research and discusses the clinical implications of sleep abnormalities in the treatment of substance use disorders.
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Affiliation(s)
- Gustavo A Angarita
- Yale University Department of Psychiatry, Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA
| | - Nazli Emadi
- Yale University Department of Psychiatry, Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA
| | - Sarah Hodges
- Yale University Department of Psychiatry, Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA
| | - Peter T Morgan
- Yale University Department of Psychiatry, Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA.
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