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Brandt L, Odom GJ, Hu MC, Castro C, Balise RR. Empirically contrasting urine drug screening-based opioid use disorder treatment outcome definitions. Addiction 2024; 119:1289-1300. [PMID: 38616571 DOI: 10.1111/add.16494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 02/21/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND AND AIMS A lack of consensus on the optimal outcome measures to assess opioid use disorder (OUD) treatment efficacy and their precise definition and computation has hampered the pooling of research data for evidence synthesis and meta-analyses. This study aimed to empirically contrast multiple clinical trial definitions of treatment success by applying them to the same dataset. METHODS Data analysis used a suite of functions, developed as a software package for the R language, to operationalize 61 treatment outcome definitions based on urine drug screening (UDS) results. Outcome definitions were derived from clinical trials that are among the most influential in the OUD treatment field. Outcome functions were applied to a harmonized dataset from three large-scale National Drug Abuse Treatment Clinical Trials Network (CTN) studies, which tested various medication for OUD (MOUD) options (n = 2492). Hierarchical clustering was employed to empirically contrast outcome definitions. RESULTS The optimal number of clusters identified was three. Cluster 1, comprising eight definitions focused on detecting opioid-positive UDS, did not include missing UDS in outcome calculations, potentially resulting in inflated rates of treatment success. Cluster 2, with the highest variability, included 10 definitions characterized by strict criteria for treatment success, relying heavily on UDS results from either a brief period or a single study visit. The 43 definitions in Cluster 3 represented a diverse range of outcomes, conceptualized as measuring abstinence, use reduction and relapse. These definitions potentially offer more balanced measures of treatment success or failure, as they avoid the extreme methodologies characteristic of Clusters 1 and 2. CONCLUSIONS Clinical trials using urine drug screening (UDS) for objective substance use assessment in outcome definitions should consider (1) incorporating missing UDS data in outcome computation and (2) avoiding over-reliance on UDS data confined to a short time frame or the occurrence of a single positive urine test following a period of abstinence.
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Affiliation(s)
- Laura Brandt
- Department of Psychology, The City College of New York, New York, New York, USA
| | - Gabriel J Odom
- Department of Biostatistics, Florida International University, Miami, Florida, USA
| | - Mei-Chen Hu
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Clinton Castro
- The Information School, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Raymond R Balise
- Division of Biostatistics, Department of Public Health Sciences, The University of Miami, Miami, Florida, USA
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Duron DI, Tanguturi P, Campbell CS, Chou K, Bejarano P, Gabriel KA, Bowden JL, Mishra S, Brackett C, Barlow D, Houseknecht KL, Blagg BSJ, Streicher JM. Inhibiting spinal cord-specific hsp90 isoforms reveals a novel strategy to improve the therapeutic index of opioid treatment. Sci Rep 2024; 14:14715. [PMID: 38926482 DOI: 10.1038/s41598-024-65637-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/21/2024] [Indexed: 06/28/2024] Open
Abstract
Opioids are the gold standard for the treatment of chronic pain but are limited by adverse side effects. In our earlier work, we showed that Heat shock protein 90 (Hsp90) has a crucial role in regulating opioid signaling in spinal cord; Hsp90 inhibition in spinal cord enhances opioid anti-nociception. Building on these findings, we injected the non-selective Hsp90 inhibitor KU-32 by the intrathecal route into male and female CD-1 mice, showing that morphine anti-nociceptive potency was boosted by 1.9-3.5-fold in acute and chronic pain models. At the same time, tolerance was reduced from 21-fold to 2.9 fold and established tolerance was rescued, while the potency of constipation and reward was unchanged. These results demonstrate that spinal Hsp90 inhibition can improve the therapeutic index of morphine. However, we also found that systemic non-selective Hsp90 inhibition blocked opioid pain relief. To avoid this effect, we used selective small molecule inhibitors and CRISPR gene editing to identify 3 Hsp90 isoforms active in spinal cord (Hsp90α, Hsp90β, and Grp94) while only Hsp90α was active in brain. We thus hypothesized that a systemically delivered selective inhibitor to Hsp90β or Grp94 could selectively inhibit spinal cord Hsp90 activity, resulting in enhanced opioid therapy. We tested this hypothesis using intravenous delivery of KUNB106 (Hsp90β) and KUNG65 (Grp94), showing that both drugs enhanced morphine anti-nociceptive potency while rescuing tolerance. Together, these results suggest that selective inhibition of spinal cord Hsp90 isoforms is a novel, translationally feasible strategy to improve the therapeutic index of opioids.
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Affiliation(s)
- David I Duron
- Department of Pharmacology, College of Medicine, University of Arizona, Box 245050, LSN563, 1501 N. Campbell Ave., Tucson, AZ, 85724, USA
| | - Parthasaradhireddy Tanguturi
- Department of Pharmacology, College of Medicine, University of Arizona, Box 245050, LSN563, 1501 N. Campbell Ave., Tucson, AZ, 85724, USA
| | - Christopher S Campbell
- Department of Pharmacology, College of Medicine, University of Arizona, Box 245050, LSN563, 1501 N. Campbell Ave., Tucson, AZ, 85724, USA
| | - Kerry Chou
- Department of Pharmacology, College of Medicine, University of Arizona, Box 245050, LSN563, 1501 N. Campbell Ave., Tucson, AZ, 85724, USA
| | - Paul Bejarano
- Department of Pharmacology, College of Medicine, University of Arizona, Box 245050, LSN563, 1501 N. Campbell Ave., Tucson, AZ, 85724, USA
| | - Katherin A Gabriel
- Department of Pharmacology, College of Medicine, University of Arizona, Box 245050, LSN563, 1501 N. Campbell Ave., Tucson, AZ, 85724, USA
| | - Jessica L Bowden
- Department of Pharmacology, College of Medicine, University of Arizona, Box 245050, LSN563, 1501 N. Campbell Ave., Tucson, AZ, 85724, USA
| | - Sanket Mishra
- Department of Chemistry and Biochemistry, College of Science, University of Notre Dame, Notre Dame, IN, USA
| | - Christopher Brackett
- Department of Chemistry and Biochemistry, College of Science, University of Notre Dame, Notre Dame, IN, USA
| | - Deborah Barlow
- Department of Biomedical Sciences, College of Osteopathic Medicine, University of New England, Biddeford, ME, USA
| | - Karen L Houseknecht
- Department of Biomedical Sciences, College of Osteopathic Medicine, University of New England, Biddeford, ME, USA
| | - Brian S J Blagg
- Department of Chemistry and Biochemistry, College of Science, University of Notre Dame, Notre Dame, IN, USA
| | - John M Streicher
- Department of Pharmacology, College of Medicine, University of Arizona, Box 245050, LSN563, 1501 N. Campbell Ave., Tucson, AZ, 85724, USA.
- Comprehensive Center for Pain and Addiction, University of Arizona, Tucson, AZ, USA.
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Tipping AD, Nowels M, Moore C, Samples H, Crystal S, Olfson M, Williams AR, Heaps-Woodruff J. Association of medications for opioid use disorder with reduced risk of repeat opioid overdose in Medicaid: A cohort study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 157:209218. [PMID: 37984564 PMCID: PMC10922317 DOI: 10.1016/j.josat.2023.209218] [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: 02/25/2023] [Revised: 06/03/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Following a nonfatal opioid overdose, patients are at high risk for repeat overdose. The objective of this study was to examine the association of MOUD after nonfatal opioid overdose with risk of repeat overdose in the following year. METHODS This retrospective cohort study analyzed Missouri Medicaid claims from July 2012 to December 2021. The study identified opioid overdoses occurring between 2013 and 2020 using diagnosis codes for opioid poisoning in an inpatient or emergency department setting. The study implemented Cox models with a time-varying covariate for post-overdose receipt of MOUD. RESULTS During the study period, MOUD receipt after overdose more than tripled, from 4.8 % to 18.9 %. Overall, only 12.1 % of patients received MOUD in the year after index. MOUD during follow-up was associated with significantly lower risk of repeat overdose (HR = 0.34, 95 % CI = 0.14-0.82). Out of 3017 individuals meeting inclusion criteria, 13.6 % had a repeat opioid overdose within 1 year. Repeat overdose risk was higher for those whose index overdose involved heroin or synthetic opioids (HR = 1.71, 95 % CI = 1.35-2.15), but MOUD was associated with significantly reduced risk in this group (HR = 0.34, 95 % CI = 0.13-0.92). CONCLUSIONS MOUD receipt was associated with reduced risk of repeat overdose. Those whose index overdoses involved heroin or synthetic opioids were at greater risk of repeat overdose, but MOUD was associated with reduced risk in this group.
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Affiliation(s)
- Andrew D Tipping
- Missouri Institute of Mental Health, University of Missouri - St. Louis, 1 University Blvd, St. Louis, MO 63121, USA.
| | - Molly Nowels
- Center for Health Services Research, Institute for Health, Rutgers University, 112 Paterson Street, New Brunswick, NJ 08901, USA.
| | - Clara Moore
- Missouri Institute of Mental Health, University of Missouri - St. Louis, 1 University Blvd, St. Louis, MO 63121, USA.
| | - Hillary Samples
- Center for Health Services Research, Institute for Health, Rutgers University, 112 Paterson Street, New Brunswick, NJ 08901, USA.
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, 112 Paterson Street, New Brunswick, NJ 08901, USA; School of Social Work, Rutgers University, 536 George Street, New Brunswick, NJ 08901, USA.
| | - Mark Olfson
- Vagelos College of Physicians and Surgeons, 630 W 168th St, Columbia University, New York, NY 10032, USA; Mailman School of Public Health, Columbia University, 722 W 168th St., New York, NY 10032, USA.
| | - Arthur Robinson Williams
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, 1051 Riverside Dr., New York, NY 10032, USA.
| | - Jodi Heaps-Woodruff
- Missouri Institute of Mental Health, University of Missouri - St. Louis, 1 University Blvd, St. Louis, MO 63121, USA.
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Rosansky JA, Howard L, Goodman H, Okst K, Fatkin T, Fredericksen AK, Sokol R, Gardiner P, Parry G, Cook BL, Weiss RD, Schuman-Olivier ZD. Effects of live-online, group mindfulness training on opioid use and anxiety during buprenorphine treatment: A comparative effectiveness RCT. Contemp Clin Trials 2024; 137:107417. [PMID: 38135210 DOI: 10.1016/j.cct.2023.107417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/24/2023] [Accepted: 12/17/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Office-based opioid treatment with buprenorphine has emerged as a popular evidence-based treatment for opioid use disorder. Unfortunately, psychosocial stress, anxiety, pain, and co-morbid substance use increase patients' risk for relapse. We designed this study to compare the effects of complementing buprenorphine treatment with 24 weeks of a live-online Mindful Recovery Opioid Care Continuum (M-ROCC) group to a time and attention-matched, live-online Recovery Support Group (RSG) active control condition. METHODS We plan to enroll a maximum of N = 280 and randomize at least N = 192 patients prescribed buprenorphine through referrals from office-based and telemedicine buprenorphine treatment providers and social media advertisements. Participants will be randomly assigned to M-ROCC or RSG and will be blinded to their treatment condition. The primary outcome for this study will be biochemically confirmed periods of abstinence from illicit opioids, as measured by self-reported use and randomly collected, video-observed oral fluid toxicology testing during the final 12 weeks of study participation. Secondary outcomes include changes in Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and pain interference scores between baseline and week 24. RESULTS The trial was funded by the National Institutes of Health, HEAL Initiative through NCCIH (R33AT010125). Data collection is projected to end by September 2023, and we expect publication of results in 2024. CONCLUSION If the M-ROCC intervention is found to be effective in this format, it will demonstrate that live-online mindfulness groups can improve outcomes and address common co-morbidities like anxiety and pain during buprenorphine treatment.
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Affiliation(s)
- Joseph A Rosansky
- Cambridge Health Alliance, Center for Mindfulness and Compassion, 350 Main Street, Suite 5126, Malden, MA 02148, United States of America; Harvard Medical School, Department of Psychiatry, 25 Shattuck St., Boston, MA 02115, United States of America
| | - Leah Howard
- Cambridge Health Alliance, Center for Mindfulness and Compassion, 350 Main Street, Suite 5126, Malden, MA 02148, United States of America
| | - Hannah Goodman
- Cambridge Health Alliance, Center for Mindfulness and Compassion, 350 Main Street, Suite 5126, Malden, MA 02148, United States of America
| | - Kayley Okst
- Cambridge Health Alliance, Center for Mindfulness and Compassion, 350 Main Street, Suite 5126, Malden, MA 02148, United States of America
| | - Thomas Fatkin
- Cambridge Health Alliance, Center for Mindfulness and Compassion, 350 Main Street, Suite 5126, Malden, MA 02148, United States of America
| | - A Kiera Fredericksen
- Cambridge Health Alliance, Center for Mindfulness and Compassion, 350 Main Street, Suite 5126, Malden, MA 02148, United States of America
| | - Randi Sokol
- Cambridge Health Alliance, Department of Family Medicine, 1493 Cambridge St., Cambridge, MA 02139, United States of America; Tufts University School of Medicine, Family Medicine Residency Training Program, 136 Harrison Ave., Boston, MA 02111, United States of America
| | - Paula Gardiner
- Cambridge Health Alliance, Center for Mindfulness and Compassion, 350 Main Street, Suite 5126, Malden, MA 02148, United States of America
| | - Gareth Parry
- Cambridge Health Alliance, Center for Mindfulness and Compassion, 350 Main Street, Suite 5126, Malden, MA 02148, United States of America; Harvard Medical School, Department of Psychiatry, 25 Shattuck St., Boston, MA 02115, United States of America
| | - Benjamin L Cook
- Cambridge Health Alliance, Center for Mindfulness and Compassion, 350 Main Street, Suite 5126, Malden, MA 02148, United States of America; Harvard Medical School, Department of Psychiatry, 25 Shattuck St., Boston, MA 02115, United States of America; Health Equity Research Lab, Cambridge Health Alliance, Cambridge, MA 02139, United States of America
| | - Roger D Weiss
- Harvard Medical School, Department of Psychiatry, 25 Shattuck St., Boston, MA 02115, United States of America; McLean Hospital, 115 Mill St., Belmont, MA 02478, United States of America
| | - Zev D Schuman-Olivier
- Cambridge Health Alliance, Center for Mindfulness and Compassion, 350 Main Street, Suite 5126, Malden, MA 02148, United States of America; Harvard Medical School, Department of Psychiatry, 25 Shattuck St., Boston, MA 02115, United States of America.
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Cole S, Olive MF, Wirkus S. The dynamics of heroin and illicit opioid use disorder, casual use, treatment, and recovery: A mathematical modeling analysis. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2024; 21:3165-3206. [PMID: 38454724 DOI: 10.3934/mbe.2024141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
A leading crisis in the United States is the opioid use disorder (OUD) epidemic. Opioid overdose deaths have been increasing, with over 100,000 deaths due to overdose from April 2020 to April 2021. This paper presents a mathematical model to address illicit OUD (IOUD), initiation, casual use, treatment, relapse, recovery, and opioid overdose deaths within an epidemiological framework. Within this model, individuals remain in the recovery class unless they relapse back to use and due to the limited availability of specialty treatment facilities for individuals with OUD, a saturation treatment function was incorporated. Additionally, a casual user class and its corresponding specialty treatment class were incorporated. We use both heroin and all-illicit opioids datasets to find parameter estimates for our models. Bistability of equilibrium solutions was found for realistic parameter values for the heroin-only dataset. This result implies that it would be beneficial to increase the availability of treatment. An alarming effect was discovered about the high overdose death rate: by 2046, the disorder-free equilibrium would be the only stable equilibrium. This consequence is concerning because it means the epidemic would end due to high overdose death rates. The IOUD model with a casual user class, its sensitivity results, and the comparison of parameters for both datasets, showed the importance of not overlooking the influence that casual users have in driving the all-illicit opioid epidemic. Casual users stay in the casual user class longer and are not going to treatment as quickly as the users of the heroin epidemic. Another result was that the users of the all-illicit opioids were going to the recovered class by means other than specialty treatment. However, the change in the relapse rate has more of an influence for those individuals than in the heroin-only epidemic. The results above from analyzing this model may inform health and policy officials, leading to more effective treatment options and prevention efforts.
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Affiliation(s)
- Sandra Cole
- Arizona State University, School of Mathematical and Natural Sciences, Glendale, AZ, USA
| | - M Foster Olive
- Arizona State University, Department of Psychology, Tempe, AZ, USA
| | - Stephen Wirkus
- Arizona State University, School of Mathematical and Natural Sciences, Glendale, AZ, USA
- The University of Texas at San Antonio, Department of Mathematics, San Antonio, TX, USA
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Roberts E, Humphreys K. Does the advent of depot therapy represent a step change in our understanding of opioid use disorder and its treatment? Drug Alcohol Rev 2024; 43:261-264. [PMID: 37525510 PMCID: PMC10828099 DOI: 10.1111/dar.13732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/06/2023] [Accepted: 07/18/2023] [Indexed: 08/02/2023]
Abstract
After years of minimal innovation in pharmacotherapeutics, impressive outcomes in the treatment of opioid use disorder are being obtained from a new way of delivering an old medication; long-acting injectable formulations of buprenorphine appear to produce compelling reductions in relapse to illicit opioid use not only during use but also following depot discontinuation. This commentary discusses potential mechanisms behind this observation, asks if the removal of the need for daily oral opioid agonist dosing furthers our understanding of addiction treatment and whether we should therefore consider expanding access to depot formulations.
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Affiliation(s)
- Emmert Roberts
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, USA
| | - Keith Humphreys
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, USA
- Veterans Affairs Palo Alto Health Care System, Menlo Park, USA
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Roberts E, Copeland C, Humphreys K, Shover CL. Drug-related deaths among housed and homeless individuals in the UK and the USA: comparative retrospective cohort study. Br J Psychiatry 2023; 223:562-568. [PMID: 37665046 PMCID: PMC10727910 DOI: 10.1192/bjp.2023.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND The UK and USA currently report their highest number of drug-related deaths since records began, with higher rates among individuals experiencing homelessness. AIMS Given that overdose prevention in homeless populations may require unique strategies, we evaluated whether substances implicated in death differed between (a) housed decedents and those experiencing homelessness and (b) between US and UK homeless populations. METHOD We conducted an internationally comparative retrospective cohort study utilising multilevel multinomial regression modelling of coronial/medical examiner-verified drug-related deaths from 1 January 2012 to 31 December 2021. UK data were available for England, Wales and Northern Ireland; US data were collated from eight county jurisdictions. Data were available on decedent age, sex, ethnicity, housing status and substances implicated in death. RESULTS Homeless individuals accounted for 16.3% of US decedents versus 3.4% in the UK. Opioids were implicated in 66.3 and 50.4% of all studied drug-related deaths in the UK and the USA respectively. UK homeless decedents had a significantly increased risk of having only opioids implicated in death compared with only non-opioids implicated (relative risk ratio RRR = 1.87, 95% CI 1.76-1.98, P < 0.001); conversely, US homeless decedents had a significantly decreased risk (RRR = 0.37, 95% CI 0.29-0.48, P < 0.001). Methamphetamine was implicated in two-thirds (66.7%) of deaths among US homeless decedents compared with 0.4% in the UK. CONCLUSIONS Both the rate and type of drug-related deaths differ significantly between homeless and housed populations in the UK and USA. The two countries also differ in drugs implicated in death. Targeted programmes for country-specific implicated drug profiles appear warranted.
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Affiliation(s)
- Emmert Roberts
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Caroline Copeland
- Institute of Pharmaceutical Science, King's College London, London, UK
| | - Keith Humphreys
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA; and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Chelsea L. Shover
- David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research, University of California – Los Angeles (UCLA), Los Angeles, California, USA
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Tamburello A, Penn J, Negron-Muñoz R, Kaliebe K. Prescribing Psychotropic Medications for Justice-Involved Juveniles. JOURNAL OF CORRECTIONAL HEALTH CARE 2023; 29:94-108. [PMID: 36637811 DOI: 10.1089/jchc.21.09.0086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Psychiatric disorders are exceedingly common in justice-involved youth. Relevant justice systems are varied, evolving, complex, and underserved. The intent of this article is to highlight the research and best practices related to managing the psychiatric disorders of justice-involved youths with a particular focus on pharmacotherapy. We review relevant features of the justice system and related case law, how prescribing for these individuals varies from both community settings and for incarcerated adults, effective assessment and medication selection, informed consent, management of nonadherence and medication diversion, and applied evidence for specific psychiatric problems common in these patients. Psychiatrists caring for justice-involved youth will benefit from tools, like this article, for training and orientation to provide timely and effective treatment services and consultation in these settings.
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Affiliation(s)
- Anthony Tamburello
- University Correctional Health Care Rutgers University-Robert Wood Johnson Medical School Department of Psychiatry, Piscataway, New Jersey, USA
| | - Joseph Penn
- Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch, Correctional Managed Care Mental Health Services, Conroe, Texas, USA
| | - Rosa Negron-Muñoz
- Department of Child and Adolescent Psychiatry, University of South Florida, Tampa, Florida, USA
| | - Kristopher Kaliebe
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, Florida, USA
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Chhabra N, Smith DL, Maloney CM, Archer J, Sharma B, Thompson HM, Afshar M, Karnik NS. The Identification of Subphenotypes and Associations with Health Outcomes in Patients with Opioid-Related Emergency Department Encounters Using Latent Class Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148882. [PMID: 35886733 PMCID: PMC9321801 DOI: 10.3390/ijerph19148882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/17/2022] [Accepted: 07/19/2022] [Indexed: 02/05/2023]
Abstract
The emergency department (ED) is a critical setting for the treatment of patients with opioid misuse. Detecting relevant clinical profiles allows for tailored treatment approaches. We sought to identify and characterize subphenotypes of ED patients with opioid-related encounters. A latent class analysis was conducted using 14,057,302 opioid-related encounters from 2016 through 2017 using the National Emergency Department Sample (NEDS), the largest all-payer ED database in the United States. The optimal model was determined by face validity and information criteria-based metrics. A three-step approach assessed class structure, assigned individuals to classes, and examined characteristics between classes. Class associations were determined for hospitalization, in-hospital death, and ED charges. The final five-class model consisted of the following subphenotypes: Chronic pain (class 1); Alcohol use (class 2); Depression and pain (class 3); Psychosis, liver disease, and polysubstance use (class 4); and Pregnancy (class 5). Using class 1 as the reference, the greatest odds for hospitalization occurred in classes 3 and 4 (Ors 5.24 and 5.33, p < 0.001) and for in-hospital death in class 4 (OR 3.44, p < 0.001). Median ED charges ranged from USD 2177 (class 1) to USD 2881 (class 4). These subphenotypes provide a basis for examining patient-tailored approaches for this patient population.
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Affiliation(s)
- Neeraj Chhabra
- Division of Medical Toxicology, Department of Emergency Medicine, Cook County Health, Chicago, IL 60612, USA
- Department of Emergency Medicine, Rush Medical College, Rush University, Chicago, IL 60612, USA
- Correspondence:
| | - Dale L. Smith
- Addiction Data Science Laboratory, Department of Psychiatry & Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA; (D.L.S.); (B.S.); (H.M.T.); (N.S.K.)
- Department of Psychology, Olivet Nazarene University, Bourbonnais, IL 60914, USA
| | - Caitlin M. Maloney
- Doctor of Medicine Program, Rush Medical College, Rush University, Chicago, IL 60612, USA;
| | - Joseph Archer
- School of Medicine and Public Health, University of Wisconsin, Madison, WI 53715, USA;
| | - Brihat Sharma
- Addiction Data Science Laboratory, Department of Psychiatry & Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA; (D.L.S.); (B.S.); (H.M.T.); (N.S.K.)
| | - Hale M. Thompson
- Addiction Data Science Laboratory, Department of Psychiatry & Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA; (D.L.S.); (B.S.); (H.M.T.); (N.S.K.)
| | - Majid Afshar
- Department of Medicine, University of Wisconsin-Madison, Madison, WI 53715, USA;
| | - Niranjan S. Karnik
- Addiction Data Science Laboratory, Department of Psychiatry & Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA; (D.L.S.); (B.S.); (H.M.T.); (N.S.K.)
- Institute for Juvenile Research, Department of Psychiatry, University of Illinois Chicago, Chicago, IL 60612, USA
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Perspectives of Patients Receiving Telemedicine Services for Opioid Use Disorder Treatment: A Qualitative Analysis of User Experiences. J Addict Med 2022; 16:702-708. [PMID: 35861337 PMCID: PMC10075257 DOI: 10.1097/adm.0000000000001006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Telemedicine for opioid use disorder (tele-OUD) has the potential to increase access to medications for OUD (MOUD). Fully virtual tele-OUD services, in which all care is provided via telemedicine, are increasingly common, yet few studies document the experiences of patients who use such services. Understanding patient perspectives is one of multiple considerations to inform the regulation and reimbursement of tele-OUD services. METHODS We conducted semi-structured interviews with 20 adults receiving care from one fully virtual tele-OUD service who had received 3 to 5 weeks of treatment. Analyses were conducted using an inductive and deductive approach informed by the modified Unified Theory of Acceptance and Use of Technology model. RESULTS Over three quarters of patients with past experience receiving in-person MOUD treatment described tele-OUD as more advantageous with its key strength being more patient centered. Over three quarters of patients said they felt tele-OUD helped to ameliorate social barriers to seeking treatment, and nearly all said they appreciated the speed at which they were able to initiate MOUD treatment via tele-OUD. Surprisingly, the pandemic was not among the factors that influenced patient interest in tele-OUD. CONCLUSIONS Patients engaged in one fully virtual tele-OUD service described unique advantages of tele-OUD. More research is needed to determine the appropriateness of tele-OUD for people in various stages of recovery, and data on long-term treatment outcomes are needed to inform decisions regarding the regulation and reimbursement of fully virtual and hybrid care models for OUD.
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Ntchana A, Daley R. Effectiveness of Remote Intensive Counseling Versus Outpatient Counseling in Substance Use Disorders: A Retrospective Cohort Study. Cureus 2022; 14:e24167. [PMID: 35592199 PMCID: PMC9110036 DOI: 10.7759/cureus.24167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 12/05/2022] Open
Abstract
Background Substance use disorders are a serious and persistent U.S. public health problem. Although a number of therapy modalities exist, few studies assessed the comparative effectiveness of specific therapies. This study empirically evaluated whether remote intensive counseling (RIC) is more effective than outpatient therapy (OT) in relapse prevention over the period of nine months in patients aged 18-45 years with a history of substance use. Methods The current study utilized a retrospective correlational cross-sectional cohort quantitative research design with multiple between-group comparisons and fixed effects. The sample (n=296) included adults of both sexes, of diverse racial/ethnic backgrounds, and of socioeconomic status (SES) between 18-45 years of age who had been using an illicit addictive substance(s) for at least six months prior and had never participated in any treatment program previously. Individuals with alcohol and/or nicotine co-dependence were excluded. Result and conclusion Remote intensive counseling (RIC) is more effective for patients aged 18-45 years with a history of substance use than outpatient therapy (OT). RIC works better for single or never married females younger than 30-year-old with higher education. The use of RIC for other age and racial/ethnic groups should be guided by whether patients belong to a younger age cohort and/or a specific race/ethnicity.
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12
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Langejan AI, de Kleijn L, Rijkels-Otters HJBM, Chudy SFJ, Chiarotto A, Koes BW. Effectiveness of non-opioid interventions to reduce opioid withdrawal symptoms in patients with chronic pain: a systematic review. Fam Pract 2022; 39:295-300. [PMID: 34849764 PMCID: PMC9030234 DOI: 10.1093/fampra/cmab159] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Dealing with the opioid crisis, medical doctors are keen to learn how to best treat opioid dependency in patients with chronic non-cancer pain. Opioid replacement therapy is commonly used, but success rates vary widely. Since many patients still experience severe withdrawal symptoms, additional interventions are necessary. OBJECTIVE To review the effectiveness of interventions in the treatment of withdrawal symptoms during opioid tapering or acute withdrawal in patients with long-term non-cancer pain. METHODS A systematic review was conducted in Embase.com, MEDLINE, Web of Science, PsycINFO, and Cochrane CENTRAL register of trials. Studies eligible for inclusion were (non-)randomized controlled trials in adults with long-term opioid prescriptions for non-cancer pain. Included trials had to compare a non-opioid intervention to placebo, usual care, no treatment, or non-opioid drug and had to report on withdrawal symptoms as an outcome. Study quality was assessed with the 2.0 Cochrane risk of bias (RoB) tool. Evidence quality was rated following the GRADE approach. RESULTS One trial (n = 21, some concerns regarding RoB) compared Varenicline to placebo. There was no statistically significant between-group reduction of withdrawal symptoms (moderate-quality evidence). CONCLUSIONS Evidence from clinical trials on interventions reducing withdrawal symptoms is scarce. Based on one trial with a small sample size, no firm conclusion can be drawn. Meanwhile, doctors are in dire need for therapeutic options to tackle withdrawal symptoms while tapering patients with prescription opioid dependence. We hope this review draws attention to this unfortunate research gap so that future research can provide doctors with answers.
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Affiliation(s)
- Annely I Langejan
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Loes de Kleijn
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | - Stan F J Chudy
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Alessandro Chiarotto
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Bart W Koes
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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13
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Modeling the Dynamics of Heroin and Illicit Opioid Use Disorder, Treatment, and Recovery. Bull Math Biol 2022; 84:48. [PMID: 35237877 PMCID: PMC8891131 DOI: 10.1007/s11538-022-01002-w] [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: 01/28/2022] [Indexed: 12/04/2022]
Abstract
Opioid use disorder (OUD) has become a serious leading health issue in the USA leading to addiction, disability, or death by overdose. Research has shown that OUD can lead to a chronic lifelong disorder with greater risk for relapse and accidental overdose deaths. While the prescription opioid epidemic is a relatively new phenomenon, illicit opioid use via heroin has been around for decades. Recently, additional illicit opioids such as fentanyl have become increasingly available and problematic. We propose a mathematical model that focuses on illicit OUD and includes a class for recovered users but allows for individuals to either remain in or relapse back to the illicit OUD class. Therefore, in our model, individuals may cycle in and out of three different classes: illicit OUD, treatment, and recovered. We additionally include a treatment function with saturation, as it has been shown there is limited accessibility to specialty treatment facilities. We used 2002–2019 SAMHSA and CDC data for the US population, scaled to a medium-sized city, to obtain parameter estimates for the specific case of heroin. We found that the overdose death rate has been increasing linearly since around 2011, likely due to the increased presence of fentanyl in the heroin supply. Extrapolation of this overdose death rate, together with the obtained parameter estimates, predict that by 2038 no endemic equilibrium will exist and the only stable equilibrium will correspond to the absence of heroin use disorder in the population. There is a range of parameter values that will give rise to a backward bifurcation above a critical saturation of treatment availability. We show this for a range of overdose death rate values, thus illustrating the critical role played by the availability of specialty treatment facilities. Sensitivity analysis consistently shows the significant role of people entering treatment on their own accord, which suggests the importance of removing two of the most prevalent SAMHSA-determined reasons that individuals do not enter treatment: financial constraints and the stigma of seeking treatment for heroin use disorder.
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14
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Guastaferro WP, Koetzle D, Lutgen-Nieves L, Teasdale B. Opioid Agonist Treatment Recipients within Criminal Justice-Involved Populations. Subst Use Misuse 2022; 57:698-707. [PMID: 35172673 DOI: 10.1080/10826084.2022.2034869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background: In 2014, nearly 2.5 million Americans had a substance use disorder for opioids (e.g., prescription pain medication or heroin) with over half estimated to have had prior contact with the criminal justice system. Despite strong evidence that opioid agonist treatment (OAT) is effective in reducing overdose, increasing treatment retention, and improving physical health and well-being outcomes, the use of OAT among justice-involved individuals is relatively rare. Methods: The current study uses national data of publicly funded admissions to substance abuse treatment to assess the extent to which OAT is used for cases referred to treatment by the criminal justice system. We explore the relationship between demographics, substance use severity, and access to treatment and OAT receipt. Results: Findings indicate that fewer than 6% of criminal justice cases received OAT as part of the treatment plan. Those with daily substance use, comorbid psychiatric problems, prior treatment, females, Latinos, and those who were older and those who were living independently were more likely to receive OAT, as were those living in the Northeast and with government health insurance. Conclusions: Improving the integration of the criminal justice system with substance use treatment programs would improve access to care and potentially reduce multiple health disparities faced by those in the justice system. As criminal justice responses to substance use disorder move toward a public health approach, it is imperative that the criminal justice system consider mechanisms for improving access and referrals to OAT.
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Affiliation(s)
- Wendy P Guastaferro
- School of Criminology and Criminal Justice, Florida Atlantic University, Boca Raton, Florida, USA
| | - Deborah Koetzle
- John Jay College of Criminal Justice, Criminal Justice, New York, USA
| | - Laura Lutgen-Nieves
- Department of Criminal Justice, University of Southern Indiana, Evansville, Indiana, USA
| | - Brent Teasdale
- Department of Criminal Justice Sciences, Illinois State University, Normal, IllinoisUSA
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15
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Marcovitz DE, White KD, Sullivan W, Limper HM, Dear ML, Buie R, Edwards DA, Chastain C, Kast KA, Lindsell CJ. Bridging Recovery Initiative Despite Gaps in Entry (BRIDGE): study protocol for a randomized controlled trial of a bridge clinic compared with usual care for patients with opioid use disorder. Trials 2021; 22:757. [PMID: 34717736 PMCID: PMC8556830 DOI: 10.1186/s13063-021-05698-4] [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: 03/19/2021] [Accepted: 10/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background Patients with substance use disorders are overrepresented among general hospital inpatients, and their admissions are associated with longer lengths of stay and increased readmission rates. Amid the national opioid crisis, increased attention has been given to the integration of addiction with routine medical care in order to better engage such patients and minimize fragmentation of care. General hospital addiction consultation services and transitional, hospital-based “bridge” clinics have emerged as potential solutions. We designed the Bridging Recovery Initiative Despite Gaps in Entry (BRIDGE) trial to determine if these clinics are superior to usual care for these patients. Methods This single-center, pragmatic, randomized controlled clinical trial is enrolling hospitalized patients with opioid use disorder (OUD) who are initiating medication for OUD (MOUD) in consultation with the addiction consult service. Patients are randomized for referral to a co-located, transitional, multidisciplinary bridge clinic or to usual care, with the assignment probability being determined by clinic capacity. The primary endpoint is hospital length of stay. Secondary endpoints include quality of life, linkage to care, self-reported buprenorphine or naltrexone fills, rate of known recurrent opioid use, readmission rates, and costs. Implementation endpoints include willingness to be referred to the bridge clinic, attendance rates among those referred, and reasons why patients were not eligible for referral. The main analysis will use an intent-to-treat approach with full covariate adjustment. Discussion This ongoing pragmatic trial will provide evidence on the effectiveness of proactive linkage to a bridge clinic intervention for hospitalized patients with OUD initiating evidence-based pharmacotherapy in consultation with the addiction consult service. Trial registration ClinicalTrials.govNCT04084392. Registered on 10 September 2019. The study has been approved by the Vanderbilt Institutional Review Board. The current approved protocol is dated version May 12, 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05698-4.
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Affiliation(s)
- David E Marcovitz
- Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1603 23rd Ave South, Nashville, TN, 37212, USA.
| | - Katie D White
- Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1603 23rd Ave South, Nashville, TN, 37212, USA
| | - William Sullivan
- Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1603 23rd Ave South, Nashville, TN, 37212, USA
| | - Heather M Limper
- Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1603 23rd Ave South, Nashville, TN, 37212, USA
| | - Mary Lynn Dear
- Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1603 23rd Ave South, Nashville, TN, 37212, USA
| | - Reagan Buie
- Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1603 23rd Ave South, Nashville, TN, 37212, USA
| | - David A Edwards
- Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1603 23rd Ave South, Nashville, TN, 37212, USA
| | - Cody Chastain
- Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1603 23rd Ave South, Nashville, TN, 37212, USA
| | - Kristopher A Kast
- Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1603 23rd Ave South, Nashville, TN, 37212, USA
| | - Christopher J Lindsell
- Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1603 23rd Ave South, Nashville, TN, 37212, USA
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16
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Phillips T, Lenhart S, Strickland WC. A Data-Driven Mathematical Model of the Heroin and Fentanyl Epidemic in Tennessee. Bull Math Biol 2021; 83:97. [PMID: 34402967 DOI: 10.1007/s11538-021-00925-0] [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: 12/07/2020] [Accepted: 07/19/2021] [Indexed: 11/28/2022]
Abstract
Opioid addiction represents a major national health issue spanning decades. In recent years, prescription opioid use disorder has increasingly led to heroin and fentanyl use, with subsequent increases in mortality rates due to overdose. In this paper, we present a mechanistic, epidemic model for prescription opioid addiction and illicit heroin or fentanyl addiction which aims to better understand and predict the dynamics between these two stages of opioid use disorder. Our model aims to be both parsimonious and robust: as a system of five differential equations it is appropriate for use in theory advancement and yet it remains powerful enough to capture state-level data from Tennessee for the period 2013-2018. A key finding from our data-driven analysis is that, in the face of changing policy around prescription opioids, heroin and fentanyl are now the driving force behind the Tennessee opioid epidemic. Model projections suggest that both addictions and overdoses related to heroin and fentanyl will continue to increase in the next few years (2020-2022), even as addiction to prescription drugs continues to fall. Finally, management strategy analysis suggests that in the changing face of the epidemic, the most successful approach will target availability of treatment with subsequent monitoring of stably recovered individuals to see that they do not relapse, coincident with direct efforts to decrease opioid overdose fatalities (e.g., further availability of Naloxone).
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Affiliation(s)
- Tricia Phillips
- Department of Mathematics, Birmingham-Southern College, Birmingham, AL, USA.
| | - Suzanne Lenhart
- Department of Mathematics, University of Tennessee, Knoxville, TN, USA
| | - W Christopher Strickland
- Department of Mathematics and Department of Ecology and Evolutionary Biology, University of Tennessee, Knoxville, TN, USA
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17
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Potru S, Tang YL. Chronic Pain, Opioid Use Disorder, and Clinical Management Among Older Adults. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:294-302. [PMID: 34690595 PMCID: PMC8475938 DOI: 10.1176/appi.focus.20210002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Because of unique factors related to physiological changes and altered metabolism in advanced age, special attention is needed concerning chronic pain, opioid use, and opioid use disorder among older adults. Clinicians need to follow the most updated clinical guidelines regarding opioid prescribing. Routine screening and awareness are the keys to identifying opioid use disorder. Comprehensive assessments often require both pain assessment (including functional status) and substance use assessment, including the use of urine toxicological testing and structured, validated screening tools and instruments. Comprehensive, interdisciplinary efforts are critical in managing the care of older adults with chronic pain and opioid use disorder. A collaborative approach that includes substance abuse treatment and pain management (including pain subspecialty care) is often recommended. Medications for opioid use disorder have been extensively studied and have the most convincing evidence to date, and psychosocial treatments may be beneficial in some circumstances.
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Affiliation(s)
- Sudheer Potru
- Department of Anesthesiology (Potru) and Department of Psychiatry and Behavioral Sciences (Tang), both at Emory University, Atlanta; Department of Anesthesiology (Potru) and Substance Abuse Treatment Program (Tang), both at Atlanta Veterans Affairs Medical Center, Decatur, Georgia
| | - Yi-Lang Tang
- Department of Anesthesiology (Potru) and Department of Psychiatry and Behavioral Sciences (Tang), both at Emory University, Atlanta; Department of Anesthesiology (Potru) and Substance Abuse Treatment Program (Tang), both at Atlanta Veterans Affairs Medical Center, Decatur, Georgia
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18
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Huntley K, Einstein E, Postma T, Thomas A, Ling S, Compton W. Advancing emergency department-initiated buprenorphine. J Am Coll Emerg Physicians Open 2021; 2:e12451. [PMID: 34179878 PMCID: PMC8208651 DOI: 10.1002/emp2.12451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/01/2021] [Accepted: 04/23/2021] [Indexed: 01/10/2023] Open
Abstract
Opioids are the main driver of drug overdose deaths in the United States, and there has been a marked increase in opioid-related overdoses during the COVID-19 public health emergency. Many emergency departments (EDs) across the country are implementing ED-initiated buprenorphine programs, and this is a method to address and prevent opioid overdoses. Resources are available to overcome barriers and take action.
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Affiliation(s)
- Kristen Huntley
- Center for the Clinical Trials NetworkThe National Institute on Drug AbuseBethesdaMarylandUSA
| | - Emily Einstein
- Office of Science Policy and CommunicationsThe National Institute on Drug AbuseBethesdaMarylandUSA
| | - Terri Postma
- Center for MedicareCenters for Medicare & Medicaid ServicesBaltimoreMarylandUSA
| | - Anita Thomas
- Center for Clinical Standards and QualityCenters for Medicare & Medicaid ServicesBaltimoreMarylandUSA
| | - Shari Ling
- Center for Clinical Standards and QualityCenters for Medicare & Medicaid ServicesBaltimoreMarylandUSA
| | - Wilson Compton
- Office of the DirectorThe National Institute on Drug AbuseBethesdaMarylandUSA
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19
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Banta-Green CJ, Hansen RN, Ossiander EM, Wasserman CR, Merrill JO. Buprenorphine utilization among all Washington State residents' based upon prescription monitoring program data - Characteristics associated with two measures of retention and patterns of care over time. J Subst Abuse Treat 2021; 127:108446. [PMID: 34049724 DOI: 10.1016/j.jsat.2021.108446] [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: 09/22/2020] [Revised: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Opioid use disorder is a serious health condition for which buprenorphine is proven effective, yet providers substantially underutilize buprenorphine. We present two approaches to measuring treatment duration, factors associated with retention, and patterns of care. METHODS The study determined incident buprenorphine prescribing for all Washingtonians utilizing prescription monitoring program data from 2012 to 2019. The study calculated episode of care and cumulative time in care. Generalized linear models estimated associations among the length of the first episode of care and cumulative time in care with sex, age, and rurality. Cox proportional hazards models estimated the time to discontinuing buprenorphine for the first four episodes of care and time to discontinuing the last episode of care. RESULTS Mean and median duration of the first episode were 320 and 84 days, respectively, and for cumulative time in care 308 and 195 days. A minority of peoples' first episodes exceeded 180 days (37%). Being female and older were significantly associated with longer first episodes and cumulative time in care. Survival analyses indicated that the proportion of those still in care at 6, 12, and 24 months into their first episode of care declined for those with more than one episode of care; conversely the study found much smaller differences in retention for the last episode of care, indicating that many people were eventually able to be retained in care for longer periods of time. CONCLUSION Episodes of care and cumulative time on buprenorphine were both short compared to minimum quality recommendations of 180 days. Median cumulative time in care was double that of the first episode, highlighting that many people engage in subsequent episodes of substantial length. Episode of care and cumulative care analyses should inform states, payers, health care systems and providers in measuring and setting treatment duration goals.
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Affiliation(s)
- Caleb J Banta-Green
- Addictions, Drug & Alcohol Institute, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, 1107 NE 45th St, Suite 120, Seattle, WA 98105, United States of America.
| | - Ryan N Hansen
- School of Pharmacy University of Washington, Box 357630, Seattle, WA 98195-7630, United States of America
| | - Eric M Ossiander
- Washington State Department of Health, 101 Israel Road SE, Tumwater, WA 98501, United States of America
| | - Cathy R Wasserman
- Washington State Department of Health, 101 Israel Road SE, Tumwater, WA 98501, United States of America
| | - Joseph O Merrill
- Department of Medicine, University of Washington, Harborview Medical Center, 401 Broadway, Seattle, WA 98122, United States of America
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20
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Curtis AC, Werder K, Reynolds S, Satterfield JM. Questioning Precedent in Unprecedented Times: Psychosocial Interventions Supporting Medications for Opioid Use Disorder. J Psychosoc Nurs Ment Health Serv 2021; 59:2-4. [PMID: 34038261 DOI: 10.3928/02793695-20210315-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
| | - Karen Werder
- Sonoma State University, Rohnert Park, California
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21
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Dos Reis Izolan L, da Silva DM, Oliveira HBL, de Oliveira Salomon JL, Peruzzi CP, Garcia SC, Dallegrave E, Zanotto C, Elisabetsky E, Gonçalves CA, Arbo MD, Konrath EL, Leal MB. Sintocalmy, a Passiflora incarnata Based Herbal, Attenuates Morphine Withdrawal in Mice. Neurochem Res 2021; 46:1092-1100. [PMID: 33544325 DOI: 10.1007/s11064-021-03237-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 12/19/2020] [Accepted: 01/06/2021] [Indexed: 11/29/2022]
Abstract
Chronic opioid use changes brain chemistry in areas related to reward processes, memory, decision-making, and addiction. Both neurons and astrocytes are affected, ultimately leading to dependence. Passiflora incarnata L. (Passifloraceae) is the basis of frequently used herbals to manage anxiety and insomnia, with proven central nervous system depressant effects. Anti-addiction properties of P. incarnata have been reported. The aim of this study was to investigate the effect of a commercial extract of Passiflora incarnata (Sintocalmy®, Aché Laboratory) in the naloxone-induced jumping mice model of morphine withdrawal. In addition, glial fibrillary acidic protein (GFAP) and S100 calcium-binding protein B (S100B) levels were assessed in the frontal cortex and hippocampus, and DNA damage was verified on blood cells. In order to improve solubilization a Sintocalmy methanol extract (SME) was used. SME is mainly composed by flavonoids isovitexin and vitexin. The effects of SME 50, 100 and 200 mg/kg (i.p.) were evaluated in the naloxone-induced withdrawal syndrome in mice. SME 50 and SME 100 mg/kg decreased naloxone-induced jumping in morphine-dependent mice without reducing locomotor activity. No alterations were found in GFAP levels, however SME 50 mg/kg prevented the S100B increase in the frontal cortex and DNA damage. This study shows anti-addiction effects for a commercial standardized extract of P. incarnata and suggests the relevance of proper clinical assessment.
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Affiliation(s)
- Lucas Dos Reis Izolan
- Programa de Pós-Graduação em Ciências Biológicas - Neurociências, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Douglas Marques da Silva
- Programa de Pós-Graduação em Ciências Biológicas - Neurociências, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.,Laboratório de Farmacologia e Toxicologia de Produtos Naturais, Departamento de Farmacologia, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Helena Beatriz Larrosa Oliveira
- Laboratório de Farmacologia e Toxicologia de Produtos Naturais, Departamento de Farmacologia, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Janaína Lucas de Oliveira Salomon
- Laboratório de Farmacologia e Toxicologia de Produtos Naturais, Departamento de Farmacologia, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Caroline Portela Peruzzi
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Solange C Garcia
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Eliane Dallegrave
- Departamento de Farmacociências, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Caroline Zanotto
- Programa de Pós-Graduação em Ciências Biológicas - Bioquímica, Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-anexo, Porto Alegre, Rio Grande do Sul, 90035-003, Brazil
| | - Elaine Elisabetsky
- Programa de Pós-Graduação em Ciências Biológicas - Bioquímica, Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-anexo, Porto Alegre, Rio Grande do Sul, 90035-003, Brazil
| | - Carlos Alberto Gonçalves
- Programa de Pós-Graduação em Ciências Biológicas - Bioquímica, Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-anexo, Porto Alegre, Rio Grande do Sul, 90035-003, Brazil
| | - Marcelo Dutra Arbo
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Eduardo Luis Konrath
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Mirna Bainy Leal
- Programa de Pós-Graduação em Ciências Biológicas - Neurociências, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil. .,Laboratório de Farmacologia e Toxicologia de Produtos Naturais, Departamento de Farmacologia, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
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22
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McMillin GA, Johnson-Davis KL, Kelly BN, Scott B, Yang YK. Impact of the Opioid Epidemic on Drug Testing. Ther Drug Monit 2021; 43:14-24. [PMID: 33230043 DOI: 10.1097/ftd.0000000000000841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND This review provides a description of how the opioid epidemic has impacted drug testing. METHODS Four major service areas of drug testing were considered, including emergency response, routine clinical care, routine forensics, and death investigations. RESULTS Several factors that the opioid epidemic has impacted in drug testing are discussed, including specimens, breadth of compounds recommended for testing, time to result required for specific applications, analytical approaches, interpretive support requirements, and examples of published practice guidelines. CONCLUSIONS Both clinical and forensic laboratories have adapted practices and developed new testing approaches to respond to the opioid epidemic. Such changes are likely to continue evolving in parallel with changes in both prescription and nonprescription opioid availability and use patterns, as well as emerging populations that are affected by the "waves" of the opioid epidemic.
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Affiliation(s)
| | | | - Brian N Kelly
- Department of Pathology, University of Utah and ARUP Laboratories; and
| | | | - Yifei K Yang
- Department of Pathology, University of Utah and ARUP Laboratories; and
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23
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Yildirim E, Selcuk M, Saylik F, Mutluer FO, Deniz O. Effect of Heroin on Electrocardiographic Parameters. Arq Bras Cardiol 2021; 115:1135-1141. [PMID: 33470313 PMCID: PMC8133719 DOI: 10.36660/abc.20190296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/29/2019] [Indexed: 11/18/2022] Open
Abstract
Fundamento Atualmente, o vício em heroína é um problema de saúde preocupante, e as informações sobre os efeitos eletrocardiográficos da heroína são limitadas. Objetivos O objetivo do presente estudo é investigar os efeitos da dependência de heroína em parâmetros eletrocardiográficos. Métodos Um total de 136 indivíduos, incluindo 66 indivíduos que fumam heroína como grupo de estudo e 70 indivíduos saudáveis sem dependência de drogas como grupo de controle, foram incluídos no estudo. Indivíduos que injetam heroína foram excluídos. A avaliação eletrocardiográfica (ECG) dos usuários de heroína foi realizada e comparada com as do grupo controle. Além disso, os ECGs pré e pós-tratamento do grupo usuário de heroína foram comparados. Um valor de p<0,05 foi aceito como estatisticamente significativo. Resultados A frequência cardíaca (77,2±12,8
versus
71,4±11,2; p=0,02) foi maior no grupo usuário de heroína em comparação com o grupo controle. Os intervalos QT (341,50±25,80
versus
379,11±45,23; p=0,01), QTc (385,12±29,11
versus
411,3±51,70; p<0,01) e o intervalo do pico ao fim da onda T (Tpe) (65,41±10,82
versus
73,3±10,13; p<0,01) foram significativamente menores no grupo usuário de heroína. Nenhuma diferença foi observada entre os grupos com respeito às razões Tpe/QT e Tpe/QTc. Na análise de subgrupo do grupo usuário de heroína, os intervalos QT (356,81±37,49
versus
381,18±40,03; p<0,01) e QTc (382,06±26,41
versus
396,06±29,80; p<0,01) foram significativamente mais curtos no período pré-tratamento. Conclusão O vício em heroína afeta significativamente os intervalos de tempo QT, QTc e Tpe. Os efeitos de arritmia desses parâmetros já são conhecidos. Os parâmetros eletrocardiográficos desses indivíduos merecem mais atenção. (Arq Bras Cardiol. 2020; 115(6):1135-1141)
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Affiliation(s)
- Ersin Yildirim
- Umraniye Training and Research Hospital, Istanbul - Turquia
| | - Murat Selcuk
- Van Egitim ve Arastirma Hastanesi, Van - Turquia
| | | | | | - Ozgur Deniz
- Van Egitim ve Arastirma Hastanesi, Van - Turquia
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Scherrer JF, Salas J, Grucza R, Sullivan MD, Lustman PJ, Copeland LA, Ballantyne JC. Depression and Buprenorphine Treatment in Patients with Non-cancer Pain and Prescription Opioid Dependence without Comorbid Substance Use Disorders. J Affect Disord 2021; 278:563-569. [PMID: 33022442 DOI: 10.1016/j.jad.2020.09.089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/02/2020] [Accepted: 09/15/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Depression occurs in 40% of patients with prescription opioid dependence (POD). Existing studies of the association between depression and buprenorphine (BUP) treatment for POD are inconsistent and often include patients with comorbid substance use disorders (SUD). We estimated the association between depression and BUP use in patients with pain and POD and free of comorbid SUD. METHODS Optum® de-identified Electronic Health Record dataset from 2010 to 2018 was used to identify 5,529 patients with chronic pain, with and without depression, receiving prescription opioids and free of substance use disorder diagnoses for one year before POD diagnoses. Unadjusted and adjusted Cox proportional hazard models and negative binomial regression models were computed to estimate the association between depression and time to BUP start, number of BUP prescriptions in the year after BUP start and time to >30 day BUP gap. RESULTS Patients' mean age was 52.4 (SD±15.3) years, 62% were female and 84% were white and 4.9% (n=270) started BUP. Depression was not associated with BUP initiation.. Among BUP starters, depression vs. no depression, was significantly associated with receiving 29% fewer BUP prescriptions (RR=0.71; 95%CI: 0.51-0.98) and an increased risk for > 30 day gap (HR=1.76; 95%CI:1.01-3.09). LIMITATIONS Missing data prevented measuring BUP dose. CONCLUSIONS Depression is likely associated with earlier BUP treatment dropout. Depression related medication non-adherence or possible worsening of depression following BUP taper could explain results. Research is needed to determine if depression severity is associated with BUP dose trajectories and multi-year BUP retention..
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Affiliation(s)
- Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis MO. 63104.
| | - Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis MO. 63104
| | - Richard Grucza
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis MO. 63104
| | - Mark D Sullivan
- Department of Psychiatry and Behavioral Science, University of Washington School of Medicine, Seattle WA. 98195
| | - Patrick J Lustman
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO. 63110; The Bell Street Clinic Opioid Addiction Treatment Programs, VA St. Louis Healthcare System, St. Louis, MO. 63106
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA 01053; Department of Quantitative Health Sciences, Univ. of Mass. Medical School, Worcester, MA 01605
| | - Jane C Ballantyne
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle WA 98195
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Pilozzi A, Carro C, Huang X. Roles of β-Endorphin in Stress, Behavior, Neuroinflammation, and Brain Energy Metabolism. Int J Mol Sci 2020; 22:E338. [PMID: 33396962 PMCID: PMC7796446 DOI: 10.3390/ijms22010338] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/23/2020] [Accepted: 12/26/2020] [Indexed: 12/25/2022] Open
Abstract
β-Endorphins are peptides that exert a wide variety of effects throughout the body. Produced through the cleavage pro-opiomelanocortin (POMC), β-endorphins are the primarily agonist of mu opioid receptors, which can be found throughout the body, brain, and cells of the immune system that regulate a diverse set of systems. As an agonist of the body's opioid receptors, β-endorphins are most noted for their potent analgesic effects, but they also have their involvement in reward-centric and homeostasis-restoring behaviors, among other effects. These effects have implicated the peptide in psychiatric and neurodegenerative disorders, making it a research target of interest. This review briefly summarizes the basics of endorphin function, goes over the behaviors and regulatory pathways it governs, and examines the variability of β-endorphin levels observed between normal and disease/disorder affected individuals.
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Affiliation(s)
| | | | - Xudong Huang
- Neurochemistry Laboratory, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA; (A.P.); (C.C.)
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Feder R. Ten Years of Experience With Buprenorphine in a Private Psychiatric Outpatient Practice. Am J Addict 2020; 29:508-514. [DOI: 10.1111/ajad.13060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/19/2020] [Accepted: 05/02/2020] [Indexed: 11/27/2022] Open
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Busch AB, Greenfield SF, Reif S, Normand SLT, Huskamp HA. Outpatient care for opioid use disorder among the commercially insured: Use of medication and psychosocial treatment. J Subst Abuse Treat 2020; 115:108040. [PMID: 32600627 PMCID: PMC7687676 DOI: 10.1016/j.jsat.2020.108040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 05/07/2020] [Accepted: 05/19/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Evidence-based outpatient treatment for opioid use disorder (OUD) consists of medications that treat OUD (MOUD) and psychosocial treatments (e.g., psychotherapy or counseling, case management). Prior studies have not examined the use of these components of care in a commercially insured population. METHODS We analyzed claims data from a large national commercial insurer of enrollees age 17-64 identified with OUD (2008-2016, N = 87,877 persons and 122,708 person-years). Multinomial logistic regression models identified factors associated with receiving in a given year: 1) both MOUD and psychosocial visits, 2) MOUD without psychosocial visits, 3) psychosocial visits without MOUD, or 4) neither. We estimated predicted probabilities for key variables of interest. RESULTS Identification of OUD nearly tripled during the observation period (0.17% in 2008, 0.45% in 2016). Among person-years identified as having OUD, 36.3% included MOUD (8.1% both MOUD and psychosocial visits and 28.2% MOUD without psychosocial visits). In adjusted analyses, women had a lower probability of receiving either treatment alone or in combination (e.g.,MOUD plus psychosocial visits: women = 6.7% [6.5%-6.9%] vs. men = 9.2% [9.0%-9.4%]). Moderate/severe vs. mild OUD was associated with a higher probability of receiving MOUD (e.g., MOUD plus psychosocial visits: 8.7% [8.6%-8.9%] vs. 0.9% [0.7%-1.0%]). In contrast, an OUD overdose was associated with a greater probability of receiving neither treatment (78.2% [77.4%-79.0%] vs. 55.5% [55.2%-55.8%]). Over time, the probability of receiving each MOUD and psychosocial treatment category increased relative to 2008, but reached a peak and then plateaued or declined, by the end of the study period. CONCLUSIONS A significant treatment gap exists among individuals identified with OUD in this commercially insured population, with greater risks of receiving no treatment for women and for individuals with mild versus moderate or severe OUD. Overdose is associated with receiving neither MOUD nor psychosocial treatment. While treated prevalence initially increased relative to 2008, rates of treatment subsequently plateaued. Additional study and monitoring to elucidate barriers to OUD treatment in commercially insured populations are warranted.
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Affiliation(s)
- Alisa B Busch
- Department of Health Care Policy, Harvard Medical School, Boston, MA, United States of America.
| | | | - Sharon Reif
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America.
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, Boston, MA, United States of America.
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, MA, United States of America.
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Varisco T, Shen C, Thornton D. Chronic prescription opioid use predicts stabilization on buprenorphine for the treatment of opioid use disorder. J Subst Abuse Treat 2020; 117:108073. [PMID: 32811630 DOI: 10.1016/j.jsat.2020.108073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/13/2020] [Accepted: 06/24/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Prescription opioid misuse is a risk factor for opioid use disorder (OUD). Patients who misuse prescribed opioids and those who misuse illicit opioids are demographically and medically distinct groups, and research has shown there is heterogeneity in treatment response between these groups. The objective of this study was to measure the adjusted odds of successful stabilization on buprenorphine in patients with baseline prescription opioid use compared to those not prescribed opioids. METHODS A cohort of patients newly prescribed a buprenorphine product indicated for OUD between January 1 and November 30, 2018, were identified from the Texas Prescription Monitoring Program. We excluded those under the age of 15 and those who filled an opioid prescription after initiating buprenorphine to limit misclassification. We then stratified the cohort based on type of prescription opioid use in the pre-index period. We defined chronic opioid use as being prescribed opioids for a period of 90 out of 120 days, ending no sooner than 90 days prior to treatment initiation. We defined acute opioid use as filling any opioid prescription in the 90 days prior to initiating buprenorphine. The outcome of interest-stabilization on buprenorphine-was met by filling two prescriptions totaling 30-days' supply with no more than a six-day gap in therapy. We used multiple logistic regression to estimate the odds of stabilization in the prescription opioid use categories compared to those with no pre-index, opioid prescriptions. RESULTS Among 6756 eligible patients, 44.1% used prescription opioids in the 90 days prior to buprenorphine initiation. Of these, 62.2% met the criteria for acute prescription opioid use and 37.8% for chronic prescription opioid use. Patients with prescription opioid use at baseline were more likely to be older and insured compared to those with no prescription opioid use. After adjustment for covariates, both prescription opioid use groups were significantly more likely to be successfully stabilized on therapy (Acute: aOR = 1.53, 95% CI = 1.37-1.72; Chronic: aOR = 2.43, 95% CI = 2.08-2.85). In a second model, those with chronic prescription opioid use were significantly more likely than those with acute prescription opioid use to be successfully stabilized (aOR = 1.60, 95% CI = 1.31-1.90). CONCLUSION Persistence to buprenorphine treatment for OUD is, in part, dependent on baseline prescription opioid use. This study suggests that patients with chronic prescription opioid use may be more likely than nonprescription opioid users to be successfully stabilized on treatment and may thus benefit more from pharmacotherapy with buprenorphine than those with no prescription opioid use. Failing to account for this variation in future studies of buprenorphine treatment persistence may lead to significant residual confounding and biased results. Extending access to buprenorphine among those with prescription OUD may have a significant impact on opioid related morbidity and mortality.
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Affiliation(s)
- Tyler Varisco
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, United States of America; Prescription Drug Misuse Education and Research Center, University of Houston College of Pharmacy, United States of America
| | - Chan Shen
- Division of Outcomes Research and Quality, Department of Surgery, Penn State University, United States of America
| | - Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, United States of America; Prescription Drug Misuse Education and Research Center, University of Houston College of Pharmacy, United States of America.
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Strayer RJ, Hawk K, Hayes BD, Herring AA, Ketcham E, LaPietra AM, Lynch JJ, Motov S, Repanshek Z, Weiner SG, Nelson LS. Management of Opioid Use Disorder in the Emergency Department: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med 2020; 58:522-546. [DOI: 10.1016/j.jemermed.2019.12.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/19/2019] [Accepted: 12/24/2019] [Indexed: 11/28/2022]
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Hastings JS, Howison M, Inman SE. Predicting high-risk opioid prescriptions before they are given. Proc Natl Acad Sci U S A 2020; 117:1917-1923. [PMID: 31937665 PMCID: PMC6994994 DOI: 10.1073/pnas.1905355117] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Misuse of prescription opioids is a leading cause of premature death in the United States. We use state government administrative data and machine learning methods to examine whether the risk of future opioid dependence, abuse, or poisoning can be predicted in advance of an initial opioid prescription. Our models accurately predict these outcomes and identify particular prior nonopioid prescriptions, medical history, incarceration, and demographics as strong predictors. Using our estimates, we simulate a hypothetical policy which restricts new opioid prescriptions to only those with low predicted risk. The policy's potential benefits likely outweigh costs across demographic subgroups, even for lenient definitions of "high risk." Our findings suggest new avenues for prevention using state administrative data, which could aid providers in making better, data-informed decisions when weighing the medical benefits of opioid therapy against the risks.
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Affiliation(s)
- Justine S Hastings
- Research Improving People's Lives, Providence, RI 02903;
- Watson Institute for International and Public Affairs, Brown University, Providence, RI 02912
- Department of Economics, Brown University, Providence, RI 02912
- National Bureau of Economic Research, Cambridge, MA 02138
| | - Mark Howison
- Research Improving People's Lives, Providence, RI 02903
- Watson Institute for International and Public Affairs, Brown University, Providence, RI 02912
| | - Sarah E Inman
- Research Improving People's Lives, Providence, RI 02903
- School of International and Public Affairs, Columbia University, New York, NY 10027
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Ruglass LM, Scodes J, Pavlicova M, Campbell ANC, Fitzpatrick S, Barbosa-Leiker C, Burlew K, Greenfield SF, Rotrosen J, Nunes EV. Trajectory classes of opioid use among individuals in a randomized controlled trial comparing extended-release naltrexone and buprenorphine-naloxone. Drug Alcohol Depend 2019; 205:107649. [PMID: 31704382 PMCID: PMC6990451 DOI: 10.1016/j.drugalcdep.2019.107649] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/01/2019] [Accepted: 09/10/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To advance our understanding of medication treatments for opioid use disorders (OUDs), identification of distinct subgroups and factors associated with differential treatment response is critical. We examined trajectories of opioid use for patients with OUD who were randomized to (but not in all cases inducted onto) buprenorphine-naloxone (BUP-NX) or extended-release naltrexone (XR-NTX), and identified characteristics associated with each trajectory. METHODS Growth mixture models (GMMs) were run to identify distinct trajectories of days of opioid use among a subsample of 535 individuals with OUD who participated in a 24-week randomized controlled trial (RCT; 2014-2016) of BUP-NX (n = 281) or XR-NTX (n = 254). RESULTS Four distinct opioid use trajectory classes were identified for BUP-NX (near abstinent/no use (59%); low use (13.2%); low use, increasing over time (15%); and moderate use, increasing over time (12.8%)). Three distinct opioid use trajectory classes were found for XR-NTX (near abstinent/no use (59.1%); low use (14.6%); and moderate use, increasing over time (26.4%)). Across both BUP-NX and XR-NTX, the near abstinent/no use class had the highest number of medical management visits. Within BUP-NX, the low use class had a greater proportion of individuals with a previous successful treatment history compared with other classes. Within XR-NTX, the moderate use, increasing over time class had the highest proportion of Hispanic participants compared with other classes. CONCLUSIONS Findings highlight the significant heterogeneity of opioid use during a RCT of BUP-NX and XR-NTX and factors associated with opioid use patterns including medical management visits and history of treatment success.
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Affiliation(s)
| | | | | | - Aimee N. C. Campbell
- Columbia University Irving Medical Center and New York State Psychiatric Institute
| | | | | | | | | | | | - Edward V. Nunes
- Columbia University Irving Medical Center and New York State Psychiatric Institute
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Kiluk BD, Yip SW, DeVito EE, Carroll KM, Sofuoglu M. Anhedonia as a key clinical feature in the maintenance and treatment of opioid use disorder. Clin Psychol Sci 2019; 7:1190-1206. [PMID: 32042509 DOI: 10.1177/2167702619855659] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
There is a critical need for research on clinical features that may influence response to treatment for opioid use disorder (OUD). Given its neurobiology and relevance to opioid use, anhedonia may be one such promising clinical feature. We identified and reviewed 11 studies that measured anhedonia in humans with OUD to characterize the current state of evidence and highlight potential implications for treatment. The majority of studies were cross-sectional, indicating higher anhedonia scores in opioid-dependent samples compared to healthy controls. Rates of participants with clinically significant anhedonia ranged from 21% to 48%. Anhedonia scores were correlated with opioid craving and use, however there are significant knowledge gaps regarding its time course and impact on treatment adherence and outcomes. Repeated assessment of anhedonia early in treatment for OUD is recommended, as it may be a unique predictor of dropout or non-response, and a potential target for behavioral and/or pharmacological intervention.
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Majid Z, Tanveer M, Ali Asghar S, Tahir F, Minhaj A, Khan HA, Sialvi T, Mahmood SH, Qadar LT, Imtiaz F. Opioids Use and Abuse: Prescription Practice, Attitude, and Beliefs among Doctors of Karachi. Cureus 2019; 11:e5253. [PMID: 31572638 PMCID: PMC6760877 DOI: 10.7759/cureus.5253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Opioid analgesics, also known as narcotics, are medicinal drugs used primarily for the management of pain secondary to any type of cancer, severe injury or surgery. Due to the ease of availability, opioids are commonly abused. In 2015, reported deaths exceeded 33,000 Americans from opioid overdose. A survey in 2013 revealed nearly 1.6 million Pakistanis abusing prescription opioids for non-medical needs. Although commonly prescribed by primary care physicians, most of them are diffident to stand by all the recommended strategies to reduce the incidence of opioid abuse. Methods A cross-sectional study was conducted during the period of August through October 2018. A sample size of 365 was determined using a 95% confidence interval at a degree of precision of 5%. A 22-item questionnaire was given to doctors with at least two years practicing experience either from a private or a public healthcare setup. Doctors who had never prescribed opioids were excluded from the study. Out of the eligible participants, 15 refused to take part in the survey, and the co-operation rate was recorded as 95.8%. Collected data were analyzed using statistical package for social science (SPSS) version 22 for Windows. Frequencies, percentages, mean, standard deviation, and chi-square were used to explore the variables. The statistical significance level was considered at p < 0.5. Results Opioids were reported to be used mainly for treating acute pain (40.5%), chronic pain (24.7%) and both acute and chronic (34.8%). A minority of doctors (29%) screened their patients for opioid addiction. A significant association (p = 0.000) between the frequency of opioid prescription and prior screening for depression was determined. Surprisingly, only 23.2% clinicians frequently screened their patients for depression before prescribing opioids. The rate of counselling regarding drug tapering was found to be 71.6%. A majority, i.e., 88%, of the respondents anticipated the misuse of opioids they prescribe whereas 74% also held a belief that patients self-medicate their untreated pain. Participants reported addiction (54%) as the most common reason for abuse followed by the role of pharmaceutical companies (43%) and pharmacies (41%). About 80.2% clinicians believed that patients addicted to opioids could get well and return to their daily routine. Conclusion The rising opioid epidemic is a major concern for doctors prescribing opioids. Adaptation of medical school curricula and appropriate training can equip doctors for better management of patients requiring opioids. This includes the screening of patients using standard risk assessment tools for opioid abuse leading to a more controlled opioid prescription practice. Dissemination of these tools will boost doctors' confidence and may help in reducing morbidity and mortality from opioid abuse.
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Affiliation(s)
- Zainab Majid
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Mahpara Tanveer
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | | | - Faryal Tahir
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Areeba Minhaj
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Hamza Aijaz Khan
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Tehzeeb Sialvi
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | | | - Laila Tul Qadar
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Fouzia Imtiaz
- Genetics, Dow University of Health Sciences, Karachi, PAK
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Meinhofer A, Williams AR, Johnson P, Schackman BR, Bao Y. Prescribing decisions at buprenorphine treatment initiation: Do they matter for treatment discontinuation and adverse opioid-related events? J Subst Abuse Treat 2019; 105:37-43. [PMID: 31443889 DOI: 10.1016/j.jsat.2019.07.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/11/2019] [Accepted: 07/19/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Buprenorphine is a highly effective medication treatment for opioid use disorder (OUD) that can be prescribed in multiple treatment settings. Treatment retention, however, remains a challenge. In this study, we examined the association of days of supply as well as daily dosage of the initial buprenorphine prescription with treatment discontinuation and adverse opioid-related events following buprenorphine initiation. METHODS 2011 to 2015 Health Care Cost Institute commercial claims data were analyzed for individuals aged 18-64 years initiating buprenorphine treatment (N = 17,158). Treatment discontinuation was defined as a gap of 30 days or more in buprenorphine use within 180 days of initiation. Adverse opioid-related events were defined as having at least one emergency department visit or inpatient admission involving opioid poisoning, dependence or abuse within 360 days of initiation. We conducted multivariate logistic regressions to estimate adjusted odds ratios of outcomes associated with daily dose (≤4 mg vs. >4 mg) and days of supply (≤7, 8-15, 16-27, or ≥ 28 days) of the initial buprenorphine prescription. RESULTS Over one-half (55%) of individuals discontinued buprenorphine within 180 days and 13% experienced at least one adverse opioid-related event within 360 days of initiation. Both a lower initial dose [≤4 mg, OR = 1.79, p < 0.01] and fewer initial days of supply [≤7 days vs. ≥28 days, OR = 1.32, p < 0.01] [8-15 days vs. ≥28 days, OR = 1.22, p < 0.01] were associated with increased odds of discontinuation. While a lower initial dose was not associated with adverse events, fewer initial days of supply were associated with a higher risk of adverse events, even after controlling for treatment discontinuation. CONCLUSION In this population of commercially insured, non-elderly adults, we found that fewer initial days of supply as well as a lower initial dose were associated with increased likelihood of treatment discontinuation, highlighting the importance of prescribing decisions when initiating buprenorphine for OUD.
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Affiliation(s)
- Angélica Meinhofer
- Weill Cornell Medicine, Department of Healthcare Policy & Research, New York, NY, United States of America.
| | - Arthur Robin Williams
- Columbia University, Department of Psychiatry, New York, NY, United States of America; New York State Psychiatric Institute, New York, NY, United States of America
| | - Phyllis Johnson
- Weill Cornell Medicine, Department of Healthcare Policy & Research, New York, NY, United States of America
| | - Bruce R Schackman
- Weill Cornell Medicine, Department of Healthcare Policy & Research, New York, NY, United States of America
| | - Yuhua Bao
- Weill Cornell Medicine, Department of Healthcare Policy & Research, New York, NY, United States of America
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Olson KM, Duron DI, Womer D, Fell R, Streicher JM. Comprehensive molecular pharmacology screening reveals potential new receptor interactions for clinically relevant opioids. PLoS One 2019; 14:e0217371. [PMID: 31170174 PMCID: PMC6553708 DOI: 10.1371/journal.pone.0217371] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/09/2019] [Indexed: 01/17/2023] Open
Abstract
Most clinically used opioids are thought to induce analgesia through activation of the mu opioid receptor (MOR). However, disparities have been observed between the efficacy of opioids in activating the MOR in vitro and in inducing analgesia in vivo. In addition, some clinically used opioids do not produce cross-tolerance with each other, and desensitization produced in vitro does not match tolerance produced in vivo. These disparities suggest that some opioids could be acting through other targets in vivo, but this has not been comprehensively tested. We thus screened 9 clinically relevant opioids (buprenorphine, hydrocodone, hydromorphone, morphine, O-desmethyl-tramadol, oxycodone, oxymorphone, tapentadol, tramadol) against 9 pain-related receptor targets (MOR, delta opioid receptor [DOR], kappa opioid receptor [KOR], nociceptin receptor [NOP], cannabinoid receptor type 1 [CB1], sigma-1 receptor [σ1R], and the monoamine transporters [NET/SERT/DAT]) expressed in cells using radioligand binding and functional activity assays. We found several novel interactions, including monoamine transporter activation by buprenorphine and σ1R binding by hydrocodone and tapentadol. Tail flick anti-nociception experiments with CD-1 mice demonstrated that the monoamine transporter inhibitor duloxetine selectively promoted buprenorphine anti-nociception while producing no effects by itself or in combination with the most MOR-selective drug oxymorphone, providing evidence that these novel interactions could be relevant in vivo. Our findings provide a comprehensive picture of the receptor interaction profiles of clinically relevant opioids, which has not previously been performed. Our findings also suggest novel receptor interactions for future investigation that could explain some of the disparities observed between opioid performance in vitro and in vivo.
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Affiliation(s)
- Keith M. Olson
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, United States of America
| | - David I. Duron
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, United States of America
| | - Daniel Womer
- Depomed, Inc., Newark, CA, United States of America
| | - Ryan Fell
- Depomed, Inc., Newark, CA, United States of America
| | - John M. Streicher
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, United States of America
- * E-mail:
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Modeling the Prescription Opioid Epidemic. Bull Math Biol 2019; 81:2258-2289. [DOI: 10.1007/s11538-019-00605-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 04/09/2019] [Indexed: 10/27/2022]
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Weiss RD, Griffin ML, Marcovitz DE, Hilton BT, Fitzmaurice GM, McHugh RK, Carroll KM. Correlates of Opioid Abstinence in a 42-Month Posttreatment Naturalistic Follow-Up Study of Prescription Opioid Dependence. J Clin Psychiatry 2019; 80:18m12292. [PMID: 30920187 PMCID: PMC6842303 DOI: 10.4088/jcp.18m12292] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 11/12/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The natural course of prescription opioid use disorder has not been examined in longitudinal studies. The current study examined correlates of opioid abstinence over time after completion of a treatment trial for prescription opioid dependence. METHODS The multisite Prescription Opioid Addiction Treatment Study examined different durations of buprenorphine-naloxone treatment and different intensities of counseling to treat prescription opioid dependence, as assessed by DSM-IV; following the clinical trial, a longitudinal study was conducted from March 2009-January 2013. At 18, 30, and 42 months after treatment entry, telephone interviews were conducted (N = 375). In this exploratory, naturalistic study, logistic regression analyses examined the association between treatment modality (including formal treatment and mutual help) and opioid abstinence rates at the follow-up assessments. RESULTS At the 3 follow-up assessments, approximately half of the participants reported engaging in current substance use disorder treatment (47%-50%). The most common treatments were buprenorphine maintenance (27%-35%) and mutual-help group attendance (27%-30%), followed by outpatient counseling (18%-23%) and methadone maintenance (4%). In adjusted analyses, current opioid agonist treatment showed the strongest association with current opioid abstinence (odds ratios [ORs] = 5.4, 4.6, and 2.8 at the 3 assessments), followed by current mutual-help attendance (ORs = 2.2, 2.7, and 1.9); current outpatient counseling was not significantly associated with abstinence in the adjusted models. CONCLUSIONS While opioid agonist treatment was most strongly associated with opioid abstinence among patients with prescription opioid dependence over time, mutual-help group attendance was independently associated with opioid abstinence. Clinicians should consider recommending both of these interventions to patients with opioid use disorder. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00316277.
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Affiliation(s)
- Roger D Weiss
- McLean Hospital, 115 Mill St, Belmont, MA 02478.
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret L Griffin
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - David E Marcovitz
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Blake T Hilton
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts, USA
| | - Garrett M Fitzmaurice
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Laboratory for Psychiatric Biostatistics, McLean Hospital, Belmont, Massachusetts, USA
| | - R Kathryn McHugh
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen M Carroll
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
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Ling W, Nadipelli VR, Ronquest NA, Albright VA, Aldridge AP, Learned SM, Mehra V, Heidbreder C. Remission from chronic opioid use—Studying environmental and socio-economic factors on recovery (RECOVER): Study design and participant characteristics. Contemp Clin Trials 2019; 76:93-103. [DOI: 10.1016/j.cct.2018.11.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/20/2018] [Accepted: 11/30/2018] [Indexed: 11/15/2022]
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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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Johnson K, Jones C, Compton W, Baldwin G, Fan J, Mermin J, Bennett J. Federal Response to the Opioid Crisis. Curr HIV/AIDS Rep 2018; 15:293-301. [PMID: 29968173 PMCID: PMC11034841 DOI: 10.1007/s11904-018-0398-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW In light of the current crisis in opioid involved overdose deaths, the federal Department of Health and Human Services operating divisions are working together to implement a data-driven, research-based strategy to reduce opioid misuse and its consequences. RECENT FINDINGS The strategy has five elements: (1) strengthening public health data collection and reporting; (2) advancing the practice of pain management; (3) improving access to addiction prevention, treatment, and recovery support services; (4) increasing availability of overdose-reversing drugs; and (5) supporting cutting-edge research in treatment of pain, opioid use disorder, and associated conditions. The Department of Health and Human Services has developed a concerted, coordinated evidence-based effort across department divisions to reduce opioid misuse, prevalence of opioid use disorder, and reduce deaths due to opioid use.
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Affiliation(s)
- Kimberly Johnson
- Substance Abuse Mental Health Services Administration (SAMHSA), Rockville, MD, USA.
- University of South Florida, Tampa, Florida, USA.
| | - Chris Jones
- Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, Washington, DC, USA
| | | | - Grant Baldwin
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jennifer Fan
- Substance Abuse Mental Health Services Administration (SAMHSA), Rockville, MD, USA
| | - Jonathan Mermin
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jean Bennett
- Substance Abuse Mental Health Services Administration (SAMHSA), Rockville, MD, USA
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Abstract
The current opioid crisis highlights an urgent need for better paradigms for prevention and treatment of chronic pain and addiction. Although many approach this complex clinical condition with the question, "Is this pain or is this addiction?," it is more than the sum of its parts. Chronic pain among those with dependence and addiction often evolves into a complex disabling condition with pain at multiple sites, psychosocial dysfunctions, medical and psychiatric disorders, polypharmacy, and polysubstance use, all interacting with each other in complex ways (multimorbidity). The authors offer an integrative therapeutic approach to manage this complex clinical scenario.
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Affiliation(s)
- Ajay Manhapra
- Veteran Affairs New England Mental Illness Research, Education and Clinical Center (MIRECC), West Haven, CT, USA; Advanced PACT Pain Clinic, VA Hampton Medical Center, 100 Emancipation Drive, PRIME 5, Hampton, VA 23667, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| | - William C Becker
- Opioid Reassessment Clinic, VA Connecticut Healthcare System, 950 Campbell Avenue, Mailstop 151B, West Haven, CT 06516, USA; Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, West Haven, CT, USA; Department of Medicine, Yale School of Medicine, New Haven, CT, USA
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Kelly JF, Bergman B, Hoeppner BB, Vilsaint C, White WL. Prevalence and pathways of recovery from drug and alcohol problems in the United States population: Implications for practice, research, and policy. Drug Alcohol Depend 2017; 181:162-169. [PMID: 29055821 PMCID: PMC6076174 DOI: 10.1016/j.drugalcdep.2017.09.028] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/23/2017] [Accepted: 09/26/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND Alcohol and other drug (AOD) problems confer a global, prodigious burden of disease, disability, and premature mortality. Even so, little is known regarding how, and by what means, individuals successfully resolve AOD problems. Greater knowledge would inform policy and guide service provision. METHOD Probability-based survey of US adult population estimating: 1) AOD problem resolution prevalence; 2) lifetime use of "assisted" (i.e., treatment/medication, recovery services/mutual help) vs. "unassisted" resolution pathways; 3) correlates of assisted pathway use. Participants (response=63.4% of 39,809) responding "yes" to, "Did you use to have a problem with alcohol or drugs but no longer do?" assessed on substance use, clinical histories, problem resolution. RESULTS Weighted prevalence of problem resolution was 9.1%, with 46% self-identifying as "in recovery"; 53.9% reported "assisted" pathway use. Most utilized support was mutual-help (45.1%,SE=1.6), followed by treatment (27.6%,SE=1.4), and emerging recovery support services (21.8%,SE=1.4), including recovery community centers (6.2%,SE=0.9). Strongest correlates of "assisted" pathway use were lifetime AOD diagnosis (AOR=10.8[7.42-15.74], model R2=0.13), drug court involvement (AOR=8.1[5.2-12.6], model R2=0.10), and, inversely, absence of lifetime psychiatric diagnosis (AOR=0.3[0.2-0.3], model R2=0.10). Compared to those with primary alcohol problems, those with primary cannabis problems were less likely (AOR=0.7[0.5-0.9]) and those with opioid problems were more likely (AOR=2.2[1.4-3.4]) to use assisted pathways. Indices related to severity were related to assisted pathways (R2<0.03). CONCLUSIONS Tens of millions of Americans have successfully resolved an AOD problem using a variety of traditional and non-traditional means. Findings suggest a need for a broadening of the menu of self-change and community-based options that can facilitate and support long-term AOD problem resolution.
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Affiliation(s)
- John F. Kelly
- Recovery Research Institute, Massachusetts General Hospital, 151 Merrimac Street, and Harvard Medical School, Boston, MA, 02114, United States,Corresponding author at: Recovery Research Institute, Massachusetts General Hospital, 151 Merrimac Street, Boston, MA, 02114, United States. (J.F. Kelly)
| | - Brandon Bergman
- Recovery Research Institute, Massachusetts General Hospital, 151 Merrimac Street, and Harvard Medical School, Boston, MA, 02114, United States
| | - Bettina B. Hoeppner
- Recovery Research Institute, Massachusetts General Hospital, 151 Merrimac Street, and Harvard Medical School, Boston, MA, 02114, United States
| | - Corrie Vilsaint
- Recovery Research Institute, Massachusetts General Hospital, 151 Merrimac Street, and Harvard Medical School, Boston, MA, 02114, United States
| | - William L. White
- Chestnut Health Systems, W Chestnut St, Bloomington, IL, 61701, United States
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Sugarman DE, Reilly ME, Greenfield SF. Treatment Outcomes for Women with Substance Use Disorders: a Critical Review of the Literature (2010–2016). CURRENT ADDICTION REPORTS 2017. [DOI: 10.1007/s40429-017-0172-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
America is in the midst of an opioid epidemic characterized by aggressive prescribing practices, highly prevalent opioid misuse, and rising rates of prescription and illicit opioid overdose-related deaths. Medical and lay public sentiment have become more cautious with respect to prescription opioid use in the past few years, but a comprehensive strategy to reduce our reliance on prescription opioids is lacking. Addressing this epidemic through reductions in unnecessary access to these drugs while implementing measures to reduce demand will be important components of any comprehensive solution. Key supply-side measures include avoiding overprescribing, reducing diversion, and discouraging misuse through changes in drug formulations. Important demand-side measures center around educating patients and clinicians regarding the pitfalls of opioid overuse and methods to avoid unnecessary exposure to these drugs. Anesthesiologists, by virtue of their expertise in the use of these drugs and their position in guiding opioid use around the time of surgery, have important roles to play in reducing patient exposure to opioids and providing education about appropriate use. Aside from the many immediate steps that can be taken, clinical and basic research directed at understanding the interaction between pain and opioid misuse is critical to identifying the optimal use of these powerful pain relievers in clinical practice.
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Affiliation(s)
- David J Clark
- From the *Department of Anesthesiology, Stanford University, Palo Alto, California; and †UCSF Department of Anesthesia and Perioperative Care, Division of Pain Medicine, San Francisco, California
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Pedersen CA. Oxytocin, Tolerance, and the Dark Side of Addiction. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 136:239-274. [PMID: 29056153 DOI: 10.1016/bs.irn.2017.08.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Substance use disorders blight the lives of millions of people and inflict a heavy financial burden on society. There is a compelling need for new pharmacological treatments as current drugs have limited efficacy and other major drawbacks. A substantial number of animal and recent clinical studies indicate that the neuropeptide, oxytocin, is a particularly promising therapeutic agent for human addictions, especially alcohol use disorders. In preliminary trials, we found that oxytocin administered by the intranasal route, which produces some neuropeptide penetration into the CNS, potently blocked withdrawal and reduced alcohol consumption in heavy drinkers. A considerable body of earlier animal studies demonstrated that oxytocin inhibits tolerance to alcohol, opioids, and stimulants as well as withdrawal from alcohol and opioids. Based on these preclinical findings and our clinical results, we hypothesize that oxytocin may exert therapeutic effects in substance dependence by the novel mechanism of diminishing established tolerance. A newer wave of studies has almost unanimously found that oxytocin decreases self-administration of a number of addictive substances in several animal models of addiction. Reduction of established tolerance should be included among the potential explanations of oxytocin effects in these studies and changes in tolerance should be examined in future studies in relationship to oxytocin influences on acquisition and reinstatement of self-administration as well as extinction of drug seeking. Oxytocin efficacy in reducing anxiety and stress responses as well as established tolerance suggests it may be uniquely effective in reducing negative reinforcement (Koob's "dark side" of addiction) that maintains chronic substance use.
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Affiliation(s)
- Cort A Pedersen
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
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