Buprenorphine from detox and beyond: preliminary evaluation of a pilot program to increase heroin dependent individuals' engagement in a full continuum of care

Prevention of 90-day inpatient detoxification readmission for opioid use disorder by a community-based life-changing individualized medically assisted evidence-based treatment (C.L.I.M.B.) program: A quasi-experimental study

BACKGROUND

Evidence for community-based strategies to reduce inpatient detoxification readmission for opioid use disorder (OUD) is scant. A pilot program was designed to provide individualized structured treatment plans, including addressing prolonged withdrawal symptoms, family/systems assessment, and contingency management, to reduce readmission after the index inpatient detoxification.

METHODS

A non-randomized quasi-experimental design was used to compare the pilot facilities (treatment) and comparison facilities before and after the program started, i.e., a simple difference-in-differences (DID) strategy. Adults 18 years and older who met the Diagnostic and Statistical Manual of Mental Disorders version 5 criteria for OUD and had an inpatient detoxification admission at any OUD treatment facility in two study periods between 7/2016 and 3/2020 were included. Readmission for inpatient detoxification in 90-days after the index stay was the primary outcome, and partial hospitalization, intensive outpatient care, outpatient services, and medications for OUD were the secondary outcomes. Six statistical estimation methods were used to triangulate evidence and adjust for potential confounding factors between treatment and comparison groups.

RESULTS

A total of 2,320 unique patients in the pilot and comparison facilities with 2,443 index inpatient detoxification admissions in the pre- and post-periods were included. Compared with patients in comparison facilities, patients in the C.L.I.M.B. facilities had higher readmission in the pre-period (unadjusted readmission 17.0% vs. 10.6%), but similar rates in the post-period (12.3% vs. 10.6%) after the implementation of the pilot program. For 90-day readmission, all DID estimates were not statistically significant (adjusted estimates ranged from 6 to 9 percentage points difference favoring the C.L.I.M.B. program). There was no significant improvement in the secondary outcomes of utilizations in lower level of care and medications for OUD in C.L.I.M.B. facilities.

CONCLUSIONS

We found a reduction in readmission in the pilot facilities between the two periods, but the results were not statistically significant compared with the comparison facilities and the utilization of lower level of care services remained low. Even though providers in the pilot OUD treatment facilities actively worked with health plans to standardize care for patients with OUD, more strategies are needed to improve treatment engagement and retention after an inpatient detoxification.

Innovating for real-world care: A systematic review of interventions to improve post-detoxification outcomes for opioid use disorder

BACKGROUND

Inpatient detoxification is a common health care entry point for people with Opioid Use Disorder (OUD). However, many patients return to opioid use after discharge and also do not access OUD treatment. This systematic review reports on the features and findings of research on interventions developed specifically to improve substance use outcomes and treatment linkage after inpatient detoxification for OUD.

METHODS

Of 6419 articles, 64 met inclusion criteria for the current review. Articles were coded on key domains including sample characteristics, study methods and outcome measures, bias indicators, intervention type, and findings.

RESULTS

Many studies did not report sample characteristics, including demographics and co-occurring psychiatric and substance use disorders, which may impact postdetoxification OUD treatment outcomes and the generalizability of interventions. Slightly more than half of studies examined interventions that were primarily medical in nature, though only a third focused on initiating medication treatment beyond detoxification. Medical and combination interventions that focused on initiating medications for OUD generally performed well, as did psychological interventions with one or more reinforcement-based components.

CONCLUSIONS

Research efforts to improve post-detoxification outcomes would benefit from clearer reporting of sample characteristics that are associated with treatment and recovery outcomes, including diagnostic comorbidities. Findings also support the need to identify ways to introduce medication for opioid use disorder (MOUD) and other effective treatments including reinforcement-based interventions during detoxification or soon after.

Transcutaneous electrical acupoint stimulation for the treatment of withdrawal syndrome in heroin addicts

OBJECTIVE

To assess the therapeutic effect of transcutaneous electric acupoint stimulation (TEAS) for the treatment of withdrawal syndrome in heroin addicts.

METHODS

A total of 63 male heroin addicts with withdrawal score higher than 20 were recruited in the Detoxification Center of Zhongshan city, Guangdong province, China. They were randomly distributed into two groups: TEAS group (n = 31) received TEAS by using a Han's acupoint nerve stimulator (HANS) model 200A with two output channels, 2-3 sessions per day, 30 minutes per session for 10 consecutive days. Electrical stimulation of alternating frequencies of 2- and 100-Hz with 3 second each, and with intensity of 10-15 mA was applied on Hegu (LI-4) and Laogong (PC-8) points on one hand, and Neiguan (PC-6) and Waiguan (SJ-5) points on the other forearm via electroconductive skin pads of 4 cm × 4 cm in size. The control group (n = 32) was treated with similar procedure except that the leads of the output of the stimulator was disconnected. Assessments of the severity of the withdrawal syndrome were conducted one day before and on each day during the whole treatment period of 10 days. Buprenorphin of 1 mg per day sublingually was provided to all subjects in the first two days, and then to those with withdrawal score over 20 in the following days.

RESULTS

The TEAS treatment dramatically alleviated the withdrawal syndrome during heroin detoxification. No significant difference was found in withdrawal scores between the two groups at the beginning of the observation. Withdrawal scores showed a more marked drop in TEAS group than the control starting from the second day, and maintained at a lower level for the whole course of treatment. The area under the curve of withdrawal score in TEAS group was only 40% of that in the control (P < 0.001, two way repeated measures analysis of variance), and the requirement of buprenorphine was only 10% of that in the control. No adverse effects were observed in either group.

CONCLUSION

TEAS of 2/100 Hz for 10 days in abrupt abstinence of the heroin addicts resulted in a marked reduction of the withdrawal syndrome as well as a reduced requirement for rescue opioids.

Implications of cortical balanced excitation and inhibition, functional heterogeneity, and sparseness of neuronal activity in fMRI

Blood-oxygenation-level-dependent (BOLD) functional magnetic resonance imaging (fMRI) studies often report inconsistent findings, probably due to brain properties such as balanced excitation and inhibition and functional heterogeneity. These properties indicate that different neurons in the same voxels may show variable activities including concurrent activation and deactivation, that the relationships between BOLD signal and neural activity (i.e., neurovascular coupling) are complex, and that increased BOLD signal may reflect reduced deactivation, increased activation, or both. The traditional general-linear-model-based-analysis (GLM-BA) is a univariate approach, cannot separate different components of BOLD signal mixtures from the same voxels, and may contribute to inconsistent findings of fMRI. Spatial independent component analysis (sICA) is a multivariate approach, can separate the BOLD signal mixture from each voxel into different source signals and measure each separately, and thus may reconcile previous conflicting findings generated by GLM-BA. We propose that methods capable of separating mixed signals such as sICA should be regularly used for more accurately and completely extracting information embedded in fMRI datasets.

Functional network overlap as revealed by fMRI using sICA and its potential relationships with functional heterogeneity, balanced excitation and inhibition, and sparseness of neuron activity

Functional magnetic resonance imaging (fMRI) studies traditionally use general linear model-based analysis (GLM-BA) and regularly report task-related activation, deactivation, or no change in activation in separate brain regions. However, several recent fMRI studies using spatial independent component analysis (sICA) find extensive overlap of functional networks (FNs), each exhibiting different task-related modulation (e.g., activation vs. deactivation), different from the dominant findings of GLM-BA. This study used sICA to assess overlap of FNs extracted from four datasets, each related to a different cognitive task. FNs extracted from each dataset overlapped with each other extensively across most or all brain regions and showed task-related concurrent increases, decreases, or no changes in activity. These findings indicate that neural substrates showing task-related concurrent but different modulations in activity intermix with each other and distribute across most of the brain. Furthermore, spatial correlation analyses found that most FNs were highly consistent in spatial patterns across different datasets. This finding indicates that these FNs probably reflect large-scale patterns of task-related brain activity. We hypothesize that FN overlaps as revealed by sICA might relate to functional heterogeneity, balanced excitation and inhibition, and population sparseness of neuron activity, three fundamental properties of the brain. These possibilities deserve further investigation.

Endogenous opiates and behavior: 2013

This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.

Hippocampal volume mediates the relationship between measures of pre-treatment cocaine use and within-treatment cocaine abstinence

BACKGROUND

Data suggest that the amygdala and hippocampus contribute to cocaine seeking and use, particularly following exposure to cocaine-related cues and contexts. Furthermore, indices of pre-treatment cocaine-use severity have been shown to correlate with treatment outcome in cocaine-dependent patients.

METHODS

The aim of this study was to assess the relationships between amygdalar and hippocampal volumes and cocaine use before and during treatment. High-resolution magnetic-resonance brain images were obtained from 23 cocaine-dependent patients prior to treatment and 54 healthy comparison individuals. Automated segmentation of the amygdala and hippocampus images was performed in FreeSurfer. Cocaine-dependent patients subsequently received behavioral therapy alone or combined with contingency management as part of a treatment trial, and cocaine-use indices (self-report, urine toxicology) were collected.

RESULTS

Comparison participants and cocaine-dependent patients did not show significant difference in amygdalar and hippocampal volumes at pre-treatment. Within the patient group, greater hippocampal volumes were correlated with more days of cocaine use before treatment and with poorer treatment outcome as indexed by shorter durations of continuous abstinence from cocaine and lower percentages of cocaine-negative urine samples during treatment. Mediation analysis indicated that pre-treatment hippocampal volumes mediated the relationships between pre-treatment cocaine use and treatment outcomes.

CONCLUSIONS

The finding of a significant correlation between hippocampal volume and pre-treatment cocaine-use severity and treatment response suggests that hippocampal volume should be considered when developing individualized treatments for cocaine dependence.