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Weleff J, Christian NJ, Wang JX, Singh M, De Aquino JP, Saxon AJ, Vassallo GG. Navigating new norms: Addiction specialists' perspectives on opioid use disorder treatments and policy challenges in the fentanyl era. Am J Addict 2024. [PMID: 39364597 DOI: 10.1111/ajad.13653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 09/11/2024] [Accepted: 09/13/2024] [Indexed: 10/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Amidst increasing opioid-related overdoses in the USA, opioid use disorder (OUD) treatment has seen few novel treatments emerge. High-potency synthetic opioids (HPSOs) have altered clinical approaches, prompting evaluation of existing medications for opioid use disorder (MOUD) and interest in slow-release oral morphine (SROM) as another therapeutic option. Here we survey addiction specialists on the influence of HPSOs on clinical practice, views on current MOUD regulations, and openness to novel therapies such as SROM. METHODS Anonymous, online survey conducted at a national conference of addiction specialists (N = 91). Pearson χ2 tests and Fisher's exact tests to compare respondent characteristics. RESULTS Approximately 89% of respondents (N = 91) acknowledge that HPSOs shifted addiction treatment in recent years, with 86% modifying their MOUD prescribing accordingly. Moreover, 84% report having patients who could benefit from other full opioid agonists beyond methadone for OUD management. Many report off-label prescribing of full agonist opioids other than methadone for withdrawal symptoms or initiating MOUD. Eighty percent reported being in favor of incorporating SROM as a third-line monotherapy for OUD. DISCUSSION AND CONCLUSION This sample of addiction specialists supports innovative alternatives for MOUD in the USA to combat the challenges posed by fentanyl and related HPSOs. Future work should further addiction specialists' opinions on barriers to OUD treatment and exploration of these international strategies in the USA. SCIENTIFIC SIGNIFICANCE This appears to be the first study exploring addiction specialists' perspectives on regulatory barriers to OUD treatment and their willingness to uptake internationally adopted strategies such as SROM.
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Affiliation(s)
- Jeremy Weleff
- Department of Psychiatry, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Nicholaus J Christian
- Office of the Clinical Director, National Institute on Drug Abuse Intramural Research Program, National Institutes of Health, Baltimore, Maryland, USA
- Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James X Wang
- British Columbia Centre on Substance Use, Vancouver, Canada
- Division of Adolescent Health and Medicine, University of British Columbia, Vancouver, Canada
| | - Mohit Singh
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Joao P De Aquino
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven, Connecticut, USA
| | - Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
- Center for Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Gabriela Garcia Vassallo
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
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Heinz A, Gutwinski S, Krausz M, Ernst G, Vogel M, Scherbaum N. [Challenges in the treatment of opioid dependence]. DER NERVENARZT 2024; 95:811-817. [PMID: 39008087 DOI: 10.1007/s00115-024-01691-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/31/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND The number of persons using opioids has increased worldwide in the last decade, particularly the use of opioid analgesics in North America and Africa. In Germany, the prevalence of heroin addiction has remained relatively stable. METHOD Narrative review of the literature. RESULTS Opioid-assisted maintenance treatment (OMT) with the established substances methadone, levomethadone, slow-release morphine and buprenorphine is recommended as the first-line treatment for heroin dependence. The OMT reduces the use of heroin, mortality and individual suffering and improves the quality of life and physical health. A diamorphine and heroine-assisted treatment is an option for people who do not benefit from conventional OMT. An alternative to the use of diamorphine could be treatment with hydromorphone hydrochloride. The regulations on carrying out maintenance treatment in the Controlled Substances Prescription Act and the guidelines of the Federal Medical Association in Germany have been loosened based on the experiences of the COVID-19 pandemic, for example with respect to take-home prescriptions. There is an ongoing intensive discussion on how to deal with the decreasing number of outpatient clinics offering OMT. CONCLUSION The first-line treatment for opioid addiction is opioid-assisted substitution treatment, including diamorphine and heroin-assisted treatment. Long-acting depot medications and implants still play a subordinate role.
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Affiliation(s)
- Andreas Heinz
- Department of Psychiatry and Neurosciences, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
- Department of Psychiatry, University Hospital Charité, St. Hedwig Hospital Berlin, Berlin, Deutschland.
- Deutsches Zentrum für Psychische Gesundheit (DZPG), Berlin-Potsdam, Deutschland.
| | - Stefan Gutwinski
- Department of Psychiatry and Neurosciences, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
- Department of Psychiatry, University Hospital Charité, St. Hedwig Hospital Berlin, Berlin, Deutschland
| | - Michael Krausz
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Kanada
| | - Gernot Ernst
- Psychological Institute, University of Oslo, Oslo, Norwegen
- Kongsberg Hospital, Anesthesiology, Vestre Viken Hospital Trust, Kongsberg, Norwegen
| | - Marc Vogel
- Department of Addictive Disorders, Psychiatric University Clinic Basel, Basel, Schweiz
| | - Norbert Scherbaum
- LVR-Universitätsklinik Essen, Klinik für Psychiatrie und Psychotherapie, Medizinische Fakultät, Universität Duisburg-Essen, Essen, Deutschland
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Rodger L, Nader M, Turner S, Lurie E. Initiation and rapid titration of methadone and slow-release oral morphine (SROM) in an acute care, inpatient setting: a case series. Eur J Med Res 2023; 28:573. [PMID: 38066517 PMCID: PMC10704823 DOI: 10.1186/s40001-023-01538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/02/2022] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Methadone titration in an outpatient setting typically involves initiation with subtherapeutic doses with slow titration to mitigate the risks of respiratory depression and overdose. In pregnancy, and generally, subtherapeutic doses of methadone and slow titrations are associated with poorer outcomes in terms of treatment retention and ongoing illicit opioid use. We aim to describe rapid titration of OAT in an inpatient setting for pregnant injection opioid users with high opioid tolerance secondary to a fentanyl-based illicit drug supply. METHODS Retrospective case series of patients admitted to a tertiary center with a primary indication of opioid withdrawal and treatment for severe opioid use disorder in pregnancy. RESULTS Twelve women received rapid methadone titrations with or without slow-release oral morphine for opioid use disorder during a total of fifteen hospital admissions. All women included in the study were active fentanyl users (12/12). Methadone dosing was increased rapidly with no adverse events with a median dose at day 7 of 65 mg (IQR 60-70 mg) and median discharge dose of 85 mg (IQR 70-92.5 mg) during their admission for titration. Slow-release oral morphine was used in half of the titration admissions (8/15) with a median dose of 340 mg (IQR 187.5-425 mg) at discharge. The median length of admission was 12 days (IQR 9.5-15). CONCLUSIONS A rapid titration of methadone was completed in an inpatient setting with or without slow-release oral morphine, without adverse events showing feasibility of this protocol for a pregnant population in an inpatient setting. Patients achieved therapeutic doses of methadone (and/or SROM) faster than outpatient counterparts with no known adverse events.
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Affiliation(s)
- Laura Rodger
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Maya Nader
- Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Suzanne Turner
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Erin Lurie
- Department of Family & Community Medicine, University of Toronto, Toronto, Canada.
- Wellesley St-James Town Health Centre, 95 Homewood Ave, Toronto, ON, M4Y 1J4, Canada.
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Ledlie S, Tadrous M, McCormack D, Campbell T, Leece P, Kleinman RA, Kolla G, Besharah J, Smoke A, Sproule B, Gomes T. Assessing the impact of the slow-release oral morphine drug shortages in Ontario, Canada: A population-based time series analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 118:104119. [PMID: 37429161 DOI: 10.1016/j.drugpo.2023.104119] [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: 03/27/2023] [Revised: 06/15/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Slow-release oral morphine (SROM) is used to manage pain, and as opioid agonist treatment (OAT). Between 2017 and 2021 in Canada, several drug shortages occurred for Kadian© (SROM-24). The purpose of this study was to evaluate the impact of these shortages on people's ability to remain on this medication. METHODS We conducted a retrospective population-based time series analysis of SROM-24 dispensed between January 1, 2014, and December 31, 2021, in Ontario, Canada. Using interventional autoregressive integrated moving average models (ARIMA) models, we evaluated the association between SROM-24 drug shortages and treatment discontinuation. Analyses were also stratified by the SROM-24 indication (pain or OAT). RESULTS We identified 22,479 SROM-24 recipients, of which one-third (33.9%) were aged 65 or above and just over half (51.9%) were female. In our primary analysis of monthly SROM-24 discontinuation, we observed a significant sustained monthly increase following the shortages in November 2019 (+0.29%/month; 95% CI: 0.16%, 0.43%; p < .001) with significant sudden, temporary changes following the shortages in March 2020 (+2.00%; 95% CI: 0.95%, 3.05%; p < .001), July 2021 (+3.53%; 95% CI: 2.20%, 4.86%; p < .001), and August 2021 (+4.98%; 95% CI: 3.49%, 6.47%; p < .001). Similar results were observed in our stratified analyses, with sustained high rates of discontinuation among people accessing SROM-24 as OAT. CONCLUSIONS The SROM-24 shortages resulted in significant treatment disruptions across all recipients. These findings have important implications for those with few treatment alternatives, including people using SROM-24 as OAT who are at risk of adverse outcomes following treatment disruptions.
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Affiliation(s)
- Shaleesa Ledlie
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Women's College Research Institute, Toronto, Ontario, Canada
| | | | - Tonya Campbell
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
| | - Pamela Leece
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Public Health Ontario, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Robert A Kleinman
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Gillian Kolla
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada; Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
| | - Jes Besharah
- Ontario Drug Policy Research Network Lived Experience Advisory Group, Toronto, Ontario, Canada
| | - Ashley Smoke
- Ontario Drug Policy Research Network Lived Experience Advisory Group, Toronto, Ontario, Canada
| | - Beth Sproule
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Treatment History and Interest in Injectable Opioid Agonist Treatment With Hydromorphone Among People Who Inject Drugs. J Addict Med 2022:01271255-990000000-00101. [PMID: 36255107 DOI: 10.1097/adm.0000000000001093] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Injectable opioid agonist treatment (iOAT) is a novel approach to treating opioid use disorder (OUD) that is typically reserved for treatment-experienced persons who inject drugs (PWID) with long-standing OUD. This study examined PWID's past OUD treatment histories and their attitudes toward iOAT with hydromorphone. METHODS This cross-sectional study recruited syringe services program participants with OUD in New York City. Participants self-reported past OUD care episodes (detoxification; outpatient, inpatient, or medication treatment; or mutual aid groups) and current interest in iOAT with hydromorphone (assessed on a 4-point scale with 3 or 4 considered "interested"). Participants with 2 or more treatment episodes in the past 5 years were considered treatment-experienced. We examined whether the number of past care episodes was associated with interest in iOAT. RESULTS Of 108 PWID, most participants were male (68.5%) and Hispanic (68.5%) with a mean age of 43 years (±10.8). Nearly all (98.1%) had severe OUD and had received past OUD care (96.3%), with the mean number of care episodes being 17.4 (SD, ±15.9). Most participants (59.8%) were treatment-experienced. Interest in iOAT with hydromorphone was high (64.8%), but there was no significant association between total past care episodes and expressing interest in iOAT (odds ratio, 1.02; 95% confidence interval, 0.99-1.05). CONCLUSION Participants were highly treatment-experienced, and iOAT interest was high regardless of prior OUD treatment. New OUD treatment options, such as iOAT with hydromorphone, would be welcomed by PWID whose OUD has not remitted with conventional treatment as well as other PWID.
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Bertin C, Bezin J, Chenaf C, Delorme J, Kerckhove N, Pariente A, Tournier M, Authier N. Oral Morphine as an Alternative Substitution Treatment for Opioid Use Disorder, a Rare but Non-risk-free Use. Front Psychiatry 2022; 13:893590. [PMID: 35845444 PMCID: PMC9282723 DOI: 10.3389/fpsyt.2022.893590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/07/2022] [Indexed: 11/26/2022] Open
Abstract
Background National health monitoring agencies have reported the alternative use of morphine sulfate painkiller for maintenance treatment of opioid use disorder (OUD), associated with a potential increase in overdose risk. Objectives This study sought to assess the prevalence of regular and occasional legally prescribed morphine use in patients treated for OUD and compare their characteristics to those of patients receiving conventional opioid maintenance treatment (OMT), buprenorphine or methadone. Then, we assessed the factors associated with opioid overdose risk. Methods Data were extracted from the French national healthcare system database, covering the entire population in 2015. Diagnosis associated with hospital discharge and long-term disease codes were extracted to select the population and identify outcomes and covariates. OUD non-chronic pain patients were divided into regular (≤35 days between dispensing and ≥3 months of continuous treatment duration) morphine users, and occasional users. Their sociodemographic and health characteristics were compared to OMT controls. A multivariate logistic regression model was performed to determine factors associated with opioid overdose. Results In patients treated for OUD, 2,237 (2.2%) morphine users (1,288 regular and 949 occasional), 64,578 (63.7%) buprenorphine and 34,638 (34.1%) methadone controls were included. The prevalence of regular morphine use among patients treated for OUD regularly receiving an opioid was 1.3%. Compared to users who receive morphine regularly, occasional users had an increased risk of overdose [OR = 2.2 (1.5-3.3)], while the risk was reduced in the buprenorphine group [OR = 0.5 (0.4-0.7)] and not significantly different for methadone [OR = 1.0 (0.7-1.4)]. Other overdose risk factors were low-income, comorbidity, i.e., psychiatric conditions, alcohol use disorder or complications related to intravenous drug use, and coprescription with benzodiazepines or pregabalin. These factors were more frequent in morphine groups. Conclusions Patients that were prescribed oral morphine represented a small minority of the treated for OUD. The poorer health condition affected by numerous comorbidities and higher risk of opioid overdose in patients treated with oral morphine compared with OMT controls points toward the need to better supervise the practices of these patients, to strengthen multidisciplinary care and risk reduction measures.
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Affiliation(s)
- Célian Bertin
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Clermont-Ferrand, France
- Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Center for Analgesic Drugs, Clermont-Ferrand, France
- Institut Analgesia, Faculté de Médecine, Clermont-Ferrand, France
| | - Julien Bezin
- Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, Inserm, DRUGS-SAFE National Platform of Pharmacoepidemiology, University of Bordeaux, Bordeaux, France
- Service de Pharmacologie médicale, Pôle de Santé Publique, CHU de Bordeaux, Bordeaux, France
| | - Chouki Chenaf
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Clermont-Ferrand, France
- Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Center for Analgesic Drugs, Clermont-Ferrand, France
| | - Jessica Delorme
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Clermont-Ferrand, France
- Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Center for Analgesic Drugs, Clermont-Ferrand, France
| | - Nicolas Kerckhove
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Clermont-Ferrand, France
- Institut Analgesia, Faculté de Médecine, Clermont-Ferrand, France
| | - Antoine Pariente
- Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, Inserm, DRUGS-SAFE National Platform of Pharmacoepidemiology, University of Bordeaux, Bordeaux, France
- Service de Pharmacologie médicale, Pôle de Santé Publique, CHU de Bordeaux, Bordeaux, France
| | - Marie Tournier
- Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, Inserm, DRUGS-SAFE National Platform of Pharmacoepidemiology, University of Bordeaux, Bordeaux, France
- Hospital Charles Perrens, Bordeaux, France
| | - Nicolas Authier
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Clermont-Ferrand, France
- Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Center for Analgesic Drugs, Clermont-Ferrand, France
- Institut Analgesia, Faculté de Médecine, Clermont-Ferrand, France
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Brothers TD, Fraser J, MacAdam E, Morgan B, Webster D. Uptake of slow-release oral morphine as opioid agonist treatment among hospitalised patients with opioid use disorder. Drug Alcohol Rev 2022; 41:430-434. [PMID: 34347327 PMCID: PMC8814044 DOI: 10.1111/dar.13365] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/11/2021] [Accepted: 07/13/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Buprenorphine and methadone are highly effective first-line medications for opioid agonist treatment (OAT) but are not acceptable to all patients. We aimed to assess the uptake of slow-release oral morphine (SROM) as second-line OAT among medically ill, hospitalised patients with opioid use disorder who declined buprenorphine and methadone. METHODS This study included consecutive hospitalised patients with untreated moderate-to-severe opioid use disorder referred to an inpatient addiction medicine consultation service, between June 2018 and September 2019, in Nova Scotia, Canada. We assessed the proportion of patients initiating first-line OAT (buprenorphine or methadone) in-hospital, and the proportion initiating SROM after declining first-line OAT. We compared rates of outpatient OAT continuation (i.e., filling outpatient OAT prescription or attending first outpatient OAT clinic visit) by medication type, and compared OAT selection between patients with and without chronic pain, using χ2 tests. RESULTS Thirty-four patients were offered OAT initiation in-hospital; six patients (18%) also had chronic pain. Twenty-one patients (62%) initiated first-line OAT with buprenorphine or methadone. Of the 13 patients who declined first-line OAT, seven (54%) initiated second-line OAT with SROM in-hospital. Rates of outpatient OAT continuation after hospital discharge were high (>80%) and did not differ between medications (P = 0.4). Patients with co-existing chronic pain were more likely to choose SROM over buprenorphine or methadone (P = 0.005). DISCUSSION AND CONCLUSIONS The ability to offer SROM (in addition to buprenorphine or methadone) increased rates of OAT initiation among hospitalised patients. Increasing access to SROM would help narrow the opioid use disorder treatment gap of unmet need.
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Affiliation(s)
- Thomas D Brothers
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada.,UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - John Fraser
- Mobile Outreach Street Health, North End Community Health Centre, Halifax, Canada.,Department of Anesthesia, Pain Management and Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Emily MacAdam
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Brendan Morgan
- Department of Anesthesia, Pain Management and Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Duncan Webster
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada.,Division of Infectious Diseases, Saint John Regional Hospital, Saint John, Canada
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Abstract
PURPOSE OF REVIEW To assess the current state of the opioid overdose crisis along three major axes: drug markets and patterns of use, the effectiveness of systems of care, and international developments. RECENT FINDINGS Overdose is a major contributor to mortality and disability among people who use drugs. The increasing number of opioid overdoses in North America especially is an indication of changing drug markets and failing regional systems of care. Globally, we see three clusters of overdose prevalence: (1) a group of countries led by the United States with historically high rates of opioid overdose, (2) a group of countries with increasing rates within a concerning range, (3) a group with very low rates. The contamination of street drugs, the quality and accessibility of treatment, and the overall system of care all contribute to the prevalence of overdose. SUMMARY Drug markets and pattern of consumption in parts of the world are shifting towards contamination and opioids like fentanyl as the drug of choice, which dismantles insufficient and largely ineffective systems of care. Furthermore, outside of North America, more countries like Estonia, Lithuania, Sweden, Finland, and Norway show very concerning numbers. Without a consistent system response, effects will be devastating.
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Affiliation(s)
- R Michael Krausz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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HIV Treatment Initiation and Retention Among Individuals Initiated on Injectable Opioid Agonist Therapy for Severe Opioid Use Disorder: A Case Series. J Addict Med 2021; 14:437-440. [PMID: 32011407 DOI: 10.1097/adm.0000000000000609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Injectable opioid agonist therapy (iOAT) has previously been demonstrated to be an effective treatment option for individuals with a severe opioid use disorder (OUD) who have been unsuccessful on first line therapy (eg, buprenorphine/naloxone or methadone). Many individuals with severe OUD may also have HIV infection. Despite this, no literature currently exists examining the relationship between antiretroviral therapy (ART) initiation and adherence following iOAT initiation in the outpatient setting. METHODS Retrospective case series (n = 3) of HIV-infected individuals with a severe OUD who were refractory to oral opioid agonist treatment and were started on iOAT in a community setting in Vancouver, Canada. Outcomes of interest included: (1) iOAT induction and maintenance dosing schedules; (2) ART adherence demonstrated by change in HIV viral load. RESULTS All 3 patients initiated and successfully reached iOAT maintenance doses with significant reduction in illicit opioid use. Stable iOAT was associated with increased ART initiation and adherence, and decreased HIV viral loads. Conversely, poor retention or discontinuation of iOAT was associated with reduced adherence to ART and in 1 patient, increased HIV viral loads. CONCLUSIONS The individual cases presented suggest that among individuals with severe OUD and HIV infection, iOAT may improve HIV treatment uptake and retention in care.
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Abstract
OBJECTIVES In 2017, almost 50,000 Americans and over 4000 Canadians died from an opioid overdose. Accordingly, an urgent need exists to improve access to evidence-based treatment for opioid addiction, and also to develop and evaluate alternative treatment options for opioid use disorder (OUD). We present a case of a patient with OUD who was successfully switched and managed on oral hydromorphone after development of a prolonged QTc interval on methadone. CASE A 51-year-old man with longstanding polysubstance use presented to an urban hospital in Vancouver, Canada, for management of alcohol intoxication and hyponatremia. At the time of admission, the patient was stable on 100 mg of methadone daily, but was found to have a persistently elevated QTc (>550 milliseconds), putting him at increased risk for Torsades de Pointes. In an effort to find an alternative opioid agonist therapy for maintenance, a trial of slow-release oral morphine was attempted, but discontinued due to the development of myoclonus. Once-daily sustained-release oral hydromorphone was then started, which was found to manage cravings well without notable side effects. DISCUSSION The case presented offers promise for the use of once-daily sustained-release oral hydromorphone as a viable treatment option for patients with OUD for whom first-line therapies are not suitable or tolerated. This case report is the first to our knowledge to demonstrate the successful use of oral hydromorphone for treatment of opioid use disorder.
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Mielau J, Vogel M, Gutwinski S, Mick I. New Approaches in Drug Dependence: Opioids. CURRENT ADDICTION REPORTS 2021; 8:298-305. [PMID: 34055568 PMCID: PMC8149259 DOI: 10.1007/s40429-021-00373-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 11/16/2022]
Abstract
Purpose of Review This article aims to provide an overview of standard and adjunctive treatment options in opioid dependence in consideration of therapy-refractory courses. The relevance of oral opioid substitution treatment (OST) and measures of harm reduction as well as heroin-assisted therapies are discussed alongside non-pharmacological approaches. Recent Findings Currently, recommendation can be given for OST with methadone, buprenorphine, slow-release oral morphine (SROM), and levomethadone. Heroin-assisted treatment using diamorphine shall be considered as a cost-effective alternative for individuals not responding to the afore-mentioned opioid agonists in order to increase retention and reduce illicit opioid use. The modalities of application and the additional benefits of long-acting formulations of buprenorphine should be sufficiently transferred to clinicians and the eligible patients; simultaneously methods to improve planning of actions and self- management need to be refined. Regarding common primary outcomes in research on opioid treatment, evidence of the effectiveness of adjunctive psychological interventions is scarce. Summary Maintaining a harm reduction approach in the treatment of opioid addiction, a larger range of formulations is available for the prescribers. Embedding the pharmacological, ideally individualized treatment into a holistic, structure-giving concept also requires a reduction of fragmentation of ancillary services available, drug policies, and treatment philosophies on a global scale.
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Affiliation(s)
- Juliane Mielau
- Department of Psychiatry and Psychotherapy, Psychiatric Hospital of Charité at St. Hedwig Hospital, Große Hamburger Straße 5- 11, 10115 Berlin, Germany
| | - Marc Vogel
- Department of Addictive Disorders, Psychiatric University Clinic Basel, Basel, Switzerland
- Department of Addictive Disorders, Psychiatric Services Thurgau, Muensterlingen, Switzerland
| | - Stefan Gutwinski
- Department of Psychiatry and Psychotherapy, Psychiatric Hospital of Charité at St. Hedwig Hospital, Große Hamburger Straße 5- 11, 10115 Berlin, Germany
| | - Inge Mick
- Department of Psychiatry and Psychotherapy, Psychiatric Hospital of Charité at St. Hedwig Hospital, Große Hamburger Straße 5- 11, 10115 Berlin, Germany
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12
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Lehmann K, Kuhn S, Baschirotto C, Jacobsen B, Walcher S, Görne H, Backmund M, Scherbaum N, Reimer J, Verthein U. Substitution treatment for opioid dependence with slow-release oral morphine: Retention rate, health status, and substance use after switching to morphine. J Subst Abuse Treat 2021; 127:108350. [PMID: 34134867 DOI: 10.1016/j.jsat.2021.108350] [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: 09/24/2020] [Revised: 12/16/2020] [Accepted: 03/01/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Since April 2015, slow-release oral morphine (SROM) has been approved for opioid agonist treatment (OAT) in Germany. Experimental studies show that benefits of SROM over methadone include less heroin craving, better tolerability, and higher patient satisfaction and mental stability. The SROMOS study (Efficacy and Tolerability of Slow-Release Oral Morphine in Opioid Substitution Treatment) aims to investigate the long-term effects (effectiveness and safety) of morphine substitution under routine care in Germany. MATERIAL AND METHODS This is a prospective, noninterventional, naturalistic, observational study. Between July 2016 and November 2017, this study recruited patients in OAT who decided to switch to SROM from 23 outpatient addiction treatment centers in Germany. The study collected data on mental health (Brief Symptom Inventory - BSI-18), substance use, somatic health (Opiate Treatment Index Health-Symptoms-Scale - OTI-HSS), opioid craving (visual analogue scale), and withdrawal symptoms (Short Opiate Withdrawal Scale) at baseline (t0) and after 3 (t3), 6 (t6) and 12 (t12) months. Physicians documented side effects as adverse events (AEs) and adverse drug reactions (ADRs). RESULTS Three-quarters of the enrolled study participants (N = 180) were male. The average age was 44.4 years. Patients were opioid-dependent for 23 years and had been in OAT for almost seven years on average. After 12 months, 60.6% were still being treated with SROM. Mental health improved significantly under SROM treatment between t0 and t12. The intention-to-treat (ITT), as well as the per-protocol (PP) analysis, shows a statistically significant improvement of the mean Global Severity Index (GSI) of the BSI-18 value of 20% (ITT) and 24% (PP). Physical health also improved significantly under SROM treatment. There were no statistically significant changes in the use of cannabis, cocaine, amphetamines, and tranquillizers in the past 30 days, but heroin use, intravenous consumption, and the number of drinking days significantly decreased. CONCLUSIONS This study provides some of the first long-term data on OAT with SROM under routine care conditions. SROM treatment is an effective alternative for a subgroup of opioid-dependent patients with an unsatisfactory course of OAT or in cases where undesirable side effects due to alternative substances have occurred. ETHICAL STATEMENT The study protocol was approved by the Ethics Committee of the Chamber of Physicians in Hamburg in March 2016 (No. PV5222). The study was conducted by following the Declaration of Helsinki and is registered with the German Register of Clinical Trials (DRKS, ID: DRKS00010712).
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Affiliation(s)
- Kirsten Lehmann
- Centre for Interdisciplinary Addiction Research of Hamburg University (CIAR), University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistr. 52, 20246 Hamburg, Germany.
| | - Silke Kuhn
- Centre for Interdisciplinary Addiction Research of Hamburg University (CIAR), University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistr. 52, 20246 Hamburg, Germany.
| | - Cinzia Baschirotto
- University of Florence, Department of Psychiatry, AOU Careggi, Largo Brambilla, 3, 50134 Florence, Italy.
| | - Britta Jacobsen
- Centre for Interdisciplinary Addiction Research of Hamburg University (CIAR), University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistr. 52, 20246 Hamburg, Germany.
| | - Stephan Walcher
- CONCEPT, Addiction Medicine Munich, Kaiserstraße 1, 80801 Munich, Germany.
| | - Herbert Görne
- MediZentrum Hamburg, Rahlstedter Str. 29, 22149 Hamburg, Germany.
| | - Markus Backmund
- Ludwig-Maximilians-University and Praxiszentrum im Tal, Tal 9, 80331 Munich, Germany.
| | - Norbert Scherbaum
- LVR-Hospital Essen, University of Duisburg-Essen, Department of Psychiatry and Psychotherapy, Virchowstraße 174, 45147 Essen, Germany.
| | - Jens Reimer
- Centre for Interdisciplinary Addiction Research of Hamburg University (CIAR), University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistr. 52, 20246 Hamburg, Germany.
| | - Uwe Verthein
- Centre for Interdisciplinary Addiction Research of Hamburg University (CIAR), University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistr. 52, 20246 Hamburg, Germany.
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13
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Busch M, Klein C, Uhl A, Haltmayer H, Cabanis M, Westenberg JN, Vogel M, Krausz RM. Retention in the Austrian opioid agonist treatment system: a national prospective cohort study. Harm Reduct J 2021; 18:25. [PMID: 33627159 PMCID: PMC7903033 DOI: 10.1186/s12954-021-00473-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/11/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Retention in care is a prerequisite for successful recovery, especially for a chronic condition like opioid dependence. Though retention varies greatly depending on the different substitution medication and treatment model, treatment retention is used as an indicator of treatment quality and effectiveness of care on a system and individual level. To monitor the overall quality of the Austrian opioid agonist treatment (OAT) system and to monitor patient satisfaction within the system, a new online-based registry called "eSuchmittel" was introduced in Austria at the beginning of 2011. The objective of this study is to analyze retention rates within the Austrian treatment system and to identify patient characteristics associated with retention, using data collected by the substitution registry. METHODS The complete Austrian sample of 4778 registered patients starting treatment between 1.1.2011 to 31.12.2012 were included in the prospective cohort study using data from the Austrian substitution registry. For the statistical analysis, multivariate Cox Regression and Kaplan-Meier survival analysis were used to evaluate retention in treatment. RESULTS The retention rate of the total cohort after two years was around 61%. Retention rates were significantly lower for men (exp(B) = .806, 95% CI 0.714-0.908) and significantly higher for patients aged 30 and older (exp(B) = 1.155, 95% CI 1.044-1.279), among patients located in Vienna (exp(B) = 1.439, 95% CI 1.273-1.626) and among patients prescribed oral slow-release morphine (SROM) (exp(B) = 2.141, 95% CI 1.885-2.430). CONCLUSIONS Average retention in the Austrian system is high in comparison to international retention rates. Nationally, SROM demonstrates higher treatment retention when compared to other available substitution medications. Sociodemographic and regional indicators also contribute to higher retention in care. A systematic monitoring of retention rates within a national registry is an important tool helping to evaluate the quality of care. In this study, the Austrian OAT system proves very high retention in care, an important success criterion.
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Affiliation(s)
- Martin Busch
- Gesundheit Österreich GmbH (GÖG), Vienna, Austria
| | | | - Alfred Uhl
- Gesundheit Österreich GmbH (GÖG), Vienna, Austria
- Sigmund Freud University, Vienna, Austria
| | | | - Maurice Cabanis
- Zentrum Für Seelische Gesundheit, Klinikum Stuttgart, Stuttgart, Germany
| | - Jean Nicolas Westenberg
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, University of British Columbia, David Strangway Building, 5950 University Boulevard, Vancouver, BC V6T 1Z3 Canada
| | - Marc Vogel
- Psychiatrische Klinik Münsterlingen, Münsterlingen, Switzerland
| | - R. Michael Krausz
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
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14
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Javadi HR, Mirakbari SM, Allami A, Yazdi Z, Katebi K. Opium-associated QT Interval Prolongation: A Cross-sectional Comparative Study. Indian J Crit Care Med 2021; 25:43-47. [PMID: 33603300 PMCID: PMC7874289 DOI: 10.5005/jp-journals-10071-23596] [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] [Indexed: 11/23/2022] Open
Abstract
Background Toxicity and side effects of long-term use of opioids are well studied, but little information exists regarding electrophysiological disturbances of opium consumption. While natural opium has been regarded safe to a great extent among traditional communities, concerns are emerging owing to the available evidence of QT prolongation that have been exposed during recent outcome surveillance of patients under opioid use. Potential QT prolonging interactions would raise a higher level of such concern in opium users during COVID pandemic and warrant attention. Materials and methods This study was designed to detect the prevalence of QTc prolongation among opium users and nonusers. Two groups were compared with regard to gender, age, and median QTc interval. Normal and prolonged QTc intervals of user group were compared with respect to age, sex, dose of opium consumption, and duration of opium consumption. Results 123 opium users and 39 controls were investigated. Median QTc interval in opium user and non-user group was 460 vs 386 milliseconds, respectively (p value < 0.001). In all, 59.3%, (95% CI: 50.51–67.62%) of cases and none of non-user had prolonged QTc interval (p value < 0.001). There was no significance between normal and prolonged QTc intervals with respect to dose and duration of opium use. Conclusion This study indicated that opium consumption is associated with QTc prolongation. This prolongation does not relate to dose and duration of opium use. Further study is propounded to assess the clinical significance of these results and to determine risk rating of opium compared to other opioids in this regard. How to cite this article Javadi HR, Mirakbari SM, Allami A, Yazdi Z, Katebi K. Opium-associated QT Interval Prolongation: A Cross-sectional Comparative Study. Indian J Crit Care Med 2021;25(1):43–47.
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Affiliation(s)
- Hamid R Javadi
- Department of Cardiology, Bu Ali Hospital, Qazvin University of Medical Sciences, Qazvin, Islamic Republic of Iran
| | - Seyed M Mirakbari
- Department of Clinical Toxicology, Bu Ali Hospital, Qazvin University of Medical Sciences, Qazvin, Islamic Republic of Iran
| | - Abbas Allami
- Department of Infectious Disease, Bu Ali Hospital, Qazvin University of Medical Sciences, Qazvin, Islamic Republic of Iran
| | - Zohreh Yazdi
- Metabolic Disease Research Center, Bu Ali Hospital, Qazvin University of Medical Sciences, Qazvin, Islamic Republic of Iran
| | - Kimia Katebi
- Faculty of Medicine, Qazvin University of Medical Sciences, Islamic Republic of Iran
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15
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Bertin C, Delorme J, Riquelme M, Peyrière H, Brousse G, Eschalier A, Ardid D, Chenaf C, Authier N. Risk assessment of using off-label morphine sulfate in a population-based retrospective cohort of opioid-dependent patients. Br J Clin Pharmacol 2020; 86:2338-2348. [PMID: 31389036 PMCID: PMC7688539 DOI: 10.1111/bcp.14082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 05/02/2019] [Accepted: 07/19/2019] [Indexed: 01/09/2023] Open
Abstract
AIMS Several addictovigilance studies have described the off-label use of morphine sulfate (MS) for nonchronic pain in opioid use disorder (OUD) patients as an alternative to conventional opioid substitution treatments (OSTs). This study primarily sought to compare the incidence of unintentional opioid-related overdose in the year following the prescription initiation in off-label MS users, compared to OST-maintained patients. METHODS Sequential cohorts of OUD patients who were regularly dispensed MS, buprenorphine, or methadone, between 1 April 2012 and 31 December 2014, were retrospectively identified using the French nationwide healthcare data system. The incidence of overdoses, deaths, doctor shopping, and complications of a viral, bacterial or thrombotic nature, was compared using the Cox regression method. RESULTS Overall, 1075, 20 834 and 9778 OUD patients without chronic-pain were included in the MS, buprenorphine, and methadone cohorts, respectively. Overdose incidence was 3.8 (P < .01 [95% confidence interval (CI): 2.1-6.8]) and 2.0 (P = .02 [95%CI: 1.1-3.6]) higher in the MS cohort vs buprenorphine and methadone, respectively. Death incidence was 9.1 (P < .01 [95%CI: 3.2-25.9]) and 3.9 (P < .01 [95%CI: 1.4-10.7]) higher in the MS cohort vs buprenorphine and methadone, respectively. The incidences of other associated risks were significantly higher in the MS group vs OSTs, except for hepatitis C viral infection and thrombotic complications. CONCLUSION This first French comprehensive nationwide study reveals increasing overdose, death, bacterial infection, abuse and diversion risks when off-label MS is initiated as alternative to OST. These results question the relevance of prescribing MS as a safe opioid maintenance treatment, considering its health risk profile.
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Affiliation(s)
- Célian Bertin
- CHU Clermont‐Ferrand, Inserm 1107, Neuro‐Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la DouleurUniversité Clermont AuvergneClermont‐FerrandFrance
- Observatoire Français des Médicaments Antalgiques (OFMA)CHU Clermont‐Ferrand and Université Clermont AuvergneClermont–FerrandFrance
| | - Jessica Delorme
- CHU Clermont‐Ferrand, Inserm 1107, Neuro‐Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la DouleurUniversité Clermont AuvergneClermont‐FerrandFrance
- Observatoire Français des Médicaments Antalgiques (OFMA)CHU Clermont‐Ferrand and Université Clermont AuvergneClermont–FerrandFrance
| | - Marie Riquelme
- CHU Clermont‐Ferrand, Inserm 1107, Neuro‐Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la DouleurUniversité Clermont AuvergneClermont‐FerrandFrance
- Observatoire Français des Médicaments Antalgiques (OFMA)CHU Clermont‐Ferrand and Université Clermont AuvergneClermont–FerrandFrance
| | - Hélène Peyrière
- CHU Montpellier, Laboratoire de Pharmacie Clinique, Département de Pharmacologie Médicale et Toxicologie, Centre AddictovigilanceUniversité de MontpellierMontpellierFrance
| | - Georges Brousse
- CIRCEA, Service de Psychiatrie‐addictologieUniversité Clermont AuvergneClermont‐FerrandFrance
| | - Alain Eschalier
- CHU Clermont‐Ferrand, Inserm 1107, Neuro‐Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la DouleurUniversité Clermont AuvergneClermont‐FerrandFrance
- Observatoire Français des Médicaments Antalgiques (OFMA)CHU Clermont‐Ferrand and Université Clermont AuvergneClermont–FerrandFrance
- Faculté de MédecineInstitut AnalgesiaClermont‐FerrandFrance
| | - Denis Ardid
- CHU Clermont‐Ferrand, Inserm 1107, Neuro‐Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la DouleurUniversité Clermont AuvergneClermont‐FerrandFrance
- Observatoire Français des Médicaments Antalgiques (OFMA)CHU Clermont‐Ferrand and Université Clermont AuvergneClermont–FerrandFrance
- Faculté de MédecineInstitut AnalgesiaClermont‐FerrandFrance
| | - Chouki Chenaf
- CHU Clermont‐Ferrand, Inserm 1107, Neuro‐Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la DouleurUniversité Clermont AuvergneClermont‐FerrandFrance
- Observatoire Français des Médicaments Antalgiques (OFMA)CHU Clermont‐Ferrand and Université Clermont AuvergneClermont–FerrandFrance
| | - Nicolas Authier
- CHU Clermont‐Ferrand, Inserm 1107, Neuro‐Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la DouleurUniversité Clermont AuvergneClermont‐FerrandFrance
- Observatoire Français des Médicaments Antalgiques (OFMA)CHU Clermont‐Ferrand and Université Clermont AuvergneClermont–FerrandFrance
- Faculté de MédecineInstitut AnalgesiaClermont‐FerrandFrance
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16
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Baschirotto C, Lehmann K, Kuhn S, Reimer J, Verthein U. Switching opioid-dependent patients in substitution treatment from racemic methadone, levomethadone and buprenorphine to slow-release oral morphine: Analysis of the switching process in routine care. J Pharmacol Sci 2020; 144:9-15. [DOI: 10.1016/j.jphs.2020.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/05/2020] [Accepted: 06/10/2020] [Indexed: 01/15/2023] Open
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Kimmel S, Bach P, Walley AY. Comparison of Treatment Options for Refractory Opioid Use Disorder in the United States and Canada: a Narrative Review. J Gen Intern Med 2020; 35:2418-2426. [PMID: 32462569 PMCID: PMC7403280 DOI: 10.1007/s11606-020-05920-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 05/08/2020] [Indexed: 11/26/2022]
Abstract
Amidst the opioid overdose crisis, there are increased efforts to expand access to medications for opioid use disorder (MOUD). Hospitalization for the complications of substance use in the United States (US) provides an opportunity to initiate methadone, buprenorphine, and extended release naltrexone and link high-risk, not otherwise engaged, patients into outpatient care. However, treatment options for patients are quickly exhausted when these medications are not desired, tolerated, or beneficial. As an example, we discuss the case of a man who was hospitalized 27 times over 2 years for complications related to his opioid use disorder (OUD), including recurring methicillin-resistant Staphylococcus aureus vertebral osteomyelitis, increasing antimicrobial resistance, new infections, and multiple overdoses in and out of the hospital. The patient suffered these complications despite efforts to treat his OUD with methadone and buprenorphine while hospitalized, and repeated attempts to link him to outpatient care. We use this case to review evidence-based treatments for refractory OUD, which are not approved in the US, but are available in Canada. If hospitalized in Vancouver, Canada, this patient could have been offered slow-release oral morphine and injectable opioid agonist therapy, as well as access to sterile syringes and injection equipment at an in-hospital supervised injection facility. Each of these approaches is supported by evidence and has been implemented successfully in Canada, yet none are available in the US. In order to combat the multiple harms from opioids, it is critical that we consider every evidence-based tool.
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Affiliation(s)
- Simeon Kimmel
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA.
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA.
- Boston University School of Medicine, Boston, MA, USA.
| | - Paxton Bach
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Alexander Y Walley
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
- Massachusetts Department of Public Health, Boston, MA, USA
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18
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Socias ME, Wood E, Dong H, Brar R, Bach P, Murphy SM, Fairbairn N. Slow release oral morphine versus methadone for opioid use disorder in the fentanyl era (pRESTO): Protocol for a non-inferiority randomized clinical trial. Contemp Clin Trials 2020; 91:105993. [PMID: 32194251 PMCID: PMC7919741 DOI: 10.1016/j.cct.2020.105993] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 03/05/2020] [Accepted: 03/12/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND North America is facing an unprecedented public health crisis of opioid-related morbidity and mortality, increasingly as a result of the introduction of illicitly manufactured fentanyl into the street drug market. Although the treatment of opioid use disorder (OUD) is a key element in the response to the opioid overdose epidemic, currently available pharmacotherapies (e.g., methadone, buprenorphine) may not be acceptable to or effective in all patients. Available evidence suggests that slow-release oral morphine (SROM) has similar efficacy rates as methadone with respect to promoting abstinence, and with improvements in a number of patient-reported outcomes among persons using heroin. However, little is known about the relative effectiveness and acceptability of SROM compared to methadone in the context of fentanyl use. This study aims to address this research gap. METHODS pRESTO is a 24-week, open-label, two arm, non-inferiority, randomized controlled trial comparing SROM versus methadone for the treatment of OUD. Participants will be 298 clinically stable, non-pregnant adults with OUD, recruited from outpatient clinics in Vancouver, Canada, where the majority of the illicit opioids are contaminated with fentanyl. The primary outcome is suppression of illicit opioid use, measured by bi-weekly urine drug screens. Secondary outcomes include: treatment retention, medication safety, overdose events, treatment satisfaction, psychological functioning, changes in drug-related problems, changes in quality of life, opioid cravings, other substance use, and cost-effectiveness. DISCUSSION pRESTO will be among the first studies to evaluate treatment options for individuals primarily using synthetic street opioids, providing important evidence to guide treatment strategies for this population.
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Affiliation(s)
- M Eugenia Socias
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Evan Wood
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Huiru Dong
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Rupinder Brar
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Paxton Bach
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sean M Murphy
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - Nadia Fairbairn
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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19
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Bruneau J, Ahamad K, Goyer MÈ, Poulin G, Selby P, Fischer B, Wild TC, Wood E. Management of opioid use disorders: a national clinical practice guideline. CMAJ 2019; 190:E247-E257. [PMID: 29507156 DOI: 10.1503/cmaj.170958] [Citation(s) in RCA: 265] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Julie Bruneau
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Keith Ahamad
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Marie-Ève Goyer
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Ginette Poulin
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Peter Selby
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Benedikt Fischer
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - T Cameron Wild
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Evan Wood
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
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20
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Plunkett AR, Peden RM. Opioid maintenance, weaning and detoxification techniques; where we have been, where we are now and what the future holds: an update. Pain Manag 2019; 9:297-306. [DOI: 10.2217/pmt-2018-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In 2017, the US Department of Health and Human Services declared a public health emergency on the opioid crisis. On average, 115 Americans die each day from an opioid overdose. The scope and breadth of this problem is continually evolving. In 2010, there was a shift in causes primarily due to the use of heroin, and currently the latest shift in opioid-related deaths involves a variety of synthetic opioids, particularly illicitly manufactured fentanyl. As the medical, sociological and political environments have drastically changed, especially in the USA, over the last 6 years with regard to opioid use and misuse, an updated review of the literature was necessary.
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Affiliation(s)
- Anthony R Plunkett
- Department of Anesthesia & Operative Services, Womack Army Medical Center Ft Bragg, NC 28310, USA
| | - Robert M Peden
- Department of Anesthesia & Operative Services, Womack Army Medical Center Ft Bragg, NC 28310, USA
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21
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Klimas J, Gorfinkel L, Giacomuzzi SM, Ruckes C, Socías ME, Fairbairn N, Wood E. Slow release oral morphine versus methadone for the treatment of opioid use disorder. BMJ Open 2019; 9:e025799. [PMID: 30944135 PMCID: PMC6500187 DOI: 10.1136/bmjopen-2018-025799] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 02/06/2019] [Accepted: 02/14/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To assess the efficacy of slow release oral morphine (SROM) as a treatment for opioid use disorder (OUD). DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs). DATA SOURCES Three electronic databases were searched through 1 May 2018: the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. We also searched the following electronic registers for ongoing trials: ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Current Controlled Trials and the EU Clinical Trials Register. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included RCTs of all durations, assessing the effect of SROM on measures of treatment retention, heroin use and craving in adults who met the diagnostic criteria for OUD. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed risk of bias. Data were pooled using the random-effects model and expressed as risk ratios (RRs) or mean differences with 95% CIs. Heterogeneity was assessed (χ2 statistic) and quantified (I2 statistic) and a sensitivity analysis was undertaken to assess the impact of particular high-risk trials. RESULTS Among 1315 records screened and four studies reviewed, four unique randomised trials met the inclusion criteria (n=471), and compared SROM with methadone. In the meta-analysis, we observed no significant differences between SROM and methadone in improving treatment retention (RR=0.98; 95%CI: 0.94 to 1.02, p=0.34) and heroin use (RR=0.96; 95% CI: 0.61 to 1.52, p=0.86). Craving data was not amenable to meta-analysis. Available data implied no differences in adverse events, heroin, cocaine or benzodiazepine use. CONCLUSIONS Meta-analysis of existing randomised trials suggests SROM may be generally equal to methadone in retaining patients in treatment and reducing heroin use while potentially resulting in less craving. The methodological quality of the included RCTs was low-to-moderate.
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Affiliation(s)
- Jan Klimas
- BC Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | | | | | - Christian Ruckes
- University Medical Center Mainz, Interdisciplinary Center Clinical Trials, Mainz, Germany
| | | | - Nadia Fairbairn
- BC Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Evan Wood
- BC Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
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22
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Prinsloo G, Ahamad K, Socías ME. Successful treatment with slow-release oral morphine following afentanyl-related overdose: A case report. Subst Abus 2019; 40:473-475. [PMID: 30829174 DOI: 10.1080/08897077.2019.1576086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Overdose deaths as a result of untreated opioid use disorder (OUD) pose a major public health concern across North America. Although slow-release oral morphine (SROM) is increasingly used as an alternative option for the treatment of OUD, research on its efficacy among individuals exposed to illicit fentanyl or those with previous unsuccessful attempts with other opioid agonist therapies (OATs) is limited and controversial. Case: We present a case of a 48-year-old male with severe OUD seeking treatment following a near-fatal fentanyl overdose. His previous treatment attempts with methadone and buprenorphine/naloxone-based OAT had been unsuccessful. As per local guidelines, he was started on SROM with subsequent cessation of opioid cravings and illicit drug use. Discussion: This case report describes a patient entering early remission for OUD when treated with SROM following unsuccessful past treatment attempts on first-line oral medications. Future studies should seek to evaluate SROM-based OAT as a potential second-line treatment alternative for OUD.
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Affiliation(s)
- Gerrit Prinsloo
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.,Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Keith Ahamad
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.,Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - M Eugenia Socías
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.,Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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23
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Nordt C, Vogel M, Dey M, Moldovanyi A, Beck T, Berthel T, Walter M, Seifritz E, Dürsteler KM, Herdener M. One size does not fit all-evolution of opioid agonist treatments in a naturalistic setting over 23 years. Addiction 2019; 114:103-111. [PMID: 30209840 DOI: 10.1111/add.14442] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/20/2018] [Accepted: 09/04/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Opioid agonist treatment (OAT) is currently the most effective treatment for people with opioid dependence. In most countries, however, access to the whole range of effective medications is restricted. This study aims to model the distribution of different OAT medications within a naturalistic and relatively unrestricted treatment setting (Zurich, Switzerland) over time, and to identify patient characteristics associated with each medication. METHODS We used generalized estimating equation analysis with data from the OAT register of Zurich and the Swiss register for heroin-assisted treatment (HAT) to model and forecast the annual proportion of opioids applying exponential distributions until 2018 and patient characteristics between 1992 and 2015. RESULTS Data from 11 895 patients were included in the analysis. Methadone remains the mainstay of OAT, being prescribed to two-thirds of patients. Following its approval, the proportion of HAT increased rapidly and is now constant at 12.16% [95% confidence interval (CI) = 11.15-13.17]. The initial increase of proportions of buprenorphine or slow-release oral morphine (SROM) following their approval for OAT was slower. While in 2014 both medications had a proportion of 10.2% and 10.3%, respectively, our model predicts a further increase of SROM to 19.9% in 2018, with a ceiling level of 25.19% (21.40-28.98%) thereafter. SROM patients display characteristics similar to those treated with methadone; buprenorphine patients show the highest social integration; and HAT patients are the most homogeneous group, with highest mean age, most widespread injecting experience and lowest social integration. CONCLUSIONS Based on data from Zurich, Switzerland from 1992 to 2015, there is no evidence for an excessive demand for a single medication in a naturalistic and liberal opioid agonist treatment setting. Rather, the specific patient characteristics associated with each medication underline the need for diversified treatment options for opioid dependence.
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Affiliation(s)
- Carlos Nordt
- Department for Psychiatry, Psychotherapy and Psychosomatics, Centre for Addictive Disorders, University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Marc Vogel
- Division of Addictive Disorders, University of Basel Psychiatric Hospital, Basel, Switzerland
| | - Michelle Dey
- Swiss Research Institute for Public Health and Addiction, University of Zurich, Zurich, Switzerland
| | - Andreas Moldovanyi
- Polyclinics for Heroin Prescription Lifeline/Crossline, City Medical Services, Zurich, Switzerland
| | - Thilo Beck
- Arud Centres for Addiction Medicine, Zurich, Switzerland
| | - Toni Berthel
- Integrierte Psychiatrie Winterthur Zürcher Unterland, Winterthur, Switzerland
| | - Marc Walter
- Division of Addictive Disorders, University of Basel Psychiatric Hospital, Basel, Switzerland
| | - Erich Seifritz
- University Hospital of Psychiatry Zurich, Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, Zurich, Switzerland
| | - Kenneth M Dürsteler
- Department for Psychiatry, Psychotherapy and Psychosomatics, Centre for Addictive Disorders, University Hospital of Psychiatry Zurich, Zurich, Switzerland.,Division of Addictive Disorders, University of Basel Psychiatric Hospital, Basel, Switzerland
| | - Marcus Herdener
- Department for Psychiatry, Psychotherapy and Psychosomatics, Centre for Addictive Disorders, University Hospital of Psychiatry Zurich, Zurich, Switzerland
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24
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Fairgrieve C, Fairbairn N, Samet JH, Nolan S. Nontraditional Alcohol and Opioid Agonist Treatment Interventions. Med Clin North Am 2018; 102:683-696. [PMID: 29933823 PMCID: PMC6650149 DOI: 10.1016/j.mcna.2018.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Despite the availability of effective medications and psychosocial interventions for the management of a substance use disorder, some individuals repeatedly fail the most aggressive treatment regimens. For such individuals, alternative treatment options exist seeking to mitigate the negative consequences of the use of harmful substances. Participation in a managed alcohol program, or the use of sustained-release oral morphine or injectable opioid agonist treatment or the creation of safe injecting facilities, are examples of such nonstandard approaches. This article reviews the available evidence of these treatment modalities.
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Affiliation(s)
- Christopher Fairgrieve
- Department of Family Medicine, University of British Columbia, St. Paul's Hospital, Room 553, 5th Floor Burrard Building, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada; British Columbia Centre on Substance Use, Providence Health Care, St. Paul's Hospital, Room 553, 5th Floor Burrard Building, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Nadia Fairbairn
- British Columbia Centre on Substance Use, Providence Health Care, St. Paul's Hospital, Room 553, 5th Floor Burrard Building, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, Room 553, 5th Floor Burrard Building, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA; Department of Community Health Sciences, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA
| | - Seonaid Nolan
- British Columbia Centre on Substance Use, Providence Health Care, St. Paul's Hospital, Room 553, 5th Floor Burrard Building, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, Room 553, 5th Floor Burrard Building, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada.
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25
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Noble F, Marie N. Management of Opioid Addiction With Opioid Substitution Treatments: Beyond Methadone and Buprenorphine. Front Psychiatry 2018; 9:742. [PMID: 30713510 PMCID: PMC6345716 DOI: 10.3389/fpsyt.2018.00742] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/14/2018] [Indexed: 12/13/2022] Open
Abstract
With the opioid crisis in North America, opioid addiction has come in the spotlight and reveals the weakness of the current treatments. Two main opioid substitution therapies (OST) exist: buprenorphine and methadone. These two molecules are mu opioid receptor agonists but with different pharmacodynamic and pharmacokinetic properties. In this review, we will go through these properties and see how they could explain why these medications are recognized for their efficacy in treating opioid addiction but also if they could account for the side effects especially for a long-term use. From this critical analysis, we will try to delineate some guidelines for the design of future OST.
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Affiliation(s)
- Florence Noble
- CNRS ERL 3649, "Neuroplasticité et thérapies des addictions", Paris, France.,INSERM UMR-S 1124, Paris, France.,Centre Universitaire des Saints Pères, Université Paris Descartes, Paris, France
| | - Nicolas Marie
- CNRS ERL 3649, "Neuroplasticité et thérapies des addictions", Paris, France.,INSERM UMR-S 1124, Paris, France.,Centre Universitaire des Saints Pères, Université Paris Descartes, Paris, France
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26
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Oviedo-Joekes E, Brissette S, MacDonald S, Guh D, Marchand K, Jutha S, Harrison S, Janmohamed A, Zhang DZ, Anis AH, Krausz M, Marsh DC, Schechter MT. Safety profile of injectable hydromorphone and diacetylmorphine for long-term severe opioid use disorder. Drug Alcohol Depend 2017; 176:55-62. [PMID: 28521199 DOI: 10.1016/j.drugalcdep.2017.02.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 02/21/2017] [Accepted: 02/21/2017] [Indexed: 11/28/2022]
Abstract
AIMS To review the safety profile of injectable hydromorphone and diacetylmorphine and explore if adverse events (AEs) or serious adverse events (SAEs) were associated with dose and patterns of attendance. METHODS This was a non-inferiority randomized double-blind controlled trial (Vancouver, Canada) testing hydromorphone (n=100) and diacetylmorphine (n=102) for the treatment of severe opioid use disorder. Medications were delivered under the supervision of trained Registered Nurses up to three times daily. AEs were described using MedDRA codes. RESULTS Most common related AEs included immediate post-injection reaction or injection site pruritus reactions, somnolence and opioid overdoses. Adjusted analysis indicated that participants in the hydromorphone group were less likely to have any related AE or SAE compared to the diacetylmorphine group. Related somnolence and opioid overdose events were distributed throughout the six months treatment period. In the diacetylmorphine group, five of the eleven related SAE opioid overdoses (requiring naloxone) occurred in the first 30days since most recent treatment initiation. Analysis of somnolence and opioid overdose (AEs and SAEs) event rates by received dose suggested a non-linear relationship. However, in the diacetylmorphine group higher event rates per person days were recorded at lower doses. CONCLUSIONS When injectable hydromorphone and diacetylmorphine are individually dosed and monitored, their opioid-related side effects, including potential fatal overdoses, are safely mitigated and treated by health care providers. In the midst of an opioid overdose epidemic, injectable options are timely to reach a very important minority of people who inject street opioids and are not attracted to other treatments.
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Affiliation(s)
- Eugenia Oviedo-Joekes
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Suzanne Brissette
- Centre de recheche du Centre Hospitalier de l'Université de Montréal, (CRCHUM), 900 St-Denis, Montréal, QC, H2X 0A9, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC V6 B 1G6, Canada
| | - Daphne Guh
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Kirsten Marchand
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Salima Jutha
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC V6 B 1G6, Canada
| | - Amin Janmohamed
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Derek Z Zhang
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Aslam H Anis
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Michael Krausz
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada; Department of Psychiatry, Faculty of Medicine, Detwiller Pavilion 2255 Wesbrook Mall, Vancouver, BC V6T 2A1, Canada
| | - David C Marsh
- Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada
| | - Martin T Schechter
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
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27
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Sutter M, Walter M, Dürsteler KM, Strasser J, Vogel M. Psychosis After Switch in Opioid Maintenance Agonist and Risperidone-Induced Pisa Syndrome: Two Critical Incidents in Dual Diagnosis Treatment. J Dual Diagn 2017; 13:157-165. [PMID: 27935442 DOI: 10.1080/15504263.2016.1269224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIMS Dual diagnosis commonly occurs among patients with an opioid use disorder. Treatment is ideally performed in an integrated fashion. We present a case that illustrates the complex and challenging psychiatric and medical therapy of such patients in the light of the literature. CASE DESCRIPTION We report on a 56-year-old patient with schizophrenia and opioid dependence who experienced both risperidone-induced Pisa syndrome and, 3 years later, acute psychosis after switching the opioid substitution medication from methadone to slow-release oral morphine due to QT prolongation. CONCLUSIONS With the current availability of a diversity of substitution opioids in Switzerland (methadone, buprenorphine, diacetylmorphine, sustained-release oral morphine), studies on differential effectiveness of these agents in opioid-dependent subpopulations with selective comorbidity profiles are desirable. The same is true for further investigation of the involvement of the opioid receptor system in schizophrenia. In clinical practice, any alteration of opioid medication in patients with dual diagnosis and a history of schizophrenia should be accompanied by close observation for psychotic symptoms.
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Affiliation(s)
- Manuel Sutter
- a Division of Substance Use Disorders , Psychiatric Hospital of the University of Basel , Basel , Switzerland
| | - Marc Walter
- a Division of Substance Use Disorders , Psychiatric Hospital of the University of Basel , Basel , Switzerland
| | - Kenneth M Dürsteler
- a Division of Substance Use Disorders , Psychiatric Hospital of the University of Basel , Basel , Switzerland
| | - Johannes Strasser
- a Division of Substance Use Disorders , Psychiatric Hospital of the University of Basel , Basel , Switzerland
| | - Marc Vogel
- a Division of Substance Use Disorders , Psychiatric Hospital of the University of Basel , Basel , Switzerland
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28
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Abstract
This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 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, drug abuse and alcohol, 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.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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Lake S, Kerr T, Buxton J, Guillemi S, Parashar S, Montaner J, Wood E, Milloy MJ. Prescription Opioid Injection Among HIV-Positive People Who Inject Drugs in a Canadian Setting. AIDS Behav 2016; 20:2941-2949. [PMID: 27146887 DOI: 10.1007/s10461-016-1369-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Prescription opioids (POs) are commonly prescribed to patients living with HIV/AIDS, while the illicit use of POs remains a major public health concern throughout Canada and the United States. We sought to identify the prevalence and correlates of PO injection among HIV-positive people who inject drugs (PWID) in Vancouver, Canada, where HIV/AIDS treatment and care is offered at no cost. We examined data from 634 individuals from an ongoing prospective cohort of HIV-positive PWID. Between December 2005 and November 2013, the median prevalence of recent PO injection was 24.2 % [interquartile range (IQR): 21.5-25.8 %]. In a multivariable generalized estimating equation model, Caucasian ethnicity, heroin injection, and drug dealing were positively associated with PO injection, while older age and methadone maintenance treatment were negatively associated with PO injection (all p < 0.05). Engagement on antiretroviral therapy was inversely associated with PO injection in a bivariable analysis, but did not remain significant after adjusting for heroin injection. These findings describe a particularly vulnerable sub-group of PWID who may benefit from targeted efforts to both minimize drug-related risk behaviors and support HIV/AIDS treatment.
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Affiliation(s)
- Stephanie Lake
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, V6T 1Z3, Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Jane Buxton
- School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, V6T 1Z3, Canada
| | - Silvia Guillemi
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Surita Parashar
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Julio Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - M-J Milloy
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Soyka M, Mutschler J. Treatment-refractory substance use disorder: Focus on alcohol, opioids, and cocaine. Prog Neuropsychopharmacol Biol Psychiatry 2016; 70:148-61. [PMID: 26577297 DOI: 10.1016/j.pnpbp.2015.11.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/23/2015] [Accepted: 11/11/2015] [Indexed: 12/20/2022]
Abstract
Substance use disorders are common, but only a small minority of patients receive adequate treatment. Although psychosocial therapies are effective, relapse is common. This review focusses on novel pharmacological and other treatments for patients with alcohol, opioid, or cocaine use disorders who do not respond to conventional treatments. Disulfiram, acamprosate, and the opioid antagonist naltrexone have been approved for the treatment of alcoholism. A novel, "as needed" approach is the use of the mu-opioid antagonist and partial kappa agonist nalmefene to reduce alcohol consumption. Other novel pharmacological approaches include the GABA-B receptor agonist baclofen, anticonvulsants such as topiramate and gabapentin, the partial nicotine receptor agonist varenicline, and other drugs. For opioid dependence, opioid agonist therapy with methadone or buprenorphine is the first-line treatment option. Other options include oral or depot naltrexone, morphine sulfate, depot or implant formulations, and heroin (diacetylmorphine) in treatment-refractory patients. To date, no pharmacological treatment has been approved for cocaine addiction; however, 3 potential pharmacological treatments are being studied, disulfiram, methylphenidate, and modafinil. Pharmacogenetic approaches may help to optimize treatment response in otherwise treatment-refractory patients and to identify which patients are more likely to respond to treatment, and neuromodulation techniques such as repeated transcranial magnetic stimulation and deep brain stimulation also may play a role in the treatment of substance use disorders. Although no magic bullet is in sight for treatment-refractory patients, some novel medications and brain stimulation techniques have the potential to enrich treatment options at least for some patients.
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Affiliation(s)
- Michael Soyka
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Nussbaumstrasse 7, 80336 Munich, Germany; Privatklinik Meiringen, Postfach 612, CH-3860 Meiringen, Switzerland.
| | - Jochen Mutschler
- Center for Addictive Disorders, Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Selnaustrasse 9, 8001 Zurich, Switzerland
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Lake S, Hayashi K, Buxton J, Milloy MJ, Dong H, Wood E, Montaner J, Kerr T. The effect of prescription opioid injection on the risk of non-fatal overdose among people who inject drugs. Drug Alcohol Depend 2015; 156:297-303. [PMID: 26454837 PMCID: PMC4633348 DOI: 10.1016/j.drugalcdep.2015.09.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/23/2015] [Accepted: 09/24/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Prescription opioid (PO) use by people who inject drugs (PWID) is a growing public health concern. Non-fatal overdose remains a leading source of morbidity among PWID, however, little is known about the relationship between PO injection and non-fatal overdose in this population. In this study we sought to examine the impact of PO injection on non-fatal overdose among PWID from Vancouver, Canada. METHODS Data were derived from two open prospective cohorts of PWID for the period of December, 2005 to May, 2014. Multivariable generalized estimating equations were used to examine the odds of overdose among those who injected: POs; heroin; and POs and heroin. RESULTS In total, 1660 PWID (33.7% women) participated in this study. In multivariable analyses, in comparison to those who were injecting non-opioid drugs, exclusive PO injection was not significantly associated with non-fatal overdose (adjusted odds ratio [AOR]: 1.17, 95% confidence interval [CI]: 0.74-1.86). The odds of non-fatal overdose were elevated for heroin injection (AOR: 1.72, 95% CI: 1.31-2.27), but were greatest for those who injected both heroin and POs (AOR: 2.46, 95% CI: 1.83-3.30). DISCUSSION Compared to injecting non-opioids, injecting POs exclusively did not increase risk of non-fatal overdose; however, injecting both POs and heroin doubled the risk. This may reflect consistencies in drug potency and composition when POs are used, as well as unique characteristics of exclusive PO injectors. Our findings call for the continued scale-up of evidence-based overdose prevention interventions for people who inject opioids, including POs.
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Affiliation(s)
- Stephanie Lake
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Kanna Hayashi
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Jane Buxton
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - M-J Milloy
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Huiru Dong
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Julio Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
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Walton G, Nolan S, Sutherland C, Ahamad K. Sustained release oral morphine as an alternative to methadone for the treatment of opioid-use disorder post Torsades de Pointes cardiac arrest. BMJ Case Rep 2015; 2015:bcr-2015-210239. [PMID: 26392442 DOI: 10.1136/bcr-2015-210239] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
In most settings, approved medications for the treatment of opioid-use disorder include methadone and buprenorphine/naloxone, and in some settings, naltrexone. We present a case in which methadone administration was associated with an in-hospital episode of Torsades de Pointes in a patient who was subsequently maintained on sustained release oral morphine (SROM) for treatment of his opioid-use disorder. This transition was made in the context of long-term compliance to methadone maintenance, and with a previous adverse reaction to buprenorphine/naloxone precluding its use. The change to SROM, supported by emerging evidence, resulted in a reduction in the patient's measured QTc interval, prevention of further arrhythmias and continued abstinence from illicit opioid-use. In this context, we believe careful consideration should be given to the use of SROM.
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Affiliation(s)
- Geoffrey Walton
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Seonaid Nolan
- Department of Medicine, Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christy Sutherland
- Department of Family Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Keith Ahamad
- Department of Family Medicine, Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, British Columbia, Canada
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