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Philippine T, Forsgren E, DeWitt C, Carter I, McCollough M, Taira BR. Provider perspectives on emergency department initiation of medication assisted treatment for alcohol use disorder. BMC Health Serv Res 2022; 22:456. [PMID: 35392901 PMCID: PMC8988541 DOI: 10.1186/s12913-022-07862-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Alcohol use disorder (AUD) is ubiquitous and its sequelae contribute to high levels of healthcare utilization, yet AUD remains undertreated. The ED encounter represents a missed opportunity to initiate medication assisted treatment (MAT) for patients with AUD. The aims of this study are to identify barriers and facilitators to the treatment of AUD in the ED, and to design interventions to address identified barriers. Methods Using an implementation science approach based on the Behavior Change Wheel framework, we conducted qualitative interviews with staff to interrogate their perspectives on ED initiation of AUD treatment. Subjects included physicians, nurses, nurse practitioners, clinical social workers, and pharmacists. Interviews were thematically coded using both inductive and deductive approaches and constant comparative analysis. Themes were further categorized as relating to providers’ capabilities, opportunities, or motivations. Barriers were then mapped to corresponding intervention functions. Results Facilitators at our institution included time allotted for continuing education, the availability of clinical social workers, and favorable opinions of MAT based on previous experiences implementing buprenorphine for opioid use disorder. Capability barriers included limited familiarity with naltrexone and difficulty determining which patients are candidates for therapy. Opportunity barriers included the limited supply of naltrexone and a lack of clarity as to who should introduce naltrexone and assess readiness for change. Motivation barriers included a sense of futility in treating patients with AUD and stigmas associated with alcohol use. Evidence-based interventions included multi-modal provider education, a standardized treatment algorithm and order set, selection of clinical champions, and clarification of roles among providers on the team. Conclusions A large evidence-practice gap exists for the treatment of AUD with Naltrexone, and the ED visit is a missed opportunity for intervention. ED providers are optimistic about implementing AUD treatment in the ED but described many barriers, especially related to knowledge, clarification of roles, and stigma associated with AUD. Applying a formal implementation science approach guided by the Behavior Change Wheel allowed us to transform qualitative interview data into evidence-based interventions for the implementation of an ED-based program for the treatment of AUD. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07862-1.
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Affiliation(s)
| | - Ethan Forsgren
- Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
| | | | - Inanna Carter
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Maureen McCollough
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
| | - Breena R Taira
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
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Perez-Macia V, Martinez- Cortes M, Mesones J, Segura-Trepichio M, Garcia-Fernandez L. Monitoring and Improving Naltrexone Adherence in Patients with Substance Use Disorder. Patient Prefer Adherence 2021; 15:999-1015. [PMID: 34040354 PMCID: PMC8140930 DOI: 10.2147/ppa.s277861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/09/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Naltrexone is an opioid antagonist used for the treatment of patients with opioid use disorder and alcohol use disorder. This population often presents problems of follow-up and therapeutic efficacy related to adherence to treatment. The purpose of our study is to provide an exhaustive summary of the current evidence regarding naltrexone adherence in people with substance use disorders and to identify possible variables that may influence adherence to naltrexone. METHODS Two searches were performed in bibliographic databases (PubMed, Embase), and studies included in the systematic review were those published from January 1, 2011 to September 2020, with participants over 18 years of age, evaluating treatment with naltrexone in alcohol use disorder and opioid use disorder. From the total of 133 articles initially selected, 36 were included and analyzed in the systematic review. RESULTS Naltrexone has not demonstrated superiority over other available treatments in terms of adherence and abstinence, although reinforcement systems have obtained favorable results as an additional strategy to improve adherence. CONCLUSION It is necessary to study other psychosocial variables involved in improving adherence, in addition to taking patient preferences into account in order to improve the external validity of the results.
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Affiliation(s)
- Virginia Perez-Macia
- Vinalopó University Hospital, Elche, Spain
- Psychology and Psychiatry Department, Catholic University of Murcia, Murcia, Spain
- Correspondence: Virginia Perez-Macia 36 Vicente Fuentes Sansano Road, Elche (Alicante), 03205, SpainTel +34 675550722 Email
| | | | - Jesus Mesones
- Vinalopó University Hospital, Elche, Spain
- Psychology and Psychiatry Department, Catholic University of Murcia, Murcia, Spain
| | | | - Lorena Garcia-Fernandez
- University Hospital of San Juan, Alicante, Spain
- Clinical Medicine Department, Miguel Hernández University, Alicante, Spain
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Abstract
This paper is the forty-first consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2018 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (2), the roles of these opioid peptides and receptors in pain and analgesia in animals (3) and humans (4), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (5), opioid peptide and receptor involvement in tolerance and dependence (6), stress and social status (7), learning and memory (8), eating and drinking (9), drug abuse and alcohol (10), sexual activity and hormones, pregnancy, development and endocrinology (11), mental illness and mood (12), seizures and neurologic disorders (13), electrical-related activity and neurophysiology (14), general activity and locomotion (15), gastrointestinal, renal and hepatic functions (16), cardiovascular responses (17), respiration and thermoregulation (18), and immunological responses (19).
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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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Abstract
Opioid use disorder (OUD) is a chronic relapsing disorder that, whilst initially driven by activation of brain reward neurocircuits, increasingly engages anti-reward neurocircuits that drive adverse emotional states and relapse. However, successful recovery is possible with appropriate treatment, although with a persisting propensity to relapse. The individual and public health burdens of OUD are immense; 26.8 million people were estimated to be living with OUD globally in 2016, with >100,000 opioid overdose deaths annually, including >47,000 in the USA in 2017. Well-conducted trials have demonstrated that long-term opioid agonist therapy with methadone and buprenorphine have great efficacy for OUD treatment and can save lives. New forms of the opioid receptor antagonist naltrexone are also being studied. Some frequently used approaches have less scientifically robust evidence but are nevertheless considered important, including community preventive strategies, harm reduction interventions to reduce adverse sequelae from ongoing use and mutual aid groups. Other commonly used approaches, such as detoxification alone, lack scientific evidence. Delivery of effective prevention and treatment responses is often complicated by coexisting comorbidities and inadequate support, as well as by conflicting public and political opinions. Science has a crucial role to play in informing public attitudes and developing fuller evidence to understand OUD and its associated harms, as well as in obtaining the evidence today that will improve the prevention and treatment interventions of tomorrow.
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Reif S, Brolin MF, Stewart MT, Fuchs TJ, Speaker E, Mazel SB. The Washington State Hub and Spoke Model to increase access to medication treatment for opioid use disorders. J Subst Abuse Treat 2020; 108:33-39. [PMID: 31358328 PMCID: PMC6893117 DOI: 10.1016/j.jsat.2019.07.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 07/08/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The federal Opioid State Targeted Response (Opioid STR) grants provided funding to each state to ramp up the range of responses to reverse the ongoing opioid crisis in the U.S. Washington State used these funds to develop and implement an integrated care model to expand access to medication treatment and reduce unmet need for people with opioid use disorders (OUD), regardless of how they enter the treatment system. This paper examines the design, early implementation and results of the Washington State Hub and Spoke Model. METHODS Descriptive data were gathered from key informants, document review, and aggregate data reported by hubs and spokes to Washington State's Opioid STR team. RESULTS The Washington State Hub and Spoke Model reflects a flexible approach that incorporates primary care and substance use treatment programs, as well as outreach, referral and social service organizations, and a nurse care manager. Hubs could be any type of program that had the required expertise and capacity to lead their network in medication treatment for OUD, including all three FDA-approved medications. Six hub-spoke networks were funded, with 8 unique agencies on average, and multiple sites. About 150 prescribers are in these networks (25 on average). In the first 18 months, nearly 5000 people were inducted onto OUD medication treatment: 73% on buprenorphine, 19% on methadone, and 9% on naltrexone. CONCLUSIONS The Washington State Hub and Spoke Model built on prior approaches to improve the delivery system for OUD medication treatment and support services, by increasing integration of care, ensuring "no wrong door," engaging with community agencies, and supporting providers who are offering medication treatment. It used essential elements from existing integrated care OUD treatment models, but allowed for organic restructuring to meet the population needs within a community. To date, there have been challenges and successes, but with this approach, Washington State has provided medication treatment for OUD to nearly 5000 people. Sustainability efforts are underway. In the face of the ongoing opioid crisis, it remains essential to develop, implement and evaluate novel models, such as Washington's Hub and Spoke approach, to improve treatment access and increase capacity.
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Affiliation(s)
- Sharon Reif
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, USA.
| | - Mary F Brolin
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, USA
| | - Maureen T Stewart
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, USA
| | - Thomas J Fuchs
- Division of Behavioral Health and Recovery, Washington State Health Care Authority, 626 8th Avenue SE, P.O. Box 45330, Olympia, WA 98504, USA
| | - Elizabeth Speaker
- Research and Data Analysis, Washington State Department of Social and Health Services, 1115 Washington Street, P.O. Box 4520, Olympia, WA 98504, USA
| | - Shayna B Mazel
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, USA
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Park K, Otte A. Prevention of Opioid Abuse and Treatment of Opioid Addiction: Current Status and Future Possibilities. Annu Rev Biomed Eng 2019; 21:61-84. [PMID: 30786212 DOI: 10.1146/annurev-bioeng-060418-052155] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prescription opioid medications have seen a dramatic rise in misuse and abuse, leading regulators and scientists to develop policies and abuse-deterrent technologies to combat the current opioid epidemic. These abuse-deterrent formulations (ADFs) are intended to deter physical and chemical tampering of opioid-based products, while still providing safe and effective delivery for therapeutic purposes. Even though formulations with varying abuse-deterrent technologies have been approved, questions remain about their effectiveness. While these formulations provide a single means to combat the epidemic, a greater emphasis should be placed on formulations for treatment of addiction and overdose to help those struggling with opioid dependence. This article analyzes various ADFs currently in clinical use and explores potential novel systems for treatment of addiction and prevention of overdose.
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Affiliation(s)
- Kinam Park
- Weldon School of Biomedical Engineering and College of Pharmacy, Purdue University, West Lafayette, Indiana 47907, USA
| | - Andrew Otte
- Weldon School of Biomedical Engineering and College of Pharmacy, Purdue University, West Lafayette, Indiana 47907, USA
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Saxon AJ, Akerman SC, Liu CC, Sullivan MA, Silverman BL, Vocci FJ. Extended-release naltrexone (XR-NTX) for opioid use disorder in clinical practice: Vivitrol's Cost and Treatment Outcomes Registry. Addiction 2018; 113:1477-1487. [PMID: 29493836 DOI: 10.1111/add.14199] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/11/2017] [Accepted: 02/12/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Extended-release naltrexone (XR-NTX), a μ-opioid receptor antagonist for prevention of relapse to opioid dependence, has demonstrated efficacy compared with placebo and comparative effectiveness with buprenorphine-naloxone. We report outcomes for XR-NTX in Vivitrol's Cost and Treatment Outcomes Registry. DESIGN Observational, open-label, single-arm, multi-center registry assessing baseline characteristics and clinical and health-related quality-of-life outcomes associated with XR-NTX treatment in clinical practice. SETTING 32 US treatment centers from 2011 to 2013. PARTICIPANTS Patients with opioid dependence who were prescribed XR-NTX treatment and then enrolled into the registry. MEASUREMENTS Monthly visits were evaluated for the full population and for patient ubgroups retrospectively, defined by injection number, focusing on the period between baseline and month 6 (1-, 2/3- or 6-XR-NTX). FINDINGS Of 403 enrolled patients, 395 were analyzed. Most patients (n = 349) received out-patient care. On average, patients received five injections (median = 3; range = 1-25). The median number of injections administered within 6 months was higher in patients who at baseline were employed (three versus two unemployed, P = 0.02) or had private insurance (five versus two self-payment, P = 0.005; versus two state-funded, P < 0.001). The 1-, 2/3- and 6-XR-NTX groups had 132, 152 and 111 patients, respectively. At baseline, the 6-XR-NTX patients were more likely to meet normal/minimal mental illness criteria and attend school and less likely to report recent drug use. Within 6 months, the 6-XR-NTX group demonstrated improvements in employment, mental health and psychosocial functioning, and decreases in opioid craving, drug use and drug-related behavior. CONCLUSIONS Among opioid-dependent people receiving XR-NTX treatment, better mental health, higher education and lower recent drug use at baseline are associated with greater treatment duration; in turn, longer treatment duration is associated with lower relapse rates and improved outcomes generally.
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Affiliation(s)
- Andrew J Saxon
- Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | | | | | - Maria A Sullivan
- Alkermes, Inc., Waltham, MA, USA.,Columbia University, New York, NY, USA
| | | | - Frank J Vocci
- Friends Research Institute, Inc., Baltimore, MD, USA
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Friedmann PD, Dunn KE, Nunes EV, O'Brien CP. Effectiveness, Implementation and Real-World Experience with Extended-Release Naltrexone (XR-NTX): A Special Issue of JSAT. J Subst Abuse Treat 2017; 85:31-33. [PMID: 29273249 DOI: 10.1016/j.jsat.2017.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Peter D Friedmann
- Office of Research and Department of Medicine, University of Massachusetts-Baystate and Baystate Health, Springfield, MA.
| | - Kelly E Dunn
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Edward V Nunes
- New York State Psychiatric Institute, Columbia University Medical Center New York, NY
| | - Charles P O'Brien
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
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Crèvecoeur-MacPhail D, Cousins SJ, Denering L, Kim T, Rawson RA. Effectiveness of extended release naltrexone to reduce alcohol cravings and use behaviors during treatment and at follow-up. J Subst Abuse Treat 2017; 85:105-108. [PMID: 29174308 DOI: 10.1016/j.jsat.2017.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 01/12/2023]
Abstract
Changes in cravings to drink alcohol and alcohol use behaviors were examined among 337 patients who were administered extended-release naltrexone (XR-NTX) in conjunction with psychosocial treatment in community-based substance use disorder treatment programs. Cravings and use behaviors were assessed at multiple time points (baseline; weeks 1, 2, and 3 after the first dose; monthly after the first four assessments; and at 30- and 60-days after the last dose). A total of 863 doses (M=2.6, SD=1.8) were administered and the majority of patients (65%) took more than one dose. Alcohol craving scores decreased from 19 to 5.7 after the first dose of XR-NTX. Days of primary alcohol use at admission (M=10.5, SD=10.1) were reduced at discharge (M=to 1.2, SD=4.6). At the first follow-up, 79.8% reported no alcohol use and 77.8% reported no alcohol use at the second follow-up. The expected side effects were reported but the medication was well tolerated and there was no relationship between side effects and subsequent dose. Unexamined or unaccounted for variables (e.g., motivation, external pressures to remain in treatment) are "real world" consequences that may have impacted the outcome of this study. Results indicated that use of the antagonist medication XR-NTX may be related to significant decreases in alcohol craving and use while a patient is in treatment, as well as at 30- and 60-days after the final dose.
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Affiliation(s)
- Desirée Crèvecoeur-MacPhail
- University of California, Los Angeles, Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., Suite 200, Los Angeles, CA 90025, USA..
| | - Sarah J Cousins
- University of California, Los Angeles, Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., Suite 200, Los Angeles, CA 90025, USA
| | - Loretta Denering
- Department of Public Health, Substance Abuse Prevention and Control (SAPC), 1000 S. Fremont Ave., Alhambra, CA 91803, USA
| | - Tina Kim
- Department of Public Health, Substance Abuse Prevention and Control (SAPC), 1000 S. Fremont Ave., Alhambra, CA 91803, USA
| | - Richard A Rawson
- University of California, Los Angeles, Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., Suite 200, Los Angeles, CA 90025, USA
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