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Cook RR, Foot C, Arah OA, Humphreys K, Rudolph KE, Luo SX, Tsui JI, Levander XA, Korthuis PT. Estimating the impact of stimulant use on initiation of buprenorphine and extended-release naltrexone in two clinical trials and real-world populations. Addict Sci Clin Pract 2023; 18:11. [PMID: 36788634 PMCID: PMC9930351 DOI: 10.1186/s13722-023-00364-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 02/01/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Co-use of stimulants and opioids is rapidly increasing. Randomized clinical trials (RCTs) have established the efficacy of medications for opioid use disorder (MOUD), but stimulant use may decrease the likelihood of initiating MOUD treatment. Furthermore, trial participants may not represent "real-world" populations who would benefit from treatment. METHODS We conducted a two-stage analysis. First, associations between stimulant use (time-varying urine drug screens for cocaine, methamphetamine, or amphetamines) and initiation of buprenorphine or extended-release naltrexone (XR-NTX) were estimated across two RCTs (CTN-0051 X:BOT and CTN-0067 CHOICES) using adjusted Cox regression models. Second, results were generalized to three target populations who would benefit from MOUD: Housed adults identifying the need for OUD treatment, as characterized by the National Survey on Drug Use and Health (NSDUH); adults entering OUD treatment, as characterized by Treatment Episodes Dataset (TEDS); and adults living in rural regions of the U.S. with high rates of injection drug use, as characterized by the Rural Opioids Initiative (ROI). Generalizability analyses adjusted for differences in demographic characteristics, substance use, housing status, and depression between RCT and target populations using inverse probability of selection weighting. RESULTS Analyses included 673 clinical trial participants, 139 NSDUH respondents (weighted to represent 661,650 people), 71,751 TEDS treatment episodes, and 1,933 ROI participants. The majority were aged 30-49 years, male, and non-Hispanic White. In RCTs, stimulant use reduced the likelihood of MOUD initiation by 32% (adjusted HR [aHR] = 0.68, 95% CI 0.49-0.94, p = 0.019). Stimulant use associations were slightly attenuated and non-significant among housed adults needing treatment (25% reduction, aHR = 0.75, 0.48-1.18, p = 0.215) and adults entering OUD treatment (28% reduction, aHR = 0.72, 0.51-1.01, p = 0.061). The association was more pronounced, but still non-significant among rural people injecting drugs (39% reduction, aHR = 0.61, 0.35-1.06, p = 0.081). Stimulant use had a larger negative impact on XR-NTX initiation compared to buprenorphine, especially in the rural population (76% reduction, aHR = 0.24, 0.08-0.69, p = 0.008). CONCLUSIONS Stimulant use is a barrier to buprenorphine or XR-NTX initiation in clinical trials and real-world populations that would benefit from OUD treatment. Interventions to address stimulant use among patients with OUD are urgently needed, especially among rural people injecting drugs, who already suffer from limited access to MOUD.
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Affiliation(s)
- R R Cook
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Sam Jackson Hall, Suite 3370, 3245 SW Pavilion Loop, Portland, OR, 97239, USA.
| | - C Foot
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Sam Jackson Hall, Suite 3370, 3245 SW Pavilion Loop, Portland, OR, 97239, USA
| | - O A Arah
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
- Division of Physical Sciences, Department of Statistics, UCLA College, Los Angeles, CA, USA
- Research Unit for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - K Humphreys
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, USA
| | - K E Rudolph
- Department of Epidemiology, School of Public Health, Columbia University, New York, NY, USA
| | - S X Luo
- Division on Substance Use Disorders, Department of Psychiatry, Columbia University, New York, USA
| | - J I Tsui
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - X A Levander
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Sam Jackson Hall, Suite 3370, 3245 SW Pavilion Loop, Portland, OR, 97239, USA
| | - P T Korthuis
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Sam Jackson Hall, Suite 3370, 3245 SW Pavilion Loop, Portland, OR, 97239, USA
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Karlsson AT, Vederhus JK, Clausen T, Weimand B, Solli KK, Tanum L. Impact of Impulsivity, Hyperactivity, and Inattention on Discontinuation Rate among Opioid-Dependent Patients Treated with Extended-Release Naltrexone. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11435. [PMID: 36141709 PMCID: PMC9517108 DOI: 10.3390/ijerph191811435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
Previous studies have indicated elevated levels of impulsivity, hyperactivity, and inattention (IHI) among opioid-dependent patients seeking outpatient treatment with extended-release naltrexone (XR-NTX). This led us to hypothesize that IHI may be associated with a higher discontinuation rate for XR-NTX treatment. In a group of 162 patients with opioid dependence, discontinuation prior to the full 24 weeks of the study period (six injections and attending the study visit at 24 weeks) occurred in 49% of the patients, primarily in the early stage of treatment. IHI above the clinical cut-off on the adult ADHD self-report scale (ASRS) was not associated with a risk of premature discontinuation. This finding was not altered when controlling for socio-demographics, substance, use and mental health severity. Conclusively, high levels of IHI per se is not contradictive for XR-NTX treatment in regard to concern for premature discontinuation.
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Affiliation(s)
| | | | - Thomas Clausen
- Addiction Unit, Sørlandet Hospital HF, 4604 Kristiansand, Norway
- Norwegian Centre for Addiction Research, University of Oslo, 0315 Oslo, Norway
| | - Bente Weimand
- Center for Mental Health and Substance Abuse, University of South-Eastern Norway, 3040 Drammen, Norway
- Department of R&D in Psychiatric Health Care, Akershus University Hospital, 1478 Oslo, Norway
| | - Kristin Klemmetsby Solli
- Norwegian Centre for Addiction Research, University of Oslo, 0315 Oslo, Norway
- Department of R&D in Psychiatric Health Care, Akershus University Hospital, 1478 Oslo, Norway
- Vestfold Hospital Trust, 3103 Tønsberg, Norway
| | - Lars Tanum
- Department of R&D in Psychiatric Health Care, Akershus University Hospital, 1478 Oslo, Norway
- Faculty for Health Science, Oslo Metropolitan University, 0130 Oslo, Norway
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Marciuch A, Brenna IH, Weimand B, Solli KK, Tanum L, Røstad BK, Birkeland B. Patients' experiences of continued treatment with extended-release naltrexone: a Norwegian qualitative study. Addict Sci Clin Pract 2022; 17:36. [PMID: 35850782 PMCID: PMC9290197 DOI: 10.1186/s13722-022-00317-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The opioid antagonist extended-release naltrexone (XR-NTX) in the treatment of opioid use disorder (OUD) is effective in terms of safety, abstinence from opioid use and retention in treatment. However, it is unclear how patients experience and adjust to losing the possibility of achieving an opioid effect. This qualitative study is the first to explore how people with opioid dependence experience XR-NTX treatment, focusing on the process of treatment over time. METHODS Using a purposive sampling strategy, semi-structured interviews were undertaken with 19 persons with opioid use disorder (15 men, four women, 22-55 years of age) participating in a clinical trial of XR-NTX in Norway. The interviewees had received at least three XR-NTX injections. Qualitative content analysis with an inductive approach was used. FINDINGS Participants described that XR-NTX treatment had many advantages. However they still faced multiple challenges, some of which they were not prepared for. Having to find a new foothold and adapt to no longer gaining an effect from opioids due to the antagonist medication was challenging. This was especially true for those struggling emotionally and transitioning into the harmful use of non-opioid substances. Additional support was considered crucial. Even so, the treatment led to an opportunity to participate in society and reclaim identity. Participants had strong goals for the future and described that XR-NTX enabled a more meaningful life. Expectations of a better life could however turn into broken hopes. Although participants were largely optimistic about the future, thinking about the end of treatment could cause apprehension. CONCLUSIONS XR-NTX treatment offers freedom from opioids and can facilitate the recovery process for people with OUD. However, our findings also highlight several challenges associated with XR-NTX treatment, emphasizing the importance of monitoring emotional difficulties and increase of non-opioid substances during treatment. As opioid abstinence in itself does not necessarily equal recovery, our findings underscore the importance of seeing XR-NTX as part of a comprehensive, individualized treatment approach. TRIAL REGISTRATION Clinicaltrials.gov # NCT03647774, first Registered: Aug 28, 2018.
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Affiliation(s)
- Anne Marciuch
- Department of Research and Development in Mental Health, Akershus University Hospital, PB. 1000, 1478, Loerenskog, HF, Norway.
- Department of Medicine, Faculty of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Ida Halvorsen Brenna
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Bente Weimand
- Department of Research and Development in Mental Health, Akershus University Hospital, PB. 1000, 1478, Loerenskog, HF, Norway
- Department of Health, Social and Welfare Studies, University of South-Eastern Norway, Drammen, Norway
| | - Kristin Klemmetsby Solli
- Department of Research and Development in Mental Health, Akershus University Hospital, PB. 1000, 1478, Loerenskog, HF, Norway
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
- Vestfold Hospital Trust, Toensberg, Norway
| | - Lars Tanum
- Department of Research and Development in Mental Health, Akershus University Hospital, PB. 1000, 1478, Loerenskog, HF, Norway
- Faculty for Health Science, Oslo Metropolitan University, Oslo, Norway
| | - Bente K Røstad
- RIO-a Norwegian users' association in the field of alcohol and drugs, Oslo, Norway
| | - Bente Birkeland
- Department of Psychosocial Health, University of Agder, Kristiansand, Norway
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Gaulen Z, Brenna IH, Fadnes LT, Šaltytė Benth J, Solli KK, Kunoe N, Opheim A, Tanum L. The Predictive Value of Degree of Preference for Extended-Release Naltrexone for Treatment Adherence, Opioid Use, and Relapse. Eur Addict Res 2022; 28:56-67. [PMID: 34569487 DOI: 10.1159/000518436] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Extended-release naltrexone (XR-NTX) is effective for illicit opioid abstinence as an opioid maintenance treatment. To improve treatment outcomes, patient's preference for the modality of treatment is an important factor. OBJECTIVES We aimed to test the relationship between baseline preference for XR-NTX and adherence to treatment, use of illicit opioids, and risk of relapse. METHODS In an open-label, Norwegian clinical trial participants with opioid use disorder were randomized to either monthly injections with XR-NTX or daily sublingual buprenorphine-naloxone (BP-NLX) for 12 weeks. Subsequently, participants could continue with their preferred medication in a 36-week follow-up and in a prolonged period of 104 weeks. RESULTS Of 153 participants who completed detoxification, 72% were men, with a mean age of 36 years. Preference levels were similar across the randomized groups, with no significant associations between preference and adherence to treatment, opioid use, or relapse. The BP-NLX group had a significantly higher risk of first relapse to opioids than the XR-NTX group for all levels of preference (p < 0.001) and a significantly higher number of days of illicit opioid use. In the follow-up period, the adherence rate was twice as high among participants with the highest preference compared to participants with the lowest preference, both among those who switched to XR-NTX and those who continued (hazard ratio 2.2; 1.2-4.0, p = 0.013). Opioid use was significantly higher among participants who switched to XR-NTX with the lowest preference than the medium (p = 0.003) or the highest (p = 0.001) preference. The risk of relapse to opioids, however, was significantly higher among XR-NTX continuing participants with the lowest (p = 0.002) or the medium (p = 0.043) preference than those with the highest preference. CONCLUSIONS Individuals who matched with their preferred treatment used less illicit opioids than those who did not during short-term treatment. However, baseline preference for XR-NTX treatment primarily influenced longer term opioid use and treatment adherence.
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Affiliation(s)
- Zhanna Gaulen
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Dentistry, University of Bergen, Bergen, Norway
| | - Ida Halvorsen Brenna
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Psychology, University of Bergen, Bergen, Norway
| | - Lars Thore Fadnes
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Blindern, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Kristin K Solli
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway.,Norwegian Center for Addiction Research, University of Oslo, Oslo, Norway.,Vestfold Hospital Trust, Tonsberg, Norway
| | - Nikolaj Kunoe
- Norwegian Center for Addiction Research, University of Oslo, Oslo, Norway.,Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Arild Opheim
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Lars Tanum
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway.,Department of Health Science, Oslo Metropolitan University, Oslo, Norway
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Brenna IH, Marciuch A, Birkeland B, Veseth M, Røstad B, Løberg EM, Solli KK, Tanum L, Weimand B. 'Not at all what I had expected': Discontinuing treatment with extended-release naltrexone (XR-NTX): A qualitative study. J Subst Abuse Treat 2021; 136:108667. [PMID: 34865937 DOI: 10.1016/j.jsat.2021.108667] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/08/2021] [Accepted: 11/19/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Extended-release naltrexone (XR-NTX), an opioid antagonist, has demonstrated equal treatment outcomes, in terms of safety, opioid use, and retention, to the recommended OMT medication buprenorphine. However, premature discontinuation of XR-NTX treatment is still common and poorly understood. Research on patient experiences of XR-NTX treatment is limited. We sought to explore participants' experiences with discontinuation of treatment with XR-NTX, particularly motivation for XR-NTX, experiences of initiation and treatment, and rationale for leaving treatment. METHODS We conducted qualitative, semi-structured interviews with participants from a clinical trial of XR-NTX. The study participants (N = 13) included seven women and six men with opioid dependence, who had received a minimum of one and maximum of four injections of XR-NTX. The study team analyzed transcribed interviews, employing thematic analysis with a critical realist approach. FINDINGS The research team identified three themes, and we present them as a chronological narrative: theme 1: Entering treatment - I thought I knew what I was going into; theme 2: Life with XR-NTX - I had something in me that I didn't want; and theme 3: Leaving treatment - I want to go somewhere in life. Patients' unfulfilled expectations of how XR-NTX would lead to a better life were central to decisions about discontinuation, including unexpected physical, emotional, or mental reactions as well as a lack of expected effects, notably some described an opioid effect from buprenorphine. A few participants ended treatment because they had reached their treatment goal, but most expressed disappointment about not achieving this goal. Some also expressed renewed acceptance of OMT. The participants' motivation for abstinence from illegal substances generally remained. CONCLUSION Our findings emphasize that a dynamic understanding of discontinuation of treatment is necessary to achieve a long-term approach to recovery: the field should understand discontinuation as a feature of typical treatment trajectories, and discontinuation can be followed by re-initiation of treatment.
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Affiliation(s)
- Ida Halvorsen Brenna
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway.
| | - Anne Marciuch
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway; Department of Medicine, University of Oslo, Oslo, Norway
| | - Bente Birkeland
- Department of Psychosocial Health, Faculty of Health and Sports Science, University of Agder, Kristiansand, Norway
| | - Marius Veseth
- Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Bente Røstad
- RIO-a Norwegian users' association in the field of alcohol and drugs, Oslo, Norway
| | - Else-Marie Løberg
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway; Department of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Kristin Klemmetsby Solli
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway; Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway; Vestfold Hospital Trust, Toensberg, Norway
| | - Lars Tanum
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway; Faculty for Health Science, Oslo Metropolitan University, Oslo, Norway
| | - Bente Weimand
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway; Department of Health, Social and Welfare Studies, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
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