Opioid addiction and abuse in primary care practice: a comparison of methadone and buprenorphine as treatment options

Nighttime Sleep and Respiratory Disturbances in Individuals Receiving Methadone to Treat Opioid Use Disorder

ABSTRACT

Opioids are a leading cause of drug overdose deaths in the United States. Methadone used as medication for opioid use disorder (MOUD) reduces drug cravings and promotes abstinence. However, individuals in methadone-based MOUD treatment commonly report subjective sleep complaints and are at risk for respiratory depression from opioids. We investigated nighttime sleep and respiratory function in eight individuals (six women, two men; ages 31-68 years) in their first 90 days of methadone-based MOUD treatment. Participants underwent overnight cardiorespiratory polysomnography. Sleep and respiratory variables were characterized with descriptive statistics for comparison to reference data from similarly aged healthy adults. Although participants spent 8.1 ± 0.3 hours (mean ± SD ) in bed, their total sleep time was only 6.8 ± 1.3 hours. They exhibited longer sleep latency and intermittent wakefulness. Sleep structure was irregular, with disrupted sleep cycles. Participants also displayed a decreased amount of N1 sleep and an increased amount of N3 sleep, compared with reference data. Participants showed respiratory depression, with an average apnea-hypopnea index of 16.5 ± 8.9 events per hour. Central sleep apneas comprised 69.1% ± 20.9% of the respiratory events. A Cheyne-Stokes-like breathing pattern, consisting of 30-second cycles of three central sleep apneas, was observed in 75% of participants. Our results suggest that individuals early in methadone-based MOUD treatment experience disordered sleep and respiratory disturbances. Such nighttime physiological changes may have serious long-term health consequences and contribute to unintended overdose rates. Identifying and treating MOUD individuals with sleep apnea could reduce risk of death.

Effects of Buprenorphine/Naloxone and Methadone on Depressive Symptoms in People with Prescription Opioid Use Disorder: A Pragmatic Randomised Controlled Trial

OBJECTIVE

This study aimed to evaluate the effectiveness of flexible take-home dosing of buprenorphine/naloxone (BUP/NX) and methadone standard model of care in reducing depressive symptoms in people with prescription-type opioid use disorder (POUD). This trial also evaluated whether improvements in depressive symptoms were mediated by opioid use.

METHODS

Analyzed data came from the OPTIMA study (clinicaltrials.gov identifier: NCT03033732), a pragmatic randomised controlled trial comparing flexible take-home dosing of BUP/NX and methadone standard model of care for reducing opioid use in people with POUD. A total of 272 participants were recruited in four Canadian provinces. Participants were randomised 1:1 to BUP/NX or methadone. After treatment induction, past two-week opioid use was measured using the Timeline Followback every two weeks for a total of 24 weeks. Depressive symptoms were measured with the Beck Depression Inventory at baseline, weeks 12 and 24.

RESULTS

Both BUP/NX and methadone significantly reduced depressive symptoms at week 12 (aβ ± SE = -3.167 ± 1.233; P < 0.001) and week 24 (aβ ± SE = -7.280 ± 1.285; P < 0.001), with no interaction between type of treatment and time (P = 0.284). Improvements in depressive symptoms were only partially mediated by a reduction in opioid use (proportion mediated = 36.8%; 95% confidence interval = -1.158 to -0.070; P = 0.015).

CONCLUSIONS

BUP/NX and methadone showed similar effectiveness in decreasing comorbid depressive symptoms in people with POUD. This effect was partially explained by a reduction in opioid use. As both treatments seem equally effective, clinicians are encouraged to tailor the selection of OAT to patients' needs and characteristics.

Cebranopadol, a novel long-acting opioid agonist with low abuse liability, to treat opioid use disorder: Preclinical evidence of efficacy

The gold standard pharmacological treatment for opioid use disorder (OUD) consists of maintenance therapy with long-acting opioid agonists such as buprenorphine and methadone. Despite these compounds having demonstrated substantial efficacy, a significant number of patients do not show optimal therapeutic responses. Moreover, the abuse liability of these medications remains a major concern. Cebranopadol, is a new, long-acting pan-opioid agonist that also activates the nociception/orphanin FQ NOP receptor. Here we used rats to explore the therapeutic potential of this agent in OUD. First, in operant intravenous self-administration experiments we compared the potential abuse liability of cebranopadol with the prototypical opioid heroin. Under a fixed ratio 1 (FR1) contingency, rats maintained responding for heroin (1, 7, 20, 60 μg/inf) to a larger extent than cebranopadol (0.03, 0.1, 0.3, 1.0, 6.0 μg/inf). When the contingency was switched to a progressive ratio (PR) reinforcement schedule, heroin maintained responding at high levels at all except the lowest dose. Conversely, in the cebranopadol groups responding decreased drastically and the break point (BP) did not differ from saline controls. Next, we demonstrated that oral administration of cebranopadol (0, 25, 50 μg/kg) significantly attenuated drug self-administration independent of heroin dose (1, 7, 20, 60 μg/inf). Cebranopadol also reduced the break point for heroin (20 μg/inf). Furthermore, in a heroin self-administration training extinction/reinstatement paradigm, pretreatment with cebranopadol significantly attenuated yohimbine stress-induced reinstatement of drug seeking. Together, these data indicate that cebranopadol has limited abuse liability compared to heroin and is highly efficacious in attenuating opioid self-administration and stress-induced reinstatement, suggesting clinical potential of this compound for OUD treatment.

The four-factor personality model and its qualitative correlates among opioid agonist therapy clients

Background

The Four Factor Personality Vulnerability model identifies four specific personality traits (e.g., sensation seeking [SS], impulsivity [IMP], anxiety sensitivity [AS], and hopelessness [HOP]) as implicated in substance use behaviors, motives for substance use, and co-occurring psychiatric conditions. Although the relationship between these traits and polysubstance use in opioid agonist therapy (OAT) clients has been investigated quantitatively, no study has examined the qualitative expression of each trait using clients' voice.

Method

Nineteen Methadone Maintenance Therapy (MMT) clients (68.4% male, 84.2% white, mean age[SD] = 42.71 [10.18]) scoring high on one of the four personality traits measured by the Substance Use Risk Profile Scale [SURPS] completed a semi-structured qualitative interview designed to explore their lived experience of their respective trait. Thematic analysis was used to derive themes, which were further quantified using content analysis.

Results

Themes emerging from interviews reflected (1) internalizing and externalizing symptoms, (2) adversity experiences, and (3) polysubstance use. Internalizing symptoms subthemes included symptoms of anxiety, fear, stress, depression, and avoidance coping. Externalizing subthemes included anger, disinhibited cognitions, and anti-social and risk-taking behaviors. Adverse experiences subthemes included poor health, poverty, homelessness, unemployment, trauma, and conflict. Finally, polysubstance use subthemes include substance types, methods of use, and motives. Differences emerged between personality profiles in the relative endorsement of various subthemes, including those pertaining to polysubstance use, that were largely as theoretically expected.

Conclusion

Personality is associated with unique cognitive, affective, and behavioral lived experiences, suggesting that personality may be a novel intervention target in adjunctive psychosocial treatment for those undergoing OAT.

A National Portrait of Public Attitudes toward Opioid Use in the US: A Latent Class Analysis

BACKGROUND

Opioid overdose rates have steadily been increasing in the United States (US) creating what is considered an overdose death crisis. The US has a mixture of public health and punitive policies aimed to address opioid use and the overdose crisis, yet little is known about public opinion relating to opioid use and policy support. Understanding the intersection of public opinion about opioid use disorder (OUD) and policy can be useful for developing interventions to address policy responses to overdose deaths.

METHODS

A national sample of cross-sectional data from the AmeriSpeak survey conducted from 27 February 2020 through 2 March 2020 was analyzed. Measures included attitudes toward OUD and policy beliefs. Latent class analysis, a person-centered approach, was used to identify groups of individuals endorsing similar stigma and policy beliefs. We then examined the relationship between the identified groups (i.e., classes) and key behavioral and demographic factors.

RESULTS

We identified three distinct groups: (1) "High Stigma/High Punitive Policy", (2) "High Stigma/Mixed Public Health and Punitive Policy", and (3) "Low Stigma/High Public Health Policy". People with higher levels of education had reduced odds of being in the "High Stigma/High Punitive Policy" group.

CONCLUSION

Public health policies are most effective in addressing OUD. We suggest targeting interventions toward the "High Stigma/Mixed Public Health and Punitive Policy" group since this group already displays some support for public health policies. Broader interventions, such as eliminating stigmatizing messaging in the media and redacting punitive policies, could reduce OUD stigma among all groups.

Mitragynine improves cognitive performance in morphine-withdrawn rats

RATIONALE

The treatment of opiate addiction is an unmet medical need. Repeated exposure to opiates disrupts cognitive performance. Opioid substitution therapy, with, e.g., methadone, may further exacerbate the cognitive deficits. Growing evidence suggests that mitragynine, the primary alkaloid from the Kratom (Mitragyna speciosa) leaves, may serve as a promising alternative therapy for opiate addiction. However, the knowledge of its health consequences is still limited.

OBJECTIVES

We aimed to examine the cognitive effects of mitragynine substitution in morphine-withdrawn rats. Furthermore, we asked whether neuronal addiction markers like the brain-derived neurotrophic factor (BDNF) and Ca²⁺/calmodulin-dependent kinase II alpha (αCaMKII) might mediate the observed effects.

METHODS

Male Sprague-Dawley rats were given morphine at escalating doses before treatment was discontinued to induce a spontaneous morphine withdrawal. Then, vehicle or mitragynine (5 mg/kg, 15 mg/kg, or 30 mg/kg) substitution was given for 3 days. A vehicle-treated group was used as a control. Withdrawal signs were scored after 24 h, 48 h, and 72 h, while novel object recognition (NOR) and attentional set-shifting (ASST) were tested during the substitution period.

RESULTS

Discontinuation of morphine significantly induced morphine withdrawal signs and cognitive deficit in the ASST. The substitution with mitragynine was able to alleviate the withdrawal signs. Mitragynine did not affect the recognition memory in the NOR but significantly improved the reversal learning deficit in the morphine-withdrawn rats.

CONCLUSIONS

These data support the idea that mitragynine could be used as safe medication therapy to treat opiate addiction with beneficial effects on cognitive deficits.

Co-occurrence of preconception maternal childhood adversity and opioid use during pregnancy: Implications for offspring brain development

Understanding of the effects of in utero opioid exposure on neurodevelopment is a priority given the recent dramatic increase in opioid use among pregnant individuals. However, opioid abuse does not occur in isolation-pregnant individuals abusing opioids often have a significant history of adverse experiences in childhood, among other co-occurring factors. Understanding the specific pathways in which these frequently co-occurring factors may interact and cumulatively influence offspring brain development in utero represents a priority for future research in this area. We highlight maternal history of childhood adversity (CA) as one such co-occurring factor that is more prevalent among individuals using opioids during pregnancy and which is increasingly shown to affect offspring neurodevelopment through mechanisms beginning in utero. Despite the high incidence of CA history in pregnant individuals using opioids, we understand very little about the effects of comorbid prenatal opioid exposure and maternal CA history on fetal brain development. Here, we first provide an overview of current knowledge regarding effects of opioid exposure and maternal CA on offspring neurodevelopment that may occur during gestation. We then outline potential mechanistic pathways through which these factors might have interactive and cumulative influences on offspring neurodevelopment as a foundation for future research in this area.

Untangling the Complexities of Substance Use Initiation and Recovery: Client Reflections on Opioid Use Prevention and Recovery From a Social-Ecological Perspective

Background:

In Canada, the rate of opioid use, opioid use disorder (OUD), and associated mortality and morbidity are higher among Indigenous Peoples than the general population. Indigenous Peoples on medications for opioid use disorders (MOUD) often face distinct barriers that hinder their clinical progress, leading to treatment attrition.

Methods:

We used a social-ecological model to inquire into clients’ experiences with a history of treatment failure for OUD. We used exploratory qualitative research to engage 22 clients with a history of OUD treatment dropouts and who are currently on MOUD. In-depth, semi-structured interviews lasting an average of 30 minutes were conducted on-site.

Results:

We identified 4 themes from the study: (a) risk for substance use; (b) factors sustaining substance use; (c) factors leading to treatment, and (d) treatment failure and re-enrollment.

Conclusion:

Using a socio-ecological model helps to understand factors that influence an individual’s risk for OUD, decision to pursue treatment, and treatment outcomes. Furthermore, social ecological model also creates possibilities to develop supportive, multilevel interventions to prevent OUD risks and support for clients on MOUD. Such interventions include mitigating adverse childhood experiences, supporting families, and creating safe community environments.

Analisi di Budget Impact della formulazione depot di buprenorfina a rilascio prolungato per la gestione di pazienti affetti da disturbo da uso di oppiacei

Background:

Opioid use disorder (OUD) is a disorder associated with significant rate of morbidity and mortality. Frequent clinic attendance for supervised consumption of sublingual buprenorphine is common. Prolonged-release buprenorphine (PRB) allows a management based on weekly or monthly subcutaneous injections, thus limiting the burdens of clinic attendance and the risks associated with sublingual formulations.

Objective:

To determine the price level of PRB that allows to obtain a neutral impact from the point of view of the economic resources absorbed, in comparison with the alternatives currently available in the Italian context for the management of patients suffering from OUD.

Methods:

The analysis assumes a daily PRB cost of € 8.526 (neutral cost). The analysis aims to determine the economic impact associated with the introduction of PRB in the Italian context for the management of OUD patients. Results are expressed in terms of differential resources absorbed in the alternative scenarios. A one-way sensitivity analysis was also carried out to test the robustness of the results.

Results:

The introduction of PRB implies an increase in the drug acquisition costs over the 5-year time horizon of € 23,016,194.61: such costs are fully compensated by the other cost driver considered in the analysis (drug tests provided, health professionals’ time destined to the provision of the treatment, indirect costs, for savings equal to € 7,255,602.59, € 10,714,320.08 and € 5,046,271.94 respectively) demonstrating its effectiveness in particular by an organizational point of view. Lower price levels for PRB would imply significant savings for the SSN.

Conclusions:

PRB resulted to be associated to a lower level of resources’ absorption in the Italian sector as compared with the available alternatives thus allowing to re-allocate health founds to other fields of the care sector ensuring greater safety for patients and a decreased misuse and diversion rate.

Factors That Affect Patient Attrition in Buprenorphine Treatment for Opioid Use Disorder: A Retrospective Real-World Study Using Electronic Health Records

PURPOSE

To describe attrition patterns of opioid use disorder (OUD) patients treated with buprenorphine (BUP) and to assess how clinical, sociodemographic, or BUP medication dosing features are associated with attrition.

PATIENTS AND METHODS

Electronic health records of adults (16+ year-olds) with OUD treated with BUP from 23 different substance use or mental health care programs across 11 US states were examined for one year following BUP initiation in inpatient (IP), intensive outpatient (IOP), or outpatient (OP) settings. Treatment attrition was declared at >37 days following the last recorded visit. Survival analyses and predictive modelling were used.

RESULTS

Retention was consistently 2-3 times higher following BUP initiation in OP (n = 2409) than in IP/IOP (n = 2749) settings after 2 (50% vs 25%), 6 (27% vs 9%) and 12 months (14% vs 4%). Retention was higher for females, whites (vs blacks), and those with less severe OUD, better global function, or not using non-psychotropic medications. Comorbid substance use, other psychiatric disorders, and the number of psychotropic medications were variously related to retention depending on the setting in which BUP was initiated. Predictive modelling revealed that a higher global assessment of functioning and a smaller OUD severity based on the Clinical Global Impression - Severity led to longer retentions, a higher initial BUP dose led to higher retention in a few cases, an OP setting of BUP initiation led to longer retentions, and a lower total number of psychotropic and non-psychotropic medications led to longer retentions. These were the most important parameters in the model, which identified 75.2% of patients who left BUP treatment within three months post-initiation, with a precision of 90.5%.

CONCLUSION

Of all the OUD patients who began BUP, 50-75% left treatment within three months, and most could be accurately identified. This could facilitate patient-centered management to better retain OUD patients in BUP treatment.

Pharmacokinetic Characterization and External Evaluation of a Quantitative Framework of Sublingual Buprenorphine in Patients with an Opioid Disorder in Puerto Rico

Background: The aim of this analysis was to characterize the pharmacokinetics (PK) of sublingual buprenorphine (BUP) and its metabolites (buprenorphine glucuronide; BUP-g, norbuprenorphine; Nor-BUP, and norbuprenorphine glucuronide; Nor-BUP-g) in opioid use disorder (OUD) patients in Puerto Rico (PR) as a first step of evidence-based BUP dosing strategies in this population. Methods: BUP and metabolites concentrations were measured from 0 to 8 h after the administration of sublingual buprenorphine/naloxone films in 12 stable OUD subjects. Results: PK non-compartmental characteristics showed considerable variability in parameters between the subjects over the 8-h sampling time (t_max = 1.5 ± 0.7 h, C_o = 1.6 ± 1.4 ng/mL, C_max= 7.1 ± 6 ng/mL, and AUC_0–8h = 26.8 ± 17.8 h·ng/mL). Subjects had a significantly higher tendency towards CYP-mediated N-demethylation, with the AUC_0–8h ratios of the molar concentrations of [Nor-BUP + Nor-BUP-g] to BUP being (3.4 ± 1.9) significantly higher compared with BUP-g to BUP (0.19 ± 0.2). A two-compartment population-PK model with linear absorption (k_a = 2.54 h⁻¹), distribution (k₁₂= 2.34 h⁻¹, k₁₄ = 1.29 h⁻¹), metabolism (k₂₄ = 1.28 × 10⁻¹ h⁻¹, k₂₃ = 6.43 × 10⁻² h⁻¹, k₃₅ = 1.23 × 10⁻¹ h⁻¹, k₄₅ = 8.73 × 10⁻¹ h⁻¹), and elimination (k₃₀ = 3.81 × 10⁻³ h⁻¹, k₅₀ = 1.27 × 10⁻¹ h⁻¹) adequately described the time-course of BUP and its metabolites, which has been externally validated using published data. Conclusions: Although limited in sampling time and number of recruited subjects, this study presents specific BUP PK characteristics that evidenced the need for additional PK studies and subsequent modeling of the data for the development of evidence-based dosing approaches in Puerto Rico.

Understanding concurrent stimulant use among people on methadone: A qualitative study

INTRODUCTION AND AIMS

Opioid-related overdoses are an epidemic in North America, prompting a greater use of medications for opioid use disorder, such as methadone. Although many people work toward overall drug abstinence while on methadone, a sub-population of people with and without histories of polysubstance use engage in stimulant use while on methadone treatment. This study explores motivations for concurrent stimulant and methadone use in a street-involved drug-using population.

DESIGN AND METHODS

Semi-structured qualitative interviews were conducted with 39 people on methadone in Vancouver, Canada. Participants were recruited from among the participants in two community-based prospective cohort studies consisting of HIV-positive and HIV-negative people who use drugs. Interview transcripts were analysed using an inductive and iterative approach.

RESULTS

Our analysis identified three primary themes. First, participants articulated how stimulants were used to counter the sedating effects of methadone and enable them to engage in daily and survival activities (e.g. income generation). Second, participants described increased stimulant use to compensate for reduced stimulant intoxication while taking methadone. Finally, participants described the desire to achieve intoxication on stimulants once stable on methadone, as their substance use treatment goals did not involve drug abstinence.

DISCUSSION AND CONCLUSION

Among a street-involved drug-using population in which people do not have abstinence-based treatment goals, there are several functional reasons to use stimulants concurrently while on methadone. A deeper and more nuanced understanding of substance use motivators may contribute to further research and inform policy and guideline changes that support low threshold and harm reduction-focused methadone treatment programs and other interventions to reduce drug-related harms.

Nicotine and Opioids: a Call for Co-treatment as the Standard of Care

The U.S. is in the midst of an opioid epidemic. At the same time, tobacco use remains the leading cause of preventable death and disability. While the shared biological underpinnings of nicotine and opioid addiction are well established, clinical implications for co-treatment of these two substance use disorders has not been emphasized in the literature, nor have researchers, clinicians, and policy makers adequately outlined pathways for incorporating co-treatment into existing clinical workflows. The current brief review characterizes the metabolic and neural mechanisms which mediate co-use of nicotine and opioids, and then outlines clinical and policy implications for concurrently addressing these two deadly epidemics. Screening, assessment, medication-assisted treatment (MAT), and tobacco-free policy are discussed. The evidence suggests that clinical care and policies that facilitate co-treatment are an expedient means of delivering healthcare to individuals that result in better health for the population while also meeting patients' substance abuse disorder recovery goals.

"It's Took Over This Region": Patient Perspectives of Prescription Drug Abuse in Appalachia

Background: Prescription drug abuse is a public health problem in the United States and the region of Appalachia, specifically. Primary care and addiction medicine-as possible points of access for prescription drugs with abuse potential and points of intervention for prescription drug abuse-are among the medical fields at its forefront. Little is known, however, about perceptions of prescription drug abuse across the two patient populations. Objectives: The objective of this qualitative analysis was to explore perceptions of the scale and context of prescription drug abuse among primary care and addiction medicine patients in Appalachia. Methods: As part of a mixed methods study, semi-structured interviews were conducted with 20 patients from primary care and addiction medicine in Central and South Central Appalachia from 2014 to 2015. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was used to identify themes. Results: Three themes were identified: (1) pervasiveness of prescription drug abuse, describing perceptions of its high prevalence and negative consequences; (2) routes and routine practices for prescription drug acquisition and distribution, describing perceptions of routes of access to prescription drugs and behaviors exhibited to acquire and distribute prescription drugs; and (3) rationales for prescription drug acquisition and distribution, describing perceptions of the two underlying reasons for these processes-tolerance/addiction and revenue source. Conclusions/Importance: Perceptions of prescription drug abuse among primary care and addiction medicine patients in Appalachia are multifaceted, especially regarding prescription drug acquisition and distribution. Clinical practice implications for mitigating prescription drug abuse are discussed.

Effects of access barriers and medication acceptability on buprenorphine-naloxone treatment utilization over 2 years: Results from a multisite randomized trial of adults with opioid use disorder

BACKGROUND

Nationwide efforts seek to address the opioid epidemic by increasing access to medications for opioid use disorder (OUD), particularly with buprenorphine. A poorly understood challenge is that among individuals with OUD who do receive buprenorphine, many do not adhere to the pharmacotherapy long enough to achieve sustained benefits. We aimed to identify factors associated with buprenorphine treatment utilization over time.

METHODS

We used random-intercept modeling to identify factors associated with buprenorphine treatment utilization over 2 years after first follow-up by 789 individuals with OUD who had participated in a multi-site randomized clinical trial of buprenorphine compared to methadone. Key predictors were participants' reports of buprenorphine treatment accessibility and acceptability (assessed at first follow-up) and their interaction effects, controlling for baseline randomization status, sociodemographics, and other covariates.

RESULTS

Approximately 9.3-11.2% of participants utilized buprenorphine treatment over the 2 years of follow-up. Interaction effects indicated that individuals who perceived buprenorphine to be both accessible and acceptable were most likely to use buprenorphine during follow-up, controlling for other factors. In contrast, individuals who perceived buprenorphine to be unacceptable were least likely to use buprenorphine, regardless the level of perceived access to the medication. Buprenorphine treatment utilization was also negatively associated with Hispanic ethnicity, West coast context, and cumulative months receiving methadone treatment and incarceration during follow-up.

CONCLUSIONS

To engage more individuals with OUD in long-term treatment with buprenorphine, interventions should target buprenorphine treatment acceptability, in addition to increasing buprenorphine access, and tailor efforts to meet the needs of vulnerable populations.

TRIAL REGISTRATION

The START Follow-up Study on ClinicalTrials.gov (NCT01592461).

Factors impeding switching from methadone to buprenorphine in heroin users receiving methadone maintenance therapy - A naturalistic cohort study

INTRODUCTION

Switching from methadone to buprenorphine/naloxone remains a challenge for heroin users receiving methadone maintenance treatment (MMT). The present study aimed to investigate the predictors for failed switching from methadone to buprenorphine/naloxone among patients receiving MMT.

METHODS

This 5-year retrospective study included 168 individuals (138 males and 30 females) with opioid dependence who attempted to switch from methadone to buprenorphine/naloxone at our MMT clinics in Taiwan. We excluded patients with psychiatric comorbidity and other substance use disorders except nicotine. A univariate Cox proportional hazards regression model (Cox model) was used to estimate the potential factors of subsequent failed switching, followed by a multivariate Cox model to identify significant predictors after adjusting for other covariates.

RESULTS

Seventy of the 168 participants (41.7%) failed switching from methadone to buprenorphine/naloxone. After forward selection in the Cox hazard regression model, a greater average dose of methadone (HR = 1.02; P = 0.01), greater maximal maintenance dose of MMT (HR = 1.02; P < 0.001), greater average dose of buprenorphine (HR = 1.10; P = 0.021), and lower average attendance rate during the three months before switching (HR = 0.09; P = 0.002) were significantly associated with failed switching.

CONCLUSIONS

This study with limited participants showed that dose of methadone, dose of buprenorphine, and attendance rates were significantly associated with failed switching. Clinicians should discuss with their patients about tapering the dose of methadone and improving their attendance if they want to switch from methadone to buprenorphine. Further studies are necessary to verify whether our findings generalize to other populations.

Discovering major opioid-related research themes over time: A text mining technique

The recent health crisis concerning opioid overdose has prompted watershed levels of publications. This study explores how opioid-related research themes have changed since 2000, using a text mining technique. The textual data were obtained from PubMed, and the research periods were divided into three periods. While a few topics appear throughout each period, many new health problems emerged as opioid abuse problems magnified. Topics such as HIV, methadone maintenance treatment, and world health organization appear consistently but diminish over time, while topics like injecting drugs, neonatal abstinence syndrome, and public health concerns are rapidly increasing. Recent widespread opioid abuse problems led to new research topics, including prescription drug monitoring programs, veteran's health issue, posttraumatic stress disorder, HCV, opioid-related deaths, and emergency department visits. Examination of scholarly publications reveals that the expanded use of opioids worsened opioid abuse problems and accelerated the emergence of new health problems.

Racial Bias in the US Opioid Epidemic: A Review of the History of Systemic Bias and Implications for Care

The opioid epidemic has been declared a US national public health emergency. Discrepancies in the rates of abuse and access to treatment exist among non-white minorities. A narrative literature review evaluated the minority racial disparities in opioid use, abuse, and care in the US. Racial disparities in the prescription of opioid-containing compounds are dramatic with the non-white individuals being prescribed at half the rate. Historical and cognitive biases may have insulated the non-white minorities, while the minorities have limited access to treatment. Physician bias, media portrayal of opioid abuse disorders, and governmental regulation are a polyfactorial root of racial inequity in the opioid epidemic. As part of the national response, addressing these issues will be an important factor in curbing this epidemic.

Intent to Refer: Exploring Bias Toward Specific Medication-Assisted Treatments by Community Corrections Employees

BACKGROUND

As opioid use increases in the United States, especially in the correctional population, the most effective treatment approaches need to be utilized. Research has shown that medication-assisted treatment (MAT) provides better outcomes than traditional treatment approaches alone, but is underutilized among correctional-supervised populations.

OBJECTIVE

This article looks at how previously identified barriers to implementing MAT can create potential biases regarding the intent to refer individuals to either buprenorphine or methadone among treatment and correctional staff within community corrections. The varying advantages of each medication are discussed to highlight the importance of individualized treatment planning.

METHODS

Data were collected from 959 treatment specialists and community-corrections officers between 2010 and 2013. The participants were employed by one of 20 community corrections agencies that were selected and randomized within a cluster design. The data were part of a larger study that tested how the experimental condition of organizational linkages impacted the use of MAT in the criminal justice system. In order to analyze the data, multinomial logistic regression was used.

RESULTS

Results showed that some community corrections employees were likely to refer clients to use methadone, but not buprenorphine (or vice versa) which was influenced by work setting, level of education, training, and negative perceptions of MAT as a substitute addiction. However, these biases could be minimized by proper training.

CONCLUSION

These findings suggest that proper training should be mandatory for these employees and include information about various MATs while also addressing the negative perception that MAT is a substitute addiction.

Drug addiction: a curable mental disorder?

Drug addiction is a chronic, relapsing brain disorder. Multiple neural networks in the brain including the reward system (e.g., the mesocorticolimbic system), the anti-reward/stress system (e.g., the extended amygdala), and the central immune system, are involved in the development of drug addiction and relapse after withdrawal from drugs of abuse. Preclinical and clinical studies have demonstrated that it is promising to control drug addiction by pharmacologically targeting the addiction-related systems in the brain. Here we review the pharmacological targets within the dopamine system, glutamate system, trace amine system, anti-reward system, and central immune system, which are of clinical interests. Furthermore, we discuss other potential therapies, e.g., brain stimulation, behavioral treatments, and therapeutic gene modulation, which could be effective to treat drug addiction. We conclude that, although drug addiction is a complex disorder that involves complicated neural mechanisms and psychological processes, this mental disorder is treatable and may be curable by therapies such as gene modulation in the future.

Targeting multiple opioid receptors - improved analgesics with reduced side effects?

Classical opioid analgesics, including morphine, mediate all of their desired and undesired effects by specific activation of the μ-opioid receptor (μ receptor). The use of morphine for treating chronic pain, however, is limited by the development of constipation, respiratory depression, tolerance and dependence. Analgesic effects can also be mediated through other members of the opioid receptor family such as the κ-opioid receptor (κ receptor), δ-opioid receptor (δ receptor) and the nociceptin/orphanin FQ peptide receptor (NOP receptor). Currently, a new generation of opioid analgesics is being developed that can simultaneously bind with high affinity to multiple opioid receptors. With this new action profile, it is hoped that additional analgesic effects and fewer side effects can be achieved. Recent research is mainly focused on the development of bifunctional μ/NOP receptor agonists, which has already led to novel lead structures such as the spiroindole-based cebranopadol and a compound class with a piperidin-4-yl-1,3-dihydroindol-2-one backbone (SR16835/AT-202 and SR14150/AT-200). In addition, the ornivol BU08028 is an analogue of the clinically well-established buprenorphine. Moreover, the morphinan-based nalfurafine exerts its effect with a dominant κ receptor-component and is therefore utilized in the treatment of pruritus. The very potent dihydroetorphine is a true multi-receptor opioid ligand in that it binds to μ, κ and δ receptors. The main focus of this review is to assess the paradigm of opioid ligands targeting multiple receptors with a single chemical entity. We reflect on this rationale by discussing the biological actions of particular multi-opioid receptor ligands, but not on their medicinal chemistry and design.

LINKED ARTICLES

This article is part of a themed section on Emerging Areas of Opioid Pharmacology. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.14/issuetoc.

Optimising treatment in opioid dependency in primary care: results from a national key stakeholder and expert focus group in Ireland

BACKGROUND

Treatment for opioid dependence in Ireland is provided predominantly by general practitioners (GP) who have undergone additional training in opioid agonist treatment (OAT) and substance misuse. The National Methadone Treatment Programme (MTP) was introduced in 1998, and was designed to treat the opioid dependent population and to regulate the prescribing regimes at the time. The past two decades have seen the increased prescribing of methadone in primary care and changes in type of opioid abused, in particular, the increased use of over the counter (OTC) and prescription medications. Despite the scaling up of OAT in Ireland, drug related deaths however have increased and waiting lists for treatment exist in some areas outside the capital, Dublin. Two previous MTP reviews have made recommendations aimed at improving and scaling up of OAT in Ireland. This study updates these recommendations and is the first time that a group of national experts have engaged in structured research to identify barriers to OAT delivery in Ireland. The aim was to explore the views of national statutory and non-statutory stakeholders and experts on current barriers within the MTP and broader OAT delivery structures in order to inform their future design and implementation.

METHODS

A single focus group with a chosen group of national key stakeholders and experts with a broad range of expertise (clinical, addiction and social inclusion management, harm reduction, homelessness, specialist GPs, academics) (n = 11) was conducted. The group included national representation from the areas of drug treatment delivery, service design, policy and practice in Ireland.

RESULTS

Four themes emerged from the narrative analysis, and centred on OAT Choices and Patient Characteristics; Systemic Barriers to Optimal OAT Service Provision; GP Training and Registration in the MTP, and Solutions and Models of Good Practice: Using What You Have.

CONCLUSION

The study identified a series of improvement strategies which could reduce barriers to access and the stigma associated with OAT, optimise therapeutic choices, enhance interagency care planning within the MTP, utilise the strengths of community pharmacy and nurse prescribers, and recruit and support methadone prescribing GPs in Ireland.

Dissatisfaction with opioid maintenance treatment partly explains reported side effects of medications

BACKGROUND

Drop-out is a core problem in opioid maintenance treatment (OMT), but patients' reactions to and acceptance of the various OMT medications are insufficiently investigated. In Norway, there has been vocal patient resistance to the newest medication, buprenorphine-naloxone (BNX), and complaints have focused on the side effect profile. There has been no comparison of patient satisfaction and side effects of the three most common OMT medications.

AIM

To compare patient satisfaction with OMT and side effects of BNX, buprenorphine monopreparate (BUP), and methadone (MET) as reported by patients.

METHODS

Data were drawn from a national peer-to-peer survey developed by a patient advocacy group. The survey engaged more than 1000 OMT patients, corresponding to one seventh of OMT patients in Norway. The associations between side effects, treatment satisfaction, and patient characteristics were tested in multinomial logistic regressions.

RESULTS

High patient satisfaction with OMT overall was reported despite lower satisfaction with medication itself and widely prevalent side effects. Among each medication group, dissatisfaction with medications or OMT in general along with poor health status increased the relative risk ratio of reporting the heaviest side effect burden. MET users reported the highest side effect burden and BNX users the lightest, but BNX users were more dissatisfied with their medication.

CONCLUSIONS

Side effects are a concern for nearly all OMT patients, and they do not appear to accumulate with age or length of treatment. BNX users' dissatisfaction with their medication is of particular concern, and expectations and preferences of medication may be influencing their dissatisfaction.

Pain Therapy Guided by Purpose and Perspective in Light of the Opioid Epidemic

Prescription opioid misuse is an ongoing and escalating epidemic. Although these pharmacological agents are highly effective analgesics prescribed for different types of pain, opioids also induce euphoria, leading to increasing diversion and misuse. Opioid use and related mortalities have developed in spite of initial claims that OxyContin, one of the first opioids prescribed in the USA, was not addictive in the presence of pain. These claims allayed the fears of clinicians and contributed to an increase in the number of prescriptions, quantity of drugs manufactured, and the unforeseen diversion of these drugs for non-medical uses. Understanding the history of opioid drug development, the widespread marketing campaign for opioids, the immense financial incentive behind the treatment of pain, and vulnerable socioeconomic and physical demographics for opioid misuse give perspective on the current epidemic as an American-born problem that has expanded to global significance. In light of the current worldwide opioid epidemic, it is imperative that novel opioids are developed to treat pain without inducing the euphoria that fosters physical dependence and addiction. We describe insights from preclinical findings on the properties of opioid drugs that offer insights into improving abuse-deterrent formulations. One finding is that the ability of some agonists to activate one pathway over another, or agonist bias, can predict whether several novel opioid compounds bear promise in treating pain without causing reward among other off-target effects. In addition, we outline how the pharmacokinetic profile of each opioid contributes to their potential for misuse and discuss the emergence of mixed agonists as a promising pipeline of opioid-based analgesics. These insights from preclinical findings can be used to more effectively identify opioids that treat pain without causing physical dependence and subsequent opioid abuse.

America's Opioid Epidemic: a Comprehensive Review and Look into the Rising Crisis

PURPOSE OF REVIEW

In the USA, there has been a sharp increase in heroin, prescription opiate, and illicitly manufactured fentanyl abuse with overdoses tripling since the 1990s. Several states have been deemed as "high-burden" abuse states where there is a greater proportion of synthetic opiate use. During the same period that prescription limitations were initially implemented throughout the country, the fentanyl epidemic started nationwide.

RECENT FINDINGS

In the setting of data demonstrating an almost fourfold increase in overdose deaths from 1999 to 2008, states began restricting access to Food and Drug Agency (FDA) approved opioid medications. Another factor further exacerbating the opioid crises is that the cost of all formulations of naloxone has increased significantly over the past several years. In order to combat the opioid epidemic, stricter prescribing practices and prescription-monitoring programs have been instituted. Also, improvements in abuse-deterrent strategies for all opioid preparations can play an important role by increasing the safety of these medications and is a major focus of the FDA.

Predictors of buprenorphine treatment success of opioid dependence in two Baltimore City grassroots recovery programs

INTRODUCTION

Despite evidence for the efficacy of buprenorphine treatment in primary care, few studies have identified factors associated with treatment success, nor have such factors been evaluated in community settings. Identifying correlates of treatment success can facilitate the development of treatment models tailored for distinct populations, including low-income communities of color. The current study examined client-level socio-demographic factors associated with treatment success in community-based buprenorphine programs serving vulnerable populations.

METHODS

Data were abstracted from client records for participants (N=445) who met DSM-IV criteria for opioid dependence and sought treatment at one of Behavioral Health Leadership Institute's two community-based recovery programs in Baltimore City from 2010 to 2015. Logistic regression estimated the odds ratios of treatment success (defined as retention in treatment for ≥90days) by sociodemographic predictors including age, race, gender, housing, legal issues and incarceration.

RESULTS

The odds of being retained in treatment ≥90days increased with age (5% increase with each year of age; p<0.001), adjusting for other sociodemographic factors. Clients who reported unstable housing had a 41% decreased odds of remaining in treatment for 90 or more days compared to clients who lived independently at intake. Treatment success did not significantly differ by several other client-level characteristics including gender, race, employment, legal issues and incarceration.

CONCLUSIONS

In vulnerable populations, the age factor appears sufficiently significant to justify creating models formulated for younger populations. The data also support attention to housing needs for people in treatment. Findings from this paper can inform future research and program development.

Opioid Prescription Drug Use and Expenditures in US Outpatient Physician Offices: Evidence from Two Nationally Representative Surveys

BACKGROUND

Opioids are widely prescribed for their analgesic properties. Chronic opioid use is a persistent problem in the US. Nevertheless, little is known about its prescribing and utilization patterns and overall expenditures.

OBJECTIVE

This study examined secular trends in opioid prescription drug utilization and expenditures, along with factors associated with opioid prescription drug use in US physician offices.

METHODS

National Ambulatory Medical Care Survey (NAMCS) and Medical Expenditure Panel Survey (MEPS) data (2006-2010), both nationally representative surveys, were used to assess the trend, predictors of opioid prescription among US adults (more than 18 years) and the opioid-associated expenditures as a whole and borne by the patients in outpatient settings.

RESULTS

Opioid prescription drugs use among US adults in outpatient settings, as a percentage of all prescription drugs, showed a gradual increase since 2006, leveling off in 2010. Opioid prescription drug expenditures showed an upward trend from 2009 after declining over three years. Mean out-of-pocket payments per prescription steadily declined over study period.

LIMITATIONS

Cross-sectional nature and visit based information of NAMCS do not provide the actual prevalence and the reason for opioid prescription.

CONCLUSIONS

Given the upward trend in opioid prescription drug utilization and associated expenditures, clinicians may benefit from evidence-based methods of monitoring prescription opioid use to prevent misuse, abuse, and other adverse patient outcomes.

FUNDING

Drs. Qureshi, Haider, Ball, Horner and Bennett's efforts are partially supported by the University of South Carolina's ASPIRE I. Dr. Wooten's effort is funded by the National Institute on Drug Abuse (K01DA037412).

Sex Differences in Regional Brain Glucose Metabolism Following Opioid Withdrawal and Replacement

Methadone and buprenorphine are currently the most common pharmacological treatments for opioid dependence. Interestingly, the clinical response to these drugs appears to be sex specific. That is, females exhibit superior therapeutic efficacy, defined as extended periods of abstinence and longer time to relapse, compared with males. However, the underlying metabolic effects of opioid withdrawal and replacement have not been examined. Therefore, using ¹⁸FDG and microPET, we measured differences in regional brain glucose metabolism in males and females following morphine withdrawal and subsequent methadone or buprenorphine replacement. In both males and females, spontaneous opioid withdrawal altered glucose metabolism in regions associated with reward and drug dependence. Specifically, metabolic increases in the thalamus, as well as metabolic decreases in insular cortex and the periaqueductal gray, were noted. However, compared with males, females exhibited increased metabolism in the preoptic area, primary motor cortex, and the amygdala, and decreased metabolism in the caudate/putamen and medial geniculate nucleus. Methadone and buprenorphine initially abolished these changes uniformly, but subsequently produced their own regional metabolic alterations that varied by treatment and sex. Compared with sex-matched control animals undergoing spontaneous opioid withdrawal, male animals treated with methadone exhibited increased caudate/putamen metabolism, whereas buprenorphine produced increased ventral striatum and motor cortex metabolism in females, and increased ventral striatum and somatosensory cortex metabolism in males. Notably, when treatment effects were compared between sexes, methadone-treated females showed increased cingulate cortex metabolism, whereas buprenorphine-treated females showed decreased metabolism in cingulate cortex and increased metabolism in the globus pallidus. Perhaps the initial similarities in males and females underlie early therapeutic efficacy, whereas these posttreatment sex differences contribute to clinical treatment failure more commonly experienced by the former.

Separate and combined effects of gabapentin and [INCREMENT]9-tetrahydrocannabinol in humans discriminating [INCREMENT]9-tetrahydrocannabinol

The aim of the present study was to examine a potential mechanism of action of gabapentin to manage cannabis-use disorders by determining the interoceptive effects of gabapentin in cannabis users discriminating [INCREMENT]-tetrahydrocannabinol ([INCREMENT]-THC) using a pharmacologically selective drug-discrimination procedure. Eight cannabis users learned to discriminate 30 mg oral [INCREMENT]-THC from placebo and then received gabapentin (600 and 1200 mg), [INCREMENT]-THC (5, 15, and 30 mg), and placebo alone and in combination. Self-report, task performance, and physiological measures were also collected. [INCREMENT]-THC served as a discriminative stimulus, produced positive subjective effects, elevated heart rate, and impaired psychomotor performance. Both doses of gabapentin substituted for the [INCREMENT]-THC discriminative stimulus and engendered subjective and performance-impairing effects that overlapped with those of [INCREMENT]-THC when administered alone. When administered concurrently, gabapentin shifted the discriminative-stimulus effects of [INCREMENT]-THC leftward/upward, and combinations of [INCREMENT]-THC and gabapentin generally produced larger effects on cannabinoid-sensitive outcomes relative to [INCREMENT]-THC alone. These results suggest that one mechanism by which gabapentin might facilitate cannabis abstinence is by producing effects that overlap with those of cannabinoids.

Knowledge and stigma regarding methadone maintenance treatment among personnel of methadone maintenance treatment and non-methadone maintenance treatment addiction facilities in Israel

Stigma attached to methadone maintenance treatment is very common. The objective of the current article is to evaluate the presence of stigma and its relation to the extent of knowledge about methadone maintenance treatment. The authors conducted a survey among methadone maintenance treatment and non-methadone maintenance treatment addiction therapists from different treatment centers in Israel, including methadone maintenance treatment clinics (Ministry of Health) and non-methadone maintenance treatment addiction facilities (Ministry of Social Services), using an anonymous questionnaire about methadone maintenance treatment stigma and knowledge. There were 63 therapists from methadone maintenance treatment clinics (63%) and 46 therapists from the social services department (SSD) non-methadone maintenance treatment addiction facilities (9.2%) who responded. Methadone maintenance treatment versus social services department personnel were older (42.7 ± 12.8 versus 37.5 ± 8.2 years; p = 0.03), with fewer females (48 versus 75%; p = 0.006), and 50% were social workers compared to 100% social workers in the SSD group (p < 0.0005). Stigma score was lower among methadone maintenance treatment personnel compared to the social services department personnel (3 ± 2.5 versus 5.0 ± 3.5; p = 0.0001), while the knowledge score about methadone maintenance treatment was higher among the methadone maintenance treatment personnel (10.3 ± 2.9 versus 7.7 ± 2.8; p < 0.0005). The difference in both the stigma and knowledge scores remained significant after controlling for age, gender, and profession. There was a negative correlation between the stigma and knowledge scores among both the methadone maintenance treatment (R = -0.5, p < 0.0005) and the social services department personnel (R = -0.33, p = 0.03). These results revealed a significant correlation between the presence of stigma and the extent of education and knowledge about methadone maintenance treatment, with ignorance and stigma against methadone maintenance treatment being more pronounced among social services department personnel. An educational intervention, especially among social services department personnel, may benefit people who use opioids and improve the overall quality of treatment for opioid addiction in Israel.

Optimising health and safety of people who inject drugs during transition from acute to outpatient care: narrative review with clinical checklist

The opioid epidemic in the USA continues to worsen. Medical providers are faced with the challenge of addressing complications from opioid use disorders and associated injection drug use. Unsafe injection practices among people who inject drugs (PWID) can lead to several complications requiring acute care encounters in the emergency department and inpatient hospital. Our objective is to provide a narrative review to help medical providers recognise and address key health issues in PWID, who are being released from the emergency department and inpatient hospital. In the midst of rises in overdose deaths and infections such as hepatitis C, we highlight several health issues for PWID, including overdose and infection prevention. We provide a clinical checklist of actions to help guide providers in the care of these complex patients. The clinical checklist includes strategies also applicable to low-resource settings, which may lack addiction treatment options. Our review and clinical checklist highlight key aspects of optimising the health and safety of PWID.

Methadone Medical Maintenance: An Early 21st-Century Perspective

Methadone medical maintenance is the treatment of stable methadone-maintained patients in primary care physicians' offices under an exemption from federal methadone regulations. Reports from seven such programs in six states show high retention and low frequencies of illicit drug use. Patients and physicians indicate high levels of satisfaction. Although methadone maintenance has a long history of safety and efficacy, most methadone medical maintenance programs are no longer operating or accepting new patients. Federal regulations for standard methadone clinics allow some features of methadone medical maintenance, and advocacy for state approval of these changes is strongly recommended.

Prescription pain reliever misuse prevalence, correlates, and origin of possession throughout the life course

INTRODUCTION

While a considerable amount of information is available concerning who is most likely to engage in prescription pain reliever misuse, few studies have examined whether the correlates of pain reliever misuse and sources of pain reliever possession are consistent across the life span.

METHODS

Data from the 2011-2012 National Survey in Drug Use and Health (NSDUH). Multivariate logistic regression examined clinical and social correlates of past-year pain reliever misuse, stratified by age. Additionally, bivariate analyses examined sources of pain reliever possession, and whether these origins differ by age.

RESULTS

Among respondents, 4.7% reported past-year prescription pain reliever misuse. Prevalence for individuals aged 12 to 17 was 5.9%, 18 to 25 was 10.2%, 26-34 was 7.7%, 35 to 49 was 4.3%, and individuals aged 50 or older was 1.7%. While many social and clinical correlates of pain reliever misuse emerged among younger respondents, these correlates diminished in significance among older adults. Only past-year illicit drug use disorders (marijuana, cocaine, crack cocaine, heroin, and hallucinogen use) was a significant predictor of pain reliever misuse among all age groups. Also, older adults were more likely to report pain reliever possession from multiple medical doctors, whereas younger individuals were more likely to possess pain reliever from friends/relatives or through purchase from a drug dealer/stranger.

CONCLUSIONS

Increased efforts to better screen for illicit drug use and greater efforts to coordinate patient prescription records among medical care providers may be high priorities in developing interventions to reduce rates of misuse of prescription pain relievers, especially among older adults.

Caring for pregnant opioid abusers in Vermont: A potential model for non-urban areas

Opioid addiction is no longer a primarily urban problem. As dependence on heroin and prescription pain relievers has become a significant issue in rural areas, the need for effective treatment of opioid-dependent pregnant women and their neonates has grown accordingly. In addition to the adverse perinatal outcomes associated with opioid addiction in pregnant women, the high costs of caring for these mothers and their babies motivate efforts to develop appropriate treatment models. We found that integration and coordination of services that promote maternal recovery and ability to parent are key requirements for treatment of opioid dependence during pregnancy. Unfortunately, lack of experience and resources makes such coordination a real challenge in rural areas. In this review, we discuss how we managed the challenges of developing a comprehensive program for treatment of opioid dependence during pregnancy. In addition, we outline our approach for facilitating the development of community-based programs to help these patients and families in rural regions of Vermont. Close relationships between our tertiary care center, local hospitals, community health care infrastructure, and legislators bolstered our efforts. In particular, appreciation for the severity and importance of the opioid-dependence problem in Vermont among health care providers and state legislators was paramount for our success in developing a state-wide treatment program. This approach can inform similar efforts in other rural regions of the United States, and has great potential to improve both access and quality of care for women struggling with opioid dependence.

Reducing Fatal Opioid Overdose: Prevention, Treatment and Harm Reduction Strategies

The opioid overdose epidemic is a major threat to the public's health, resulting in the development and implementation of a variety of strategies to reduce fatal overdose. Many strategies are focused on primary prevention and increased access to effective treatment, although the past decade has seen an exponential increase in harm reduction initiatives. To maximize identification of opportunities for intervention, initiatives focusing on prevention, access to effective treatment, and harm reduction are examined independently, although considerable overlap exists. Particular attention is given to harm reduction approaches, as increased public and political will have facilitated widespread implementation of several initiatives, including increased distribution of naloxone and policy changes designed to increase bystander assistance during a witnessed overdose.

Buprenorphine Maintenance for Opioid Dependence in Public Sector Healthcare: Benefits and Barriers

BACKGROUND

Since its U.S. FDA approval in 2002, buprenorphine has been available for maintenance treatment of opiate dependence in primary care physicians' offices. Though buprenorphine was intended to facilitate access to treatment, disparities in utilization have emerged; while buprenorphine treatment is widely used in private care setting, public healthcare integration of buprenorphine lags behind.

RESULTS

Through a review of the literature, we found that U.S. disparities are partly due to a shortage of certified prescribers, concern of patient diversion, as well as economic and institutional barriers. Disparity of buprenorphine treatment dissemination is concerning since buprenorphine treatment has specific characteristics that are especially suited for low-income patient population in public sector healthcare such as flexible dosing schedules, ease of concurrently treating co-morbidities such as HIV and hepatitis C, positive patient attitudes towards treatment, and the potential of reducing addiction treatment stigma.

CONCLUSION

As the gap between buprenorphine treatment in public sector settings and private sector settings persists in the U.S., current research suggests ways to facilitate its dissemination.

National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted Treatment

OBJECTIVES

We estimated national and state trends in opioid agonist medication-assisted treatment (OA-MAT) need and capacity to identify gaps and inform policy decisions.

METHODS

We generated national and state rates of past-year opioid abuse or dependence, maximum potential buprenorphine treatment capacity, number of patients receiving methadone from opioid treatment programs (OTPs), and the percentage of OTPs operating at 80% capacity or more using Substance Abuse and Mental Health Services Administration data.

RESULTS

Nationally, in 2012, the rate of opioid abuse or dependence was 891.8 per 100 000 people aged 12 years or older compared with national rates of maximum potential buprenorphine treatment capacity and patients receiving methadone in OTPs of, respectively, 420.3 and 119.9. Among states and the District of Columbia, 96% had opioid abuse or dependence rates higher than their buprenorphine treatment capacity rates; 37% had a gap of at least 5 per 1000 people. Thirty-eight states (77.6%) reported at least 75% of their OTPs were operating at 80% capacity or more.

CONCLUSIONS

Significant gaps between treatment need and capacity exist at the state and national levels. Strategies to increase the number of OA-MAT providers are needed.

Post-operative Analgesia in Opioid Dependent Patients: Comparison of Intravenous Morphine and Sublingual Buprenorphine

BACKGROUND

Acute and chronic pain is prevalent in patients with opioid dependence. Lack of knowledge concerning the complex relationship between pain, opioid use, and withdrawal syndrome can account for the barriers encountered for pain management. This study was designed to evaluate the efficacy of sublingual (SL) buprenorphine for post-operative analgesia, compared with intravenous (IV) morphine.

METHODS

A total of 68 patients, aged 20-60 years were randomly selected from whom had been underwent laparotomy due to acute abdomen in a University Teaching Hospital in Arak, Iran, and were also opioid (opium or heroin) abuser according to their history. After end of the surgery and patients' arousal, the patients were evaluated for abdominal pain and withdrawal syndrome by visual analog scale (VAS) and clinical opioid withdrawal score (COWS), respectively 1, 6, and 24 h after the surgery. They received either morphine 5 mg IV or buprenorphine 2 mg SL, 1 h after end of the surgery, and then every 6 h for 24 h.

FINDINGS

VAS was 4.47 ± 0.73 and 2.67 ± 0.53 at h 6 and 24 in buprenorphine group, respectively. The corresponding score was 5.88 ± 0.69 and 4.59 ± 0.74 in morphine group. At the same time, patients in buprenorphine experienced less severe withdrawal syndrome.

CONCLUSION

The present study confirmed the efficacy of SL buprenorphine as a non-invasive, but effective method for management of post-operative pain in opioid dependent patients. Result of this study showed that physicians can rely on SL buprenorphine for post-operative analgesia.

Failure to identify or effectively manage prescription opioid dependence acted as a gateway to heroin use-buprenorphine/naloxone treatment and recovery in a surgical patient

The prescribing of opioid pain medication has increased markedly in recent years, with strong opioid dispensing increasing 18-fold in Tayside, Scotland since 1995. Despite this, little data is available to quantify the problem of opioid pain medication dependence (OPD) and until recently there was little guidance on best-practice treatment. We report the case of a young mother prescribed dihydrocodeine for postoperative pain relief who became opioid dependent. When her prescription was stopped without support, she briefly used heroin to overcome her withdrawal. After re-exposure to dihydrocodeine following surgery 9 years later and treatment with methadone for dependency, she was transferred to buprenorphine/naloxone. In our clinical experience and in agreement with Department of Health and Royal College of General Practitioner guidance, buprenorphine/naloxone is the preferred opioid substitution treatment for OPD. Our patient remains within her treatment programme and has returned to work on buprenorphine 16 mg/naloxone 4 mg in conjunction with social and psychological support.

The Baltimore Buprenorphine Initiative: understanding the role of buprenorphine in addressing heroin addiction in an urban-based community

Adequate drug treatment for substance users continues to be a challenge for most U.S. cities. To address heroin addiction in Baltimore, the Baltimore Buprenorphine Initiative was implemented as a joint project to promote individualized, patient-centered buprenorphine therapy in conjunction with behavioral treatment to accelerate recovery from opioid addiction. The purpose of this analysis was to explore differences in recovery trajectories predicting length of stay and use this information to predict characteristics that influence an individual's ability to remain in the Baltimore Buprenorphine Initiative program. The sample consisted of 1,039 subjects enrolled in the program between January 2008 and June 2009. The regression modeling determined that age, income, employment, and higher level of treatment were significant predictors of length of stay in the recovery program. The findings of this study have practical implications for the design and implementation of heroin addiction programs. The research indicates that focusing on these specific predictive variables early in the program design phase could increase recovery success rates as measured by length of stay.

Utilizing buprenorphine-naloxone to treat illicit and prescription-opioid dependence

OBJECTIVES

To review current evidence on buprenorphine-naloxone (bup/nx) for the treatment of opioid-use disorders, with a focus on strategies for clinical management and office-based patient care.

QUALITY OF EVIDENCE

Medline and the Cochrane Database of Systematic Reviews were searched. Consensus reports, guidelines published, and other authoritative sources were also included in this review. Apart from expert guidelines, data included in this review constitute level 1 evidence.

FINDINGS

Bup/nx is a partial μ-opioid agonist combined with the opioid antagonist naloxone in a 4:1 ratio. It has a lower abuse potential, carries less stigma, and allows for more flexibility than methadone. Bup/nx is indicated for both inpatient and ambulatory medically assisted withdrawal (acute detoxification) and long-term substitution treatment (maintenance) of patients who have a mild-to-moderate physical dependence. A stepwise long-term substitution treatment with regular monitoring and follow-up assessment is usually preferred, as it has better outcomes in reducing illicit opioid use, minimizing concomitant risks such as human immunodeficiency virus and hepatitis C transmission, retaining patients in treatment and improving global functioning.

CONCLUSION

Bup/nx is safe and effective for opioid detoxification and substitution treatment. Its unique pharmaceutical properties make it particularly suitable for office-based maintenance treatment of opioid-use disorder.

Simultaneous determination of opiates, methadone, buprenorphine and metabolites in human urine by superficially porous liquid chromatography tandem mass spectrometry

For monitoring compliance of methadone or buprenorphine maintenance patient, a method for the simultaneous determination of methadone, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), buprenorphine, norbuprenorphine, opiates (morphine, codeine, 6-monoacetylmorphine) in urine by superficially porous liquid chromatography tandem mass spectrometry was developed and validated. After enzyme digestion and liquid-liquid extraction, reverse-phase separation was achieved in 5.2 min and quantification was performed by multiple reaction monitoring. Chromatographic separation was performed at 40 °C on a reversed phase Poroshell column with gradient elution. The mobile phase consisted of water and methanol, each containing 0.1% formic acid, at a flow rate of 0.32 mL/min. Intra-day and inter-day precision were less than 12.1% and accuracy was between -9.8% and 13.7%. Extraction efficiencies were more than 68%. Although ion suppression was detected, deuterated internal standards compensated for these effects. Carryover was minimal, less than 0.20%. All analytes were stable at room temperature for 16 h, 4 °C for 72 h, and after three freeze-thaw cycles. The assay also fulfilled compound identification criteria in accordance with the European Commission Decision 2002/657/EC. We analyzed 62 urine samples from patients received maintenance therapy and found that 54.8% of the patient samples tested were detected for morphine, codeine, or 6-monoacetylmorphine. This method provides a reliable and simultaneous quantification of opiates, maintenance drugs, and their metabolites in urine samples. It facilitates the routine monitoring in individuals prescribed the drug to ensure compliance and help therapeutic process.