Buprenorphine versus methadone maintenance treatment in an ambulant setting: a health-related quality of life assessment

Quality of life and associated factors of heroin-dependent patients receiving methadone and buprenorphine maintenance treatment

AIM

Although studies in Western countries have investigated the quality of life (QoL) of heroin users, limited research on this topic has been conducted in Asia. The present study assessed QoL in patients with heroin dependence receiving medications to treat opioid use disorder.

METHODS

We performed a cross-sectional study of patients with heroin dependence receiving methadone and buprenorphine treatment. The demographic and substance use variables of patients receiving methadone and buprenorphine were compared. The Chinese Health Questionnaire (CHQ-12), Obsessive Compulsive Drug Use Scale (OCDUS), and World Health Organization Quality of Life Short Form Taiwan version (WHOQOL-BREF-T) were administered to measure patient mental health problems, addiction severity, and QoL, respectively. Multivariate regression was used to identify the factors associated with QoL.

RESULTS

A total of 149 patients receiving methadone and 31 receiving buprenorphine completed the questionnaires. Individuals in the buprenorphine group were more likely to be married (p = 0.024) or employed (p = 0.024), have a higher educational level (p = 0.013), have lower drug craving (OCDUS: p = 0.035), or have higher QoL (WHOQOL-BREF-T: p = 0.004) than those in the methadone group. After adjustment for other variables, employment was positively associated with the physical, psychological, and environmental domains of QoL. Receiving buprenorphine treatment (p = 0.032) and longer treatment duration (p = 0.016) were associated with higher psychological QoL.

CONCLUSION

Several factors were associated with QoL in patients with heroin dependence. Some measures may improve their QoL, such as reducing employment barriers, improving treatment adherence, or increasing accessibility to buprenorphine treatment.

Costs of implementing a multi-site facilitation intervention to increase access to medication treatment for opioid use disorder

BACKGROUND

The United States has been grappling with the opioid epidemic, which has resulted in over 75,000 opioid-related deaths between April 2020 and 2021. Evidence-based pharmaceutical interventions (buprenorphine, methadone, and naltrexone) are available to reduce opioid-related overdoses and deaths. However, adoption of these medications for opioid use disorder has been stifled due to individual- and system-level barriers. External facilitation is an evidence-based implementation intervention that has been used to increase access to medication for opioid use disorder (MOUD), but the implementation costs of external facilitation have not been assessed. We sought to measure the facility-level direct costs of implementing an external facilitation intervention for MOUD to provide decision makers with estimates of the resources needed to implement this evidence-based program.

METHODS

We performed a cost analysis of the pre-implementation and implementation phases, including an itemization of external facilitation team and local site labor costs. We used labor estimates from the Bureau of Labor and Statistics, and sensitivity analyses were performed using labor estimates from the Veterans Health Administration (VHA) Financial Management System general ledger data.

RESULTS

The average total costs for implementing an external facilitation intervention for MOUD per site was $18,847 (SD 6717) and ranged between $11,320 and $31,592. This translates to approximately $48 per patient with OUD. Sites with more encounters and participants with higher salaries in attendance had higher costs. This was driven mostly by the labor involved in planning and implementation activities. The average total cost of the pre-implementation and implementation activities were $1031 and $17,816 per site, respectively. In the sensitivity analysis, costs for VHA were higher than BLS estimates likely due to higher wages.

CONCLUSIONS

Implementing external facilitation to increase MOUD prescribing may be affordable depending on the payer's budget constraints. Our study reported that there were variations in the time invested at each phase of implementation and the number and type of participants involved with implementing an external facilitation intervention. Participant composition played an important role in total implementation costs, and decision makers will need to identify the most efficient and optimal number of stakeholders to involve in their implementation plans.

Buprenorphine use and courses of care for opioid use disorder treatment within the Veterans Health Administration

BACKGROUND

Retention of patients in buprenorphine medication treatment for opioid use disorder (B-MOUD) reduces harms associated with opioid use disorder (OUD). We sought to characterize the patients receiving B-MOUD and courses of B-MOUD in a large healthcare system.

METHODS

We conducted a retrospective, open cohort study of patients with OUD who either did or did not receive B-MOUD courses within the Veterans Health Administration (VHA) from January 2006 through July 2019, using VHA clinical data. We compared patients receiving or not receiving B-MOUD, characterized B-MOUD courses (e.g., length and doses), and examined persistence, across patient characteristics, over time. We used analyses for normally or non-normally distributed continuous variables, categorical data, and persistence over time (Kaplan-Meier persistence curves).

RESULTS

We identified 255,726 Veterans with OUD; 40,431 (15.8%) had received 63,929 B-MOUD courses. Compared to patients with OUD without B-MOUD, patients with B-MOUD were younger, more often of white race, and had more co-morbidities. The frequency of new B-MOUD starts and prevalent B-MOUD patients ranged from 1550 and 1989 in 2007 to 8146 and 16,505 in 2018, respectively. The median duration of B-MOUD was 157 (IQR: 37-537) days for all courses and 33.8% patients had more than one course. The average proportion days covered was 90% (SD: 0.15), and the average prescribed daily dose was 13.44 (SD: 6.5).

CONCLUSIONS

Within a VHA B-MOUD cohort, courses increased more than 10-fold from 2006 to 2016 with nearly half of patients experiencing multiple courses. Patient demographics seem to dictate the length of courses.

Buprenorphine versus methadone for the treatment of opioid dependence: a systematic review and meta-analysis of randomised and observational studies

BACKGROUND

Opioid dependence is associated with substantial health and social burdens, and opioid agonist treatment (OAT) is highly effective in improving multiple outcomes for people who receive this treatment. Methadone and buprenorphine are common medications provided as OAT. We aimed to examine buprenorphine compared with methadone in the treatment of opioid dependence across a wide range of primary and secondary outcomes.

METHODS

We did a systematic review and meta-analysis in accordance with GATHER and PRISMA guidelines. We searched Embase, MEDLINE, CENTRAL, and PsycINFO from database inception to Aug 1, 2022; clinical trial registries and previous relevant Cochrane reviews were also reviewed. We included all RCTs and observational studies of adults (aged ≥18 years) with opioid dependence comparing treatment with buprenorphine or methadone. Primary outcomes were retention in treatment at 1, 3, 6, 12, and 24 months, treatment adherence (measured through doses taken as prescribed, dosing visits attended, and biological measures), or extra-medical opioid use (measured by urinalysis and self-report). Secondary outcomes were use of benzodiazepines, cannabis, cocaine, amphetamines, and alcohol; withdrawal; craving; criminal activity and engagement with the criminal justice system; overdose; mental and physical health; sleep; pain; global functioning; suicidality and self-harm; and adverse events. Single-arm cohort studies and RCTs that collected data on buprenorphine retention alone were also reviewed. Data on study, participant, and treatment characteristics were extracted. Study authors were contacted to obtain additional data when required. Comparative estimates were pooled with use of random-effects meta-analyses. The proportion of individuals retained in treatment across multiple timepoints was pooled for each drug. This study is registered with PROSPERO (CRD42020205109).

FINDINGS

We identified 32 eligible RCTs (N=5808 participants) and 69 observational studies (N=323 340) comparing buprenorphine and methadone, in addition to 51 RCTs (N=11 644) and 124 observational studies (N=700 035) that reported on treatment retention with buprenorphine. Overall, 61 studies were done in western Europe, 162 in North America, 14 in north Africa and the Middle East, 20 in Australasia, five in southeast Asia, seven in south Asia, two in eastern Europe, three in central Europe, one in east Asia, and one in central Asia. 1 040 827 participants were included in these primary studies; however, gender was only reported for 572 111 participants, of whom 377 991 (66·1%) were male and 194 120 (33·9%) were female. Mean age was 37·1 years (SD 6·0). At timepoints beyond 1 month, retention was better for methadone than for buprenorphine: for example, at 6 months, the pooled effect favoured methadone in RCTs (risk ratio 0·76 [95% CI 0·67-0·85]; I·=74·2%; 16 studies, N=3151) and in observational studies (0·77 [0·68-0·86]; I·=98·5%; 21 studies, N=155 111). Retention was generally higher in RCTs than observational studies. There was no evidence suggesting that adherence to treatment differed with buprenorphine compared with methadone. There was some evidence that extra-medical opioid use was lower in those receiving buprenorphine in RCTs that measured this outcome by urinalysis and reported proportion of positive urine samples (over various time frames; standardised mean difference -0·20 [-0·29 to -0·11]; I·=0·0%; three studies, N=841), but no differences were found when using other measures. Some statistically significant differences were found between buprenorphine and methadone among secondary outcomes. There was evidence of reduced cocaine use, cravings, anxiety, and cardiac dysfunction, as well as increased treatment satisfaction among people receiving buprenorphine compared with methadone; and evidence of reduced hospitalisation and alcohol use in people receiving methadone. These differences in secondary outcomes were based on small numbers of studies (maximum five), and were often not consistent across study types or different measures of the same constructs (eg, cocaine use).

INTERPRETATION

Evidence from trials and observational studies suggest that treatment retention is better for methadone than for sublingual buprenorphine. Comparative evidence on other outcomes examined showed few statistically significant differences and was generally based on small numbers of studies. These findings highlight the imperative for interventions to improve retention, consideration of client-centred factors (such as client preference) when selecting between methadone and buprenorphine, and harmonisation of data collection and reporting to strengthen future syntheses.

FUNDING

Australian National Health and Medical Research Council.

Design, Implementation, and Evolution of the Medicaid Outcomes Distributed Research Network (MODRN)

BACKGROUND

In the US, Medicaid covers over 80 million Americans. Comparing access, quality, and costs across Medicaid programs can provide policymakers with much-needed information. As each Medicaid agency collects its member data, multiple barriers prevent sharing Medicaid data between states. To address this gap, the Medicaid Outcomes Distributed Research Network (MODRN) developed a research network of states to conduct rapid multi-state analyses without sharing individual-level data across states.

OBJECTIVE

To describe goals, design, implementation, and evolution of MODRN to inform other research networks.

METHODS

MODRN implemented a distributed research network using a common data model, with each state analyzing its own data; developed standardized measure specifications and statistical software code to conduct analyses; and disseminated findings to state and federal Medicaid policymakers. Based on feedback on Medicaid agency priorities, MODRN first sought to inform Medicaid policy to improve opioid use disorder treatment, particularly medication treatment.

RESULTS

Since its 2017 inception, MODRN created 21 opioid use disorder quality measures in 13 states. MODRN modified its common data model over time to include additional elements. Initial barriers included harmonizing utilization data from Medicaid billing codes across states and adapting statistical methods to combine state-level results. The network demonstrated its utility and addressed barriers to conducting multi-state analyses of Medicaid administrative data.

CONCLUSIONS

MODRN created a new, scalable, successful model for conducting policy research while complying with federal and state regulations to protect beneficiary health information. Platforms like MODRN may prove useful for emerging health challenges to facilitate evidence-based policymaking in Medicaid programs.

Systematic review and meta-analysis of changes in quality of life following initiation of buprenorphine for opioid use disorder

BACKGROUND

People with opioid use disorder (OUD) experience lower quality of life (QoL) than the general population, but buprenorphine treatment for OUD could help improve QoL of individuals with OUD. Thus, we conducted a systematic review and meta-analysis of the impact of buprenorphine on QoL among people with OUD.

METHODS

Seven databases were searched through August 2020. We included English-language studies with pre- and post- QoL assessments internationally. Standardized mean differences were calculated for five domains of QoL measures using a random effects model for correlated effect sizes with robust variance estimation. Meta-regression was used to assess variation in effect sizes based on QoL domain, treatment, and patient factors.

RESULTS

Twenty-one peer-reviewed studies from twelve countries were included. Only three studies included a no-treatment control group and five studies assigned groups using randomization. Improvements between baseline and follow-up were observed across all five domains of QoL measures (overall, physical, psychological, social, and environmental). The certainty of evidence was low for all domains of QoL, and very low for environmental QoL. We did not observe differences in the effect of buprenorphine on QoL by QoL domain, duration, dose, participant characteristics, or adjunctive counseling services.

CONCLUSIONS

Buprenorphine treatment likely improves overall, physical, psychological, and social QoL, and may improve environmental QoL, for individuals with OUD. Findings are limited by study quality, including lack of control groups and incomplete reporting. Future studies with more rigorous methods and comprehensive reporting are needed.

Roles and Perceptions of Nurses During Implementation of a Medication Treatment for Opioid Use Disorder National Initiative

BACKGROUND

In the United States, a national priority exists to improve access to medication treatment for opioid use disorder (MOUD). Nurses can be an essential component of that care. We examined the perceptions and evolving roles of nurses in a national Veterans Health Administration (VHA) initiative designed to improve MOUD access within general medical settings.

METHODS

From April 15, 2021, to June 16, 2021, we recruited nurses participating in VHA's Stepped Care for Opioid Use Disorder Train the Trainer Initiative-a national program intending to implement MOUD in general medical settings-to participate in an interview about their roles, perceptions, and experiences. The respondents answered our inquiries through an interview or responded to an email solicitation with written responses, which were then recorded, transcribed, and independently coded to identify themes.

RESULTS

Nurses from 10 VHA facilities participated in an interview (n = 7) or completed the questionnaire (n = 4). Inadequate staffing, high patient-to-provider ratios, and time constraints were identified as barriers to MOUD care. Mentorship activities, existing VHA informational resources, and patients' willingness to accept treatment were identified as facilitators of MOUD care. The Stepped Care for Opioid Use Disorder Train the Trainer Initiative processes were acknowledged to promote role confidence, which in turn increased job satisfaction and empowered nurses to become content experts. Respondents often identified nurses as local lead facilitators in MOUD care.

CONCLUSIONS

In a national initiative to implement MOUD within general medical settings, nurses identified several barriers and facilitators to MOUD implementation. Nurses play vital collaborative care roles in enhancing access to MOUD.

Subsequent Buprenorphine Treatment Following Emergency Physician Buprenorphine Prescription Fills: A National Assessment 2019 to 2020

STUDY OBJECTIVE

Buprenorphine treatment for opioid use disorder provided in the emergency department with subsequent buprenorphine treatment by community prescribers is associated with improved outcomes, but the frequency with which this occurs is unknown. We examined the rates of subsequent buprenorphine treatment for buprenorphine-naïve individuals filling buprenorphine prescriptions from emergency physicians and initiated buprenorphine treatment and how such rates varied before and during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Using pharmacy claims capturing an estimated 92% of prescriptions filled at US retail pharmacies, we identified buprenorphine prescriptions filled between February 1, 2019, and November 30, 2020, written by emergency physicians. In this observational study, we calculated the rate at which patients subsequently filled buprenorphine prescriptions from other nonemergency clinicians, the frequency with which subsequent filled prescriptions were from different types of prescribers, and the changes in the rates of subsequent prescriptions following the declaration of the COVID-19 public health emergency.

RESULTS

We identified 22,846 prescriptions written by emergency physicians and filled by buprenorphine-naïve patients. They were most commonly paid for by Medicaid and were in metropolitan counties; 28.5% of patients subsequently filled buprenorphine prescriptions written by other clinicians. Adult primary care physicians and advanced practice providers (eg, physician assistants and nurse practitioners) were responsible for most of the subsequent prescriptions. The rates of subsequent prescriptions were 3.5% lower after the COVID-19 public health emergency declaration.

CONCLUSION

The majority of patients filling buprenorphine prescriptions written by emergency physicians do not subsequently fill prescriptions written by other clinicians, and the rates of subsequent prescriptions were lower after the declaration of the COVID-19 public health emergency. These findings highlight the need for a system of care that improves buprenorphine treatment continuity of care for patients with opioid use disorder from emergency settings to community treatment providers.

Are x-waiver trainings enough? Facilitators and barriers to buprenorphine prescribing after x-waiver trainings

BACKGROUND

In the United States, an x-waiver credential is necessary to prescribe buprenorphine medication treatment for opioid use disorder (B-MOUD). Historically, this process has required certified training, which could be a barrier to obtaining an x-waiver and subsequently prescribing. To address this barrier, the US recently removed the training requirement for some clinicians. We sought to determine if clinicians who attended x-waiver training went on to obtain an x-waiver and prescribe B-MOUD, and to examine what facilitated or impeded B-MOUD prescribing.

METHODS

In September 2020, we conducted a cross-sectional, electronic survey of attendees of 15 in-person x-waiver pieces of training from June 2018 to January 2020 within the Veterans Health Administration (VHA). Of the attendees (n = 321), we surveyed current VHA clinicians who recalled taking the training. The survey assessed whether clinicians obtained the x-waiver, had prescribed B-MOUD, and barriers or facilitators that influenced B-MOUD prescribing.

RESULTS

Of 251 eligible participants, 62 (24.7%) responded to the survey, including 27 (43.5%) physicians, 16 (25.8%) advanced practice clinicians, and 12 (19.4%) pharmacists. Of the 43 clinicians who could prescribe, 29 (67.4%) had obtained their x-waiver and 16 (37.2%) had reported prescribing B-MOUD. Prominent barriers to prescribing B-MOUD included a lack of supporting clinical staff and competing demands on time. The primary facilitator to prescribing was leadership support.

CONCLUSIONS

Nine months after x-waiver training, two-thirds of clinicians with prescribing credentials had obtained their x-waiver and one-third were prescribing B-MOUD. Removing the x-waiver training may not have the intended policy effect as other barriers to B-MOUD prescribing persist.

Sociodemographic and Clinical Characteristics Associated with Improvements in Quality of Life for Participants with Opioid Use Disorder

Background: The Houston Emergency Opioid Engagement System was established to create an access pathway into long-term recovery for individuals with opioid use disorder. The program determines effectiveness across multiple dimensions, one of which is by measuring the participant’s reported quality of life (QoL) at the beginning of the program and at successive intervals. Methods: A visual analog scale was used to measure the change in QoL among participants after joining the program. We then identified sociodemographic and clinical characteristics associated with changes in QoL. Results: 71% of the participants (n = 494) experienced an increase in their QoL scores, with an average improvement of 15.8 ± 29 points out of a hundred. We identified 10 factors associated with a significant change in QoL. Participants who relapsed during treatment experienced minor increases in QoL, and participants who attended professional counseling experienced the largest increases in QoL compared with those who did not. Conclusions: Insight into significant factors associated with increases in QoL may inform programs on areas of focus. The inclusion of counseling and other services that address factors such as psychological distress were found to increase participants’ QoL and success in recovery.

Quality of life during a randomized trial of a therapeutic-workplace intervention for opioid use disorder: Web-based mobile assessments reveal effects of drug abstinence and access to paid work

Background

Employment and improved quality of life (QOL) are, separately, valued outcomes of substance use disorder (SUD) treatment. It is also important to understand QOL changes caused by employment itself; therefore, we assessed QOL during a randomized trial of a contingency-management-based Therapeutic Workplace for people with opioid use disorder.

Methods

For 12 weeks, participants (n = 61) responded to QOL questionnaires in a mobile web app accessed with study-issued smartphones. At enrollment, participants were randomized to work in the Therapeutic Workplace immediately (immediate work group, IWG) or after a 3-week waitlist delay (delayed work group, DWG). Once both groups could work, wage-resetting contingencies were introduced for their opiate- and cocaine-urinalysis. Data were analyzed by (1) access to work with and without contingencies and (2) overall urinalysis-verified opiate- and cocaine-abstinence.

Results

DWG and/or IWG reported improvements in several QOL areas (sleep, transportation, recreation); however, they also reported increased money-related difficulties and less time spent with friends/family. These changes did not coincide with DWG's work access, but some (more sleep, money-related difficulties) coincided with the urinalysis contingencies. Greater opiate- and/or cocaine-abstinence was also associated with several improvements: sleep, paying bills, time spent with friends/family, and exercising. Surprisingly, intermediate cocaine abstinence was associated with reductions in work-capacity satisfaction and recreation.

Conclusions

Participants reported complex QOL differences during their experimental employment and associated with drug abstinence. Future work should help participants address issues that may be relevant to employment generally (e.g., time with friends/family) or contingency management specifically (e.g., money-related issues for non-abstinent participants).

Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative: Expanding access to medication treatment for opioid use disorder within Veterans Health Administration facilities

The US is confronted with a rise in opioid use disorder (OUD), opioid misuse, and opioid-associated harms. Medication treatment for opioid use disorder (MOUD)-including methadone, buprenorphine and naltrexone-is the gold standard treatment for OUD. MOUD reduces illicit opioid use, mortality, criminal activity, healthcare costs, and high-risk behaviors. The Veterans Health Administration (VHA) has invested in several national initiatives to encourage access to MOUD treatment. Despite these efforts, by 2017, just over a third of all Veterans diagnosed with OUD received MOUD. VHA OUD specialty care is often concentrated in major hospitals throughout the nation and access to this care can be difficult due to geography or patient choice. Recognizing the urgent need to improve access to MOUD care, in the Spring of 2018, the VHA initiated the Stepped Care for Opioid Use Disorder, Train the Trainer (SCOUTT) Initiative to facilitate access to MOUD in VHA non-SUD care settings. The SCOUTT Initiative's primary goal is to increase MOUD prescribing in VHA primary care, mental health, and pain clinics by training providers working in those settings on how to provide MOUD and to facilitate implementation by providing an ongoing learning collaborative. Thirteen healthcare providers from each of the 18 VHA regional networks across the VHA were invited to implement the SCOUTT Initiative within one facility in each network. We describe the goals and initial activities of the SCOUTT Initiative leading up to a two-day national SCOUTT Initiative conference attended by 246 participants from all 18 regional networks in the VHA. We also discuss subsequent implementation facilitation and evaluation plans for the SCOUTT Initiative. The VHA SCOUTT Initiative could be a model strategy to implement MOUD within large, diverse health care systems.

Beyond abstinence and relapse II: momentary relationships between stress, craving, and lapse within clusters of patients with similar patterns of drug use

RATIONALE

Given that many patients being treated for opioid-use disorder continue to use drugs, identifying clusters of patients who share similar patterns of use might provide insight into the disorder, the processes that affect it, and ways that treatment can be personalized.

OBJECTIVES AND METHODS

We applied hierarchical clustering to identify patterns of opioid and cocaine use in 309 participants being treated with methadone or buprenorphine (in a buprenorphine-naloxone formulation) for up to 16 weeks. A smartphone app was used to assess stress and craving at three random times per day over the course of the study.

RESULTS

Five basic patterns of use were identified: frequent opioid use, frequent cocaine use, frequent dual use (opioids and cocaine), sporadic use, and infrequent use. These patterns were differentially associated with medication (methadone vs. buprenorphine), race, age, drug-use history, drug-related problems prior to the study, stress-coping strategies, specific triggers of use events, and levels of cue exposure, craving, and negative mood. Craving tended to increase before use in all except those who used sporadically. Craving was sharply higher during the 90 min following moderate-to-severe stress in those with frequent use, but only moderately higher in those with infrequent or sporadic use.

CONCLUSIONS

People who share similar patterns of drug-use during treatment also tend to share similarities with respect to psychological processes that surround instances of use, such as stress-induced craving. Cluster analysis combined with smartphone-based experience sampling provides an effective strategy for studying how drug use is related to personal and environmental factors.

It will end in tiers: A strategy to include "dabblers" in the buprenorphine workforce after the X-waiver

Buprenorphine is one of the gold standard medication treatments for opioid use disorder (OUD), with proven effectiveness in preventing overdose, increasing abstinence, and improving quality of life. In the United States, buprenorphine can be legally prescribed and administered in office-based settings from clinicians who are specially credentialed to provide that care under the X-waiver. We believe the X-waiver will ultimately be repealed, but there is a need for a variety of strategies to create a new treatment system after the X-waiver. Building a new tier of treatment capacity will require educational outreach, systems strategies, and enhanced payments.

Medication treatment for opioid use disorder and community pharmacy: Expanding care during a national epidemic and global pandemic

Medications for opioid use disorder (MOUD), such as methadone and buprenorphine, are effective strategies for treatment of opioid use disorder (OUD) and reducing overdose risk. MOUD treatment rates continue to be low across the US, and currently, some evidence suggests access to evidence-based treatment is becoming increasingly difficult for those with OUD as a result of the 2019 novel corona virus (COVID-19). A major underutilized source to address these serious challenges in the US is community pharmacy given the specialized training of pharmacists, high levels of consumer trust, and general availability for accessing these service settings. Canadian, Australian, and European pharmacists have made important contributions to the treatment and care of those with OUD over the past decades. Unfortunately, US pharmacists are not permitted to prescribe MOUD and are only currently allowed to dispense methadone for the treatment of pain, not OUD. US policymakers, regulators, and practitioners must work to facilitate this advancement of community pharmacy-based through research, education, practice, and industry. Advancing community pharmacy-based MOUD for leading clinical management of OUD and dispensation of treatment medications will afford the US a critical innovation for addressing the opioid epidemic, fallout from COVID-19, and getting individuals the care they need.

Impact of Pharmacological Treatments for Opioid Use Disorder on Mortality

The use of pharmacological treatments for opioid use disorders, including methadone, buprenorphine and naltrexone has been associated with a reduction in mortality compared with illicit opioid use. However, these treatments can also contribute significantly to the risk of death. The opioid agonists methadone and buprenorphine achieve clinical efficacy in patients with an opioid use disorder through suppressing craving and diminishing the effectiveness of illicit opioid doses, while the antagonist naltrexone blocks the action of opioids. Pharmacological differences between opioid pharmacotherapies then create different temporal patterns of protection and mortality risk, different risks of relapse to illicit opioid use, and variations in direct and indirect toxicity, which are revealed in clinical and epidemiological studies. Induction onto methadone and the cessation of oral naltrexone treatment are associated with an elevated risk of opioid poisoning, which is not apparent in patients treated with buprenorphine or sustained-release naltrexone. Beyond drug-related mortality, these pharmacotherapies can impact a participant's risk of death. Buprenorphine may also have some advantages over methadone in patients with depressive disorders or cardiovascular abnormalities. Naltrexone, which is also commonly prescribed to manage problem alcohol use, may reduce deaths in chronic co-alcohol users. Understanding these pharmacologically driven patterns then guides the judicious choice of drug and dosing schedule and the proactive risk management that is crucial to minimising the risk of death in treatment.

What place for prolonged-release buprenorphine depot-formulation Buvidal® in the treatment arsenal of opioid dependence? Insights from the French experience on buprenorphine

Introduction: Since the 1990s, opioid maintenance treatments (OMTs), i.e. mostly methadone and buprenorphine, have represented the therapeutic cornerstone of opioid dependence. In France, the public health strategy on opioid dependence, identified here as the 'French model', has consisted of offering a facilitated access to buprenorphine, to reach a large treatment coverage and reduce opioid-related mortality. Areas covered: Recently, a new formulation of subcutaneous buprenorphine depot (Buvidal®) has been approved in Europe for treatment of opioid dependence. The place of Buvidal® among the pre-existing arsenal of OMTs is discussed in the light of the pharmacological specificities of this new formulation, and with the particular standpoint of the French model on opioid dependence. Expert opinion: Buvidal® could constitute a promising treatment option mainly in case of: 1) OMT initiation, including in non-specialized addiction medicine care; 2) Discharge from prison or hospital; Diversion/misuse of 3) buprenorphine or 4) methadone; 5) Clinically stabilized patients wishing to avoid daily oral taking of the medication. As such, this new formulation should be highly accessible, which will require specific pathways through care as the product is intended to be administered by a healthcare professional.

Health Related Quality of Life in Individuals Transferred from a Needle Exchange Program and Starting Opioid Agonist Treatment

Background

Opioid agonist treatment (OAT), for the treatment of heroin dependence, has been reported to improve overall health and lower mortality. Drug use and retention in treatment have often been used as measures of treatment success. More recently, however, researchers have suggested that measurements of quality of life should be an outcome in substance use treatment evaluations. In a recent randomized controlled trial we demonstrated high rates of successful rapid referral from a needle exchange program (NEP) to OAT. The aim of this study was to see whether an improvement in health related quality of life (HRQoL) could be seen at 3-month follow-up after starting OAT and whether it was associated with any baseline characteristics. We also wanted to compare our sample to a sample from the general population with regard to HRQoL.

Methods

This was a 3-month follow-up of 71 patients who started OAT. Measurements of HRQoL with EQ-5D (an instrument developed by the EuroQol group) were made at baseline and at three months.

Results

Mean EQ-5D VAS (visual analogue scale) for the study sample at baseline was 47.3, which was lower than a Swedish reference population reporting 83.3. Individuals reporting being prescribed a drug for a psychiatric condition had significantly lower EQ-5D index values. Improvement in EQ-5D index score was significantly less for individuals reporting previous overdoses (-0.10, p=0.025). Individuals reporting previous suicide attempts had significantly lower EQ-5D VAS score at baseline. A significant increase of the EQ-5D VAS difference over time was found with a mean difference of 10.94 (p=0.008) for the total sample.

Conclusion

To our knowledge this is the first time HRQoL as an outcome is reported in a population transferred from a NEP to OAT. Our results indicate that OAT can result in increased HRQoL, even with this type of rapid low-threshold referral.

Treatment outcomes among a cohort of African American buprenorphine patients: Follow-up at 12 months

BACKGROUND

Although buprenorphine/naloxone (bup/nal) is well-established as a safe and effective treatment for opioid use disorders (OUDs), there are few studies reporting 12-month outcomes of patients receiving bup/nal in formerly drug-free outpatient programs.

OBJECTIVES

To examine 12-month outcomes by bup/nal treatment enrollment status among a cohort of African American patients enrolled in a clinical trial.

METHODS

This analysis builds upon a randomized trial of 300 opioid-dependent African American bup/nal patients in two outpatient programs in Baltimore, MD. A subset of participants (N = 133, n = 47 female) were tracked for a 12-month follow-up interview.

RESULTS

The participants receiving bup/nal at 12 months had significantly fewer opioid-positive urine screens (44% v. 73%) and days of self-reported heroin use (M [SE] = 1.13 [.34] v. 7.12 [1.44]) than the out-of-bup/nal-treatment group (both ps ≤ .001). Similarly, those receiving bup/nal reported significantly fewer days of cocaine use (M [SE] = 0.85 [0.23] v. 2.88[0.75]) and alcohol use (M [SE] = 1.44 [0.38] v. 3.69 [1.04]; both ps<.05). There were no significant differences related to criminal activity, quality of life, and most ASI composite scores. Models adjusting for the baseline value, prior treatment experience, and assigned study condition largely confirmed these findings, except that participants in treatment had fewer days of crime and higher psychological quality of life scores compared to those out-of-treatment.

CONCLUSIONS

Those receiving bup/nal at 12 months had significantly lower rates of illicit opioid use than those who were not. Approaches to improve bup/nal treatment retention and reengagement of patients with OUD are needed.

Effects of medication assisted treatment (MAT) for opioid use disorder on functional outcomes: A systematic review

This systematic review synthesizes evidence on the effects of Medication-Assisted Treatment (MAT) for opioid use disorder (OUD) on functional outcomes, including cognitive (e.g., memory), physical (e.g., fatigue), occupational (e.g., return to work), social/behavioral (e.g., criminal activity), and neurological (e.g., balance) function. Five databases were searched from inception to July 2017 to identify English-language controlled trials, case control studies, and cohort comparisons of one or more groups; cross-sectional studies were excluded. Two independent reviewers screened identified literature, abstracted study-level information, and assessed the quality of included studies. Meta-analyses used the Hartung-Knapp method for random-effects models. The quality of evidence was assessed using the GRADE approach. A comprehensive search followed by 1411 full text publication screenings yielded 30 randomized controlled trials (RCTs) and 10 observational studies meeting inclusion criteria. The studies reported highly diverse functional outcome measures. Only one RCT was rated as high quality, but several methodologically sound observational studies were identified. The statistical power to detect differences in functional outcomes was unclear in most studies. When compared with matched "healthy" controls with no history of substance use disorder (SUD), in two studies MAT patients had significantly poorer working memory and cognitive speed. One study found MAT patients scored worse in aggressive responding than did "healthy" controls. A large observational study found that MAT users had twice the odds of involvement in an injurious traffic accident as non-users. When compared with persons with OUD not on MAT, one cohort study found lower fatigue rates among buprenorphine-treated OUD patients. No differences were reported for occupational outcomes and results for criminal activity and other social/behavioral areas were mixed. There were few differences among MAT drug types. A pooled analysis of three RCTs found a significantly lower prevalence of fatigue with buprenorphine compared to methadone, while a meta-analysis of the same RCTs found no statistical difference in insomnia prevalence. Three RCTs that focused on cognitive function compared the effects of buprenorphine to methadone; no statistically significant differences in memory, cognitive speed and flexibility, attention, or vision were reported. The quality of evidence for most functional outcomes was rated low or very low. In sum, weaknesses in the body of evidence prevent strong conclusions about the effects of MAT for opioid use disorder on functional outcomes. Rigorous studies of functional effects would strengthen the body of literature.

Traditional Chinese medicine-facilitated treatments may relieve anxiety symptoms during drug switching from methadone to buprenorphine/naloxone for treating opioid dependence

This study investigated a 51-year-old married man with a history of heroin dependence who underwent methadone maintenance treatment for 7 years. He received traditional Chinese medicine (TCM)-facilitated treatments and switched from methadone to buprenorphine/naloxone. Strong anxiety symptoms were observed during the initial stage; therefore, we prescribed a combination of Chaihu-Shugan-San, Zhi Bai Di Huang and Chin-Gin-Kuan-Ming decoction as the major herbal synergic regimen to relieve the symptoms of opioid withdrawal, anxiety and insomnia. During the treatment course, no precipitating withdrawal syndromes were noted, and the subject was gradually relieved of his anxiety symptoms through continual TCM treatments. In conclusion, TCM is effective in facilitating the switch from methadone to buprenorphine/naloxone and relieving anxiety symptoms. Therefore, focus on TCM-facilitated treatments for heroin dependence should be increased.

Characterizing Long-Term Health Related Quality of Life Trajectories of Individuals With Opioid Use Disorder

OBJECTIVES

Health related quality of life (HRQoL) has been increasingly considered an endpoint in evaluations of treatment for substance use disorders. We aimed to characterize longitudinal patterns of HRQoL in individuals with opioid use disorder (OUD) and with a history of opioid agonist treatment (OAT) with methadone.

METHODS

The EuroQol EQ-5D, a preference-weighted measure of HRQoL, was assessed in individuals with OUD and with a history of OAT enrolled in three prospective cohort studies between December 2011 and May 2014, with a maximum of five biannual assessments. We used latent class growth analysis to identify HRQoL trajectory classes and their association with self-reported current OAT receipt. Class assignment was derived from posterior probabilities and we explored time-invariant and time-varying determinants of trajectory class membership.

RESULTS

Our study included 443 individuals (median age 47, 37% female); 24.6% reported use of illicit opioids at every follow-up, 69.1% during at least one follow-up. We identified three latent HRQoL trajectory classes that were stable regardless of current OAT receipt: stably high (n=107, 24.2%), stably moderate (n=260, 58.7%) and stably low HRQoL (n=76, 17.2%). A history of either a physical disability or of a mental health illness increased the probability of membership assignment to a lower HRQoL class.

CONCLUSIONS

The non-significant association of OAT with HRQoL may suggest that the modest immediate HRQoL gains after OAT engagement, observed in short-term studies, may not persist over time. Implications for cost-effectiveness analysis and clinical practice are discussed.

Short term health-related quality of life improvement during opioid agonist treatment

BACKGROUND

Opioid dependence is associated with high levels of morbidity, yet sparse data exists regarding the health-related quality of life (HRQoL) of individuals with opioid dependence, particularly following treatment initiation. To inform cost-effectiveness analyses of treatment modalities, this study investigates short-term changes in HRQoL following enrollment into opioid agonist treatment (OAT), across treatment modalities and patient subgroups.

METHODS

Data was analyzed from the Starting Treatment with Agonist Replacement Therapies (START) and Prescription Opioid Addiction Treatment Studies (POATS) randomized controlled trials. Participants included individuals dependent on prescription opioids (POs) or heroin, receiving limited-term or time-unlimited treatment. PO- or heroin-users in START received buprenorphine/naloxone (BUP/NX) or methadone (MET) over 24 weeks. PO-users in POATS received psychosocial care and short-term (4-week) taper with BUP/NX, with non-responders offered subsequent extended (12-week) stabilization and taper. HRQoL was assessed using the short-form SF-6D while in and out of OAT, with distinction between MMT and BUP/NX in START. Linear mixed effects regression models were fitted to determine the independent effects of OAT on HRQoL and characterize HRQoL trajectories.

RESULTS

Treatment had a similar immediate and modest positive association with HRQoL in each patient subgroup. The association of OAT on HRQoL was statistically significant in each model, with effect sizes between 0.039 (heroin-users receiving BUP/NX) and 0.071 (PO-users receiving MET). After initial improvement, HRQoL decreased slightly, or increased at a diminished rate.

CONCLUSIONS

OAT, whether delivered in time-limited or unlimited form, using BUP/NX or MET, is associated with modest immediate HRQoL improvements, with diminishing benefits thereafter.

Patient Perspectives Associated with Intended Duration of Buprenorphine Maintenance Therapy

Patients with opioid use disorders frequently discontinue opioid maintenance therapy (OMT) prematurely, reducing retention and possibly limiting the efficacy of OMT. The current study is a cross-sectional survey of patients (N=69) enrolled in buprenorphine maintenance therapy (BMT). We examined patient demographics, BMT characteristics (e.g., dose, time in BMT), and patient perspectives regarding intended duration of BMT. In addition, patients' reasons for continuing or discontinuing BMT were investigated. Results revealed that the majority (82%) of participants reported wanting to continue BMT for at least 12months. Age at first drug use, time in BMT, concern about pain, and concern about relapse were all positively associated with intended duration of BMT. The following were negatively associated with intended duration of BMT: recent discussion with a treatment provider about BMT discontinuation, prior attempt to discontinue BMT, concern about withdrawal symptoms, experiencing pleasurable effects from taking buprenorphine, and perceived conflicts of BMT with life, work, or school obligations. The most common reasons for wanting to continue BMT included concerns about withdrawal symptoms, relapse, and pain. Although preliminary, the findings highlight key issues with regard to patients' perspectives of BMT. The results of this study provide information that may be useful in improving OMT programs and treatment outcomes.

Discontinuation of buprenorphine maintenance therapy: perspectives and outcomes

Buprenorphine maintenance therapy (BMT) is increasingly the preferred opioid maintenance agent due to its reduced toxicity and availability in an office-based setting in the United States. Although BMT has been shown to be highly efficacious, it is often discontinued soon after initiation. No current systematic review has yet investigated providers' or patients' reasons for BMT discontinuation or the outcomes that follow. Hence, provider and patient perspectives associated with BMT discontinuation after a period of stable buprenorphine maintenance and the resultant outcomes were systematically reviewed with specific emphasis on pre-buprenorphine-taper parameters predictive of relapse following BMT discontinuation. Few identified studies address provider or patient perspectives associated with buprenorphine discontinuation. Within the studies reviewed providers with residency training in BMT were more likely to favor long term BMT instead of detoxification, and providers were likely to consider BMT discontinuation in the face of medication misuse. Patients often desired to remain on BMT because of fear of relapse to illicit opioid use if they were to discontinue BMT. The majority of patients who discontinued BMT did so involuntarily, often due to failure to follow strict program requirements, and 1 month following discontinuation, rates of relapse to illicit opioid use exceeded 50% in every study reviewed. Only lower buprenorphine maintenance dose, which may be a marker for attenuated addiction severity, predicted better outcomes across studies. Relaxed BMT program requirements and frequent counsel on the high probability of relapse if BMT is discontinued may improve retention in treatment and prevent the relapse to illicit opioid use that is likely to follow BMT discontinuation.

Former Heroin-Dependent Alcohol Use Disorder Patients. Prevalence, Addiction History and Clinical Features

AIMS

To examine the prevalence of former heroin dependence (FHA) in Alcohol Use Disorder (AUD) patients; to compare the clinical characteristics of FHA-AUD patients versus AUD patients without any past use of heroin at alcohol treatment entry; to document the heroin dependence history of FHA-AUD patients, and review treatment strategies for this group.

METHODS

Retrospective case review of 448 consecutive AUD patients.

RESULTS

The annual entry of FHA-AUD showed stability over the study period of 3 years overall 60/448 (13.3%). FHA-AUD patients showed higher concomitant use of cocaine, benzodiazepines, cannabis and hallucinogens than other heroin addicts. They consumed higher amounts of alcohol at the beginning of their alcohol dependence history, and reached a high maximum level of alcohol consumption, than other AUD patients, and tended to have more physical disorders. The most important signals of FHA-AUD were polyabuse and older age at the time of presentation. FHA-AUD patients tended to have had a severe pattern of heroin dependence associated with inadequate agonist opiate treatment.

CONCLUSIONS

The prevalence of FHA-AUD patients is not negligible. This may relate to previous inadequate treatment of heroin addiction contributing to the development of severe AUD. For these patients we propose a reconsideration of 'soft' (low dose) agonist opiate treatment.

Considerations on the role of buprenorphine in recovery from heroin addiction from a UK perspective

The United Kingdom Drug Strategy emphasises recovery as a key focus in the treatment of drug dependence. A framework for recovery is defined in the Recovery-Orientated Drug Treatment report, written by an expert working group, and comprises four key phases: engagement and stabilisation, including the establishment of treatment goals; preparation for change, involving engagement in psychosocial and pharmacological interventions; active change, including detoxification and medical withdrawal; and completion, including interventions that strengthen community integration. A body of evidence supports the benefits of buprenorphine, a partial agonist at mu opioid receptors, in supporting individualised recovery based on this framework, specifically in relation to the potential for rapid stabilisation, flexibility to transition to other treatment options or achieve abstinence, effective blocking of on-top use of illicit drugs, the treatment of comorbidities through the minimisation of drug-drug interactions, and a good safety profile. In addition, the newer abuse-deterrent formulation of buprenorphine combined with the opioid antagonist naloxone is likely to strengthen recovery-orientated systems of care due to its potential to reduce misuse and diversion. Progress through the recovery journey and the ability to sustain recovery will depend on individual needs and goals and on the amount of recovery capital that individuals have developed.

Characteristics and quality of life of opioid-dependent pregnant women in Austria

This study investigated pregnant opioid-dependent women undergoing maintenance therapy, applying a multidisciplinary, case-management approach at the Addiction Clinic of the Medical University of Vienna, Austria. It aimed at characterizing the patients' basic demographic and clinical parameters and evaluating their overall quality of life (QoL) prepartum and postpartum. Three hundred ninety women were treated between 1994 and 2009 with buprenorphine (n = 77), methadone (n = 184), or slow-release oral morphine (SROM) (n = 129) on an outpatient basis throughout their pregnancy and postpartum period. All patients were subject to standardized prepartum and postpartum medical and psychiatric assessments, including QoL assessments using a German adaptation of the Lancashire QoL Profile (Berliner Lebensqualitaetsprofil), and regular supervised urine toxicologies. No medication group differences were revealed regarding basic demographic or clinical data. Mean maintenance doses (SD) at time of delivery were as follows: 64 mg (36 mg) methadone, 10 mg (6 mg) buprenorphine, 455 mg (207 mg) SROM. However, buprenorphine-medicated women showed significantly less concomitant benzodiazepine consumption than methadone- or SROM-maintained women (p = 0.005), and significantly less concomitant opioid consumption than methadone-maintained women (p = 0.033) during the last trimester. Overall QoL was good prepartum and postpartum in all measured domains except "finances" and "prospect of staying in the same housing situation," and no differences were observed in QoL among the three medication groups (p = 0.177). QoL improved significantly after delivery in most of the domains (p < 0.001). Although opioid-dependent pregnant women face high-risk pregnancies and show variability in addiction severity, they report good QoL independent of the medication administered. These results show that individually tailored treatment interventions are effective for this patient population and suggest a QoL improvement after delivery.

Quality of life and health of opioid-dependent subjects in India

BACKGROUND AND OBJECTIVES

The quality of life (QoL) of substance abusers is known to be severely impaired. This study was carried out to assess the impact of opioid dependence on the QoL of subjects and compared it with the normal subjects.

MATERIALS AND METHODS

Based on specified inclusion criteria a total of 47 subjects were recruited from a tertiary care center from India. The WHOQoL-BREF scale domain scores obtained at baseline were compared to that of normal subjects. An assessment of dysfunction and reasons for continuing and other parameters were assessed.

RESULTS

WHOQoL-BREF domains (Physical, Psychological, Social relationships and Environment) showed significantly lower scores and the difference was statistically significant.

INTERPRETATION AND CONCLUSIONS

The results showed that QoL is an important parameter in assessment of substance abusers and can be used for long-term prognosis of these individuals.

Using the PRECEDE model in understanding determinants of quality of life among Iranian male addicts

Quality of Life (QOL) in opiate-addicted patients who are receiving methadone maintenance therapy is one of the important issues to be considered in the treatment of addiction. To determine a needs assessment using the PRECEDE model to find out factors related to QOL among Iranian male opiate addicts. This cross-sectional study was conducted in Kermanshah, Iran in 2013. A total of 762 male opiate addicts, who were referred to addiction treatment centers for receiving methadone maintenance treatment, were randomly selected to participate voluntarily in the study. SF-12, predisposing factors, enabling factors, reinforcement factors, and methadone maintenance treatment intention were used to find the related factors. Data were analyzed by the SPSS software (ver. 21.0) using the t-test, one-way analysis of variance (ANOVA), bivariate correlations, and linear regression at 95% significant level. Linear regression analysis showed the determinant variable accounted for 17% of the variation in QOL. Our findings suggest, providing social support for addicts could be beneficial results for the increasing quality of life among them.

Effects of family-centered empowerment model based education program on quality of life in methamphetamine users and their families

BACKGROUND

Nowadays there are more concerns about drug treatment of methamphetamine abusers whereas quality of life (QOL) related supportive psychotherapy is less credited.

OBJECTIVES

This study aimed to evaluate the effects of family-centered empowerment model on social support and QOL of methamphetamine users and their families.

PATIENTS AND METHODS

This study was a randomized clinical trial; individuals were randomly allocated to three groups: a group for educating methamphetamine users in recovery (95 subjects), a group for educating a family member of methamphetamine users in recovery (95 subjects) and a control group (95 subjects). Data collecting instruments were standard questionnaires of social support and health-related quality of life (HRQOL). Data were analyzed using χ2-test, t-test, paired t-test, Pearson's correlation and ANOVA.

RESULTS

Mean scores of QOL and social support dimensions changed significantly in two intervention groups (P < 0.0001), but didn't change in the control group (P > 0.05). Also, there was a positive significant relation (P < 0.05) between total social support and all dimensions of QOL for all study groups.

CONCLUSIONS

Family-centered empowerment model, easily adapted to methamphetamine users and their families, leads to improved social supports and QOL.

Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence

BACKGROUND

Buprenorphine maintenance treatment has been evaluated in randomised controlled trials against placebo medication, and separately as an alternative to methadone for management of opioid dependence.

OBJECTIVES

To evaluate buprenorphine maintenance compared to placebo and to methadone maintenance in the management of opioid dependence, including its ability to retain people in treatment, suppress illicit drug use, reduce criminal activity, and mortality.

SEARCH METHODS

We searched the following databases to January 2013: Cochrane Drugs and Alcohol Review Group Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Current Contents, PsycLIT, CORK, Alcohol and Drug Council of Australia, Australian Drug Foundation, Centre for Education and Information on Drugs and Alcohol, Library of Congress, reference lists of identified studies and reviews. We sought published/unpublished randomised controlled trials (RCTs) from authors.

SELECTION CRITERIA

Randomised controlled trials of buprenorphine maintenance treatment versus placebo or methadone in management of opioid-dependent persons.

DATA COLLECTION AND ANALYSIS

We used Cochrane Collaboration methodology.

MAIN RESULTS

We include 31 trials (5430 participants), the quality of evidence varied from high to moderate quality.There is high quality of evidence that buprenorphine was superior to placebo medication in retention of participants in treatment at all doses examined. Specifically, buprenorphine retained participants better than placebo: at low doses (2 - 6 mg), 5 studies, 1131 participants, risk ratio (RR) 1.50; 95% confidence interval (CI) 1.19 to 1.88; at medium doses (7 - 15 mg), 4 studies, 887 participants, RR 1.74; 95% CI 1.06 to 2.87; and at high doses (≥ 16 mg), 5 studies, 1001 participants, RR 1.82; 95% CI 1.15 to 2.90. However, there is moderate quality of evidence that only high-dose buprenorphine (≥ 16 mg) was more effective than placebo in suppressing illicit opioid use measured by urinanalysis in the trials, 3 studies, 729 participants, standardised mean difference (SMD) -1.17; 95% CI -1.85 to -0.49, Notably, low-dose, (2 studies, 487 participants, SMD 0.10; 95% CI -0.80 to 1.01), and medium-dose, (2 studies, 463 participants, SMD -0.08; 95% CI -0.78 to 0.62) buprenorphine did not suppress illicit opioid use measured by urinanalysis better than placebo.There is high quality of evidence that buprenorphine in flexible doses adjusted to participant need,was less effective than methadone in retaining participants, 5 studies, 788 participants, RR 0.83; 95% CI 0.72 to 0.95. For those retained in treatment, no difference was observed in suppression of opioid use as measured by urinalysis, 8 studies, 1027 participants, SMD -0.11; 95% CI -0.23 to 0.02 or self report, 4 studies, 501 participants, SMD -0.11; 95% CI -0.28 to 0.07, with moderate quality of evidence.Consistent with the results in the flexible-dose studies, in low fixed-dose studies, methadone (≤ 40 mg) was more likely to retain participants than low-dose buprenorphine (2 - 6 mg), (3 studies, 253 participants, RR 0.67; 95% CI: 0.52 to 0.87). However, we found contrary results at medium dose and high dose: there was no difference between medium-dose buprenorphine (7 - 15 mg) and medium-dose methadone (40 - 85 mg) in retention, (7 studies, 780 participants, RR 0.87; 95% CI 0.69 to 1.10) or in suppression of illicit opioid use as measured by urines, (4 studies, 476 participants, SMD 0.25; 95% CI -0.08 to 0.58) or self report of illicit opioid use, (2 studies, 174 participants, SMD -0.82; 95% CI -1.83 to 0.19). Similarly, there was no difference between high-dose buprenorphine (≥ 16 mg) and high-dose methadone (≥ 85 mg) in retention (RR 0.79; 95% CI 0.20 to 3.16) or suppression of self-reported heroin use (SMD -0.73; 95% CI -1.08 to -0.37) (1 study, 134 participants).Few studies reported adverse events ; two studies compared adverse events statistically, finding no difference between methadone and buprenorphine, except for a single result indicating more sedation among those using methadone.

AUTHORS' CONCLUSIONS

Buprenorphine is an effective medication in the maintenance treatment of heroin dependence, retaining people in treatment at any dose above 2 mg, and suppressing illicit opioid use (at doses 16 mg or greater) based on placebo-controlled trials.However, compared to methadone, buprenorphine retains fewer people when doses are flexibly delivered and at low fixed doses. If fixed medium or high doses are used, buprenorphine and methadone appear no different in effectiveness (retention in treatment and suppression of illicit opioid use); however, fixed doses are rarely used in clinical practice so the flexible dose results are more relevant to patient care. Methadone is superior to buprenorphine in retaining people in treatment, and methadone equally suppresses illicit opioid use.

Pharmacokinetics of buprenorphine: a comparison of sublingual tablet versus liquid after chronic dosing

Although buprenorphine is approved for use in the outpatient treatment of opioid addiction in 2 tablet formulations, a monoproduct containing buprenorphine only (Subutex) and a buprenorphine/naloxone combination product (Suboxone), much of the clinical data that support the approval by the U.S. Food and Drug Administration were generated by using a sublingual liquid. To interpret the literature in prescribing parameters for tablet buprenorphine, this study was designed to determine steady state buprenorphine plasma levels for the 2 formulations and to assess the relative bioavailability of each. A randomized, double-blind, crossover study with dose increases was conducted during a 12-week period at an outpatient treatment clinic. Of the 184 subjects initially randomized to treatment, 133 (72.3%) were evaluated for the steady-state trough plasma concentration, 16 (8.7%) for relative bioavailability, and 31 (16.8%) for dose proportionality. At steady state, differences in the trough plasma concentrations of buprenorphine between the 2 formulations were found across all the dose levels. Average plasma concentration (Cavg) of the tablet at twice the milligram dose of the liquid was twice that of the liquid; intersubject variability was greater for the tablet. At double the dose of tablet, there is no difference in steady state plasma concentrations. The bioavailability seems equivalent for the 2 formulations across all the dose levels.

Health-related quality of life changes associated with buprenorphine treatment for opioid dependence

BACKGROUND

Few studies have described improvement in health-related quality of life (HRQOL) associated with opioid dependence treatment with buprenorphine (ODT-B).

OBJECTIVE

To evaluate HRQOL changes in domain scores, physical and mental component summaries, and health utilities (HUs) associated with ODT-B using the Short Form 36 (SF-36).

METHODS

We assessed HRQOL changes in a substudy of a pharmacokinetic study that compared buprenorphine oral tablet and liquid dosage formulations over 16 weeks. Individuals, aged 18-65 years, were screened for opioid dependence. They were excluded if they would not agree to birth control or had a serious medical condition. Subjects received psychosocial counseling and weekly group therapy. The SF-36 was administered upon enrollment and at 4-week intervals. We used the SF-6D to estimate HUs. We performed intention to treat (ITT) analyses based on the last observation available for each subject. Paired t tests of each domain and HU, limited to remaining patients at each 4-week interval, were also conducted.

RESULTS

Of 96 subjects enrolled, cumulative dropouts over time resulted in 80, 69, 59, and 44 subjects remaining at 4, 8, 12, and 16 weeks. There were no significant differences in opioid-positive urines, dropout rates, or dosage changes between formulations. In the ITT analyses, HRQOL improvements over time were bodily pain (62.1 vs. 69.1, P = 0.017), vitality (49.8 vs. 56.5, P = 0.001), mental health (59.9 vs. 66.0, P = 0.001), social function (66.4 vs. 74.7, P = 0.001), role emotional (59.4 vs. 71.9, P = 0.003), role physical (60.9 vs. 70.6, P = 0.005), and mental component summary (41.9 vs. 45.4, P<0.001). HU scores also improved (0.674 vs. 0.715, P = 0.001). Results from paired t tests, with only concurrently enrolled patients, showed similar improvements from baseline to 4, 8, 12, or 16 weeks.

CONCLUSION

Buprenorphine, accompanied with psychosocial counseling, was associated with improved HRQOL and HUs.

The application of the Drug User Quality of Life Scale (DUQOL) in Australia

Background

The concept of quality of life relates to the perceptions of individuals about their mental and physical health as well as non-health related areas. The evaluation of quality of life in the context of substance abuse has been conducted using generic instruments. The Drug Users Quality of Life Scale (DUQOL) is a specific assessment tool in which the most pertinent and salient areas to drug abusers are taken into consideration. In this study, the authors report the results of a validation study in which the DUQOL was used for the first time in Australia.

Methods

A sample of 120 participants from inpatient and outpatient treatment facilities completed a series of questionnaires, including the DUQOL and the World Health Organization Quality of Life Assessment-BREF (WHOQOL-BREF). Parameters investigated in this study included the demographic characteristics of the sample, internal structure, and convergent validity. Correlations between the DUQOL scale scores and the scores of the WHOQOL-Bref test were investigated via Pearson product-moment correlation analyses.

Results

The English version of the DUQOL attained a significant overall Cronbach's alpha of 0.868. The factorial analysis of the DUQOL identified one principal factor that accounted for 28.499% of the variance. Convergent validity analyses demonstrate significant correlations (p < 0.01) between the DUQOL scores and the scores of all four dimensions of the WHOQOL-BREF questionnaire.

Conclusions

This study demonstrates that the DUQOL constitutes a reliable research instrument for evaluating quality of life of substance users in Australia.

Validation of the English version of the Health-Related Quality of Life for Drug Abusers (HRQoLDA) test

BACKGROUND

The Health-Related Quality of Life for Drug Abusers (HRQoLDA) test was designed to specifically evaluate quality of life among substance users. In this study, the validity and reliability of the English version of the HRQoLDA test are reported for the first time.

METHODS

A sample of 121 participants from inpatient and outpatient treatment facilities completed the HRQoLDA test.

RESULTS

The mean HRQoLDA score was 45.9 (SD = 16.9), while the overall Cronbach's alpha coefficient was 0.905. The factorial analysis of the HRQoLDA test revealed a unidimensional structure. Convergent validity analyses demonstrated significant correlations between the HRQoLDA test scores and the scores of the World Health Organization Quality of Life Assessment-Bref Questionnaire in different dimensions.

CONCLUSION

The results revealed that the HRQoLDA was successfully adapted to English. The HRQoLDA is a reliable research instrument for evaluating quality of life of substance users.

Health related quality of life trajectories of patients in opioid substitution treatment

BACKGROUND

While opioid substitution treatment (OST) provides the opportunity for substantial improvements in health related quality of life (HRQoL), this relationship is seldom documented and poorly understood. Our objectives were to identify differences in trajectories of HRQoL among chronic opioid-dependent patients and factors associated with improvement and deterioration in HRQoL following enrolment in opioid substitution treatment.

METHODS

In the North American Opiate Medication Initiative (NAOMI) randomized controlled trial, the Euroqol (EQ-5D) and other measures of demographic, health and drug use characteristics were collected at baseline and quarterly follow-up. Latent class growth analysis was applied to identify classes of HRQoL trajectories during treatment, while baseline correlates of class membership and factors associated with changes in HRQoL were identified in multivariate analyses.

RESULTS

Three classes of individual HRQoL growth trajectories were identified: class 1: low and constant (19.5%), class 2: moderate and improved (61.2%), and class 3: high and constant (19.3%). Class 1 members were younger and more likely to be female, while class 3 members were less likely to have chronic conditions and had lower illicit drug use severity at baseline. Changes in HRQoL were associated with improvements in housing status (positive), medical events (negative) and decreases in illicit drug use (positive).

CONCLUSIONS

Insight into the extent of HRQoL response and characteristics of patients responding to treatment can be used to design interventions that maximize HRQoL improvement. Given its role in economic evaluation and subsequent resource allocation decisions, HRQoL should be considered an endpoint in treatment evaluations for opioid dependence.

Quality of life and its correlates among heroin users in Taiwan

The aims of this study were to compare the quality of life (QOL) between subjects with and without heroin use and to examine the association of QOL with sociodemographic characteristics, characteristics of heroin use, family support, and depression among heroin users at entry to a methadone maintenance treatment program. A group of 123 heroin users who visited an outpatient addiction treatment clinic in southern Taiwan for methadone maintenance treatment were recruited into this study. We also recruited 106 subjects who had never used heroin as the control group. Their QOL status was assessed by the short form of the Taiwan Version of the World Health Organization Questionnaire on Quality of Life (the WHOQOL-BREF Taiwan version). The level of QOL between subjects with and without heroin use was compared, and the correlates of QOL among heroin users were examined. Heroin users had poorer QOL than nonusers in the physical, psychological, and social relationship domains but not the environment domain of the WHOQOL-BREF after controlling for the influences of other factors. In addition, heroin users with obvious depression had poorer QOL in all four domains than those without obvious depression. Also, heroin users who perceived higher family support had better QOL in the social relationship and environment domains. Heroin users had poorer QOL than nonusers in multiple domains. Relief of depressive symptoms and enhancement of family support should be important strategies to improve QOL in heroin users.

Improved quality of life for opioid-dependent patients receiving buprenorphine treatment in HIV clinics

BACKGROUND

Opioid dependence and HIV infection are associated with poor health-related quality of life (HRQOL). Buprenorphine/naloxone (bup/nx) provided in HIV care settings may improve HRQOL.

METHODS

We surveyed 289 HIV-infected opioid-dependent persons treated with clinic-based bup/nx about HRQOL using the Short Form Health Survey (SF-12) administered at baseline, 3, 6, 9, and 12 months. We used normalized SF-12 scores, which correspond to a mean HRQOL of 50 for the general US population (SD 10, possible range 0-100). We compared mean normalized mental and physical composite and component scores in quarters 1, 2, 3, and 4 with baseline scores using generalized estimating equation models. We assessed the effect of clinic-based bup/nx prescription on HRQOL composite scores using mixed effects regression with site as random effect and time as repeated effect.

RESULTS

Baseline normalized SF-12 scores were lower than the general US population for all HRQOL domains. Average composite mental HRQOL improved from 38.3 (SE 12.5) to 43.4 (SE 13.2) [β 1.13 (95% CI: 0.72 to 1.54)] and composite physical HRQOL remained unchanged [β 0.21 (95% CI: -0.16 to 0.57)] over 12 months follow-up. Continued bup/nx treatment across all 4 quarters was associated with improvements in both physical [β 2.38 (95% CI: 0.63 to 4.12)] and mental [β 2.51 (95% CI: 0.42 to 4.60)] HRQOL after adjusting for other contributors to HRQOL.

CONCLUSIONS

Clinic-based bup/nx maintenance therapy is potentially effective in ameliorating some of the adverse effects of opioid dependence on HRQOL for HIV-infected populations.

Exploratory study on domain-specific determinants of opiate-dependent individuals' quality of life

BACKGROUND/AIMS

Studies on determinants of quality of life (QoL) among opiate-dependent individuals are scarce. Moreover, findings concerning the role of severity of drug use are inconsistent. This exploratory study investigates the association between domain-specific QoL and demographic, social, person, health and drug-related variables, and potential indirect effects of current heroin use on opiate-dependent individuals' QoL.

METHODS

A cohort of opiate-dependent individuals who started outpatient methadone treatment at least 5 years previously (n = 159) were interviewed about their current QoL, psychological distress, satisfaction with methadone treatment and the severity of drug-related problems using the Lancashire Quality of Life Profile, the Brief Symptom Inventory, the Verona Service Satisfaction Scale for Methadone Treatment and the EuropASI.

RESULTS

None of the QoL domains were defined by the same compilation of determinants. No direct effect of current heroin use on QoL was retained, but path analyses demonstrated its indirect effects on the domains of 'living situation', 'finances' and 'leisure and social participation'.

CONCLUSION

These findings illustrate the particularity of each QoL domain and the need for a multidimensional approach to the concept. The relationship between current heroin use and various domains of opiate-dependent individuals' QoL is complex, indirect and mediated by psychosocial and treatment-related variables.

Gender differences in health related quality of life of young heroin users

BACKGROUND

Health Related Quality of Life (HRQL) of opiate users has been studied in treatment settings, where assistance for drug use was sought. In this study we ascertain factors related to HRQL of young opiate users recruited outside treatment facilities, considering both genders separately.

METHODS

Current opiate users (18-30 y) were recruited in outdoor settings in three Spanish cities (Barcelona, Madrid, Seville). Standardised laptop interviews included socio-demographic data, drug use patterns, health related issues, the Severity of Dependence Scale (SDS) and the Nottingham Health Profile (NHP).

RESULTS

A total of 991 subjects (73% males), mean age = 25.7 years were interviewed. The mean global NHP score differed by gender (women: 41.2 (sd:23.8); men:34.1(sd:23.6);p < 0.05). Multivariate analysis was implemented separately by gender, variables independently related with global NHP score, both for males and females, were heroin and cocaine SDS scores. For women, only other drug related variables (alcohol intake and length of cocaine use) were independently associated with their HRQL. HIV+ males who suffered an opiate overdose or had psychiatric care in the last 12 months perceived their health as poorer, while those who had ever been in methadone treatment in the last 12 months perceived it as better. The model with both genders showed all factors for males plus quantity of alcohol and an interaction between gender and HIV status.

CONCLUSIONS

Heroin users were found to be at a considerable risk of impaired HRQL, even in these young ages. A score approaching severity of dependence was the factor with the strongest relation with it.

Buprenorphine in maintenance treatment: experience among Italian physicians in drug addiction centers

The aim of this study was to assess the attitudes of Italian physicians regarding buprenorphine and its clinical use approximately 6 years after the medication was introduced into clinical practice. The sample consisted of 305 randomly selected physicians, working in public centers of drug addiction. In Italy buprenorphine seems a valid tool in the field of drug addiction treatment, although it is far from replacing methadone even though it seems to guarantee better compliance. Interviewees follow clinical experience more than international guidelines, with pharmaceutical company representatives as the most cited source for information about the medication. The data also suggests a need for the development of formal guidelines for treatment with buprenorphine in Italy.

Current quality of life and its determinants among opiate-dependent individuals five years after starting methadone treatment

Purpose

This study explores the current QoL of opiate-dependent individuals who started outpatient methadone treatment at least 5 years ago and assesses the influence of demographic, psychosocial, drug and health-related variables on individuals’ QoL.

Methods

Participants (n = 159) were interviewed about their current QoL, psychological distress and severity of drug-related problems, using the Lancashire Quality of Life Profile, the Brief Symptom Inventory and the Addiction Severity Index. Potential determinants of QoL were assessed in a multiple linear regression analysis.

Results

Five years after the start of methadone treatment, opiate-dependent individuals report low QoL scores on various domains. No association was found between drug-related variables and QoL, but a significant negative impact of psychological distress was identified. Severity of psychological distress, taking medication for psychological problems and the inability to change one’s living situation were associated with lower QoL. Having at least one good friend and a structured daily activity had a significant, positive impact on QoL.

Conclusions

Opiate-dependent individuals’ QoL is mainly determined by their psychological well-being and a number of psychosocial variables. These findings highlight the importance of a holistic approach to treatment and support in methadone maintenance treatment, which goes beyond fixing the negative physical consequences of opiate dependence.

Improved quality of life, clinical, and psychosocial outcomes among heroin-dependent patients on ambulatory buprenorphine maintenance

AIM

A prospective longitudinal design was employed to examine the effects of buprenorphine maintenance on quality of life (QOL), clinical, and psychosocial characteristics of heroin-dependent patients.

METHOD

Between 2003 and 2005 data were collected on 259 patients attending the outpatient centers for treatment of drug addictions across Israel, of which 157 were reevaluated 16 weeks later and 105 reevaluated 32 weeks later using the Clinical Global Impression, Distress Scale for Adverse Symptoms, Quality of Life Enjoyment and Satisfaction Questionnaire, General Health Questionnaire, General Self-Efficacy Scale, and the Multidimensional Scale of Perceived Social Support. Univariate and multivariate analyses were conducted to examine the association between the parameters and the cross-sectional and longitudinal predictions of the QOL outcomes.

RESULTS

The groups did not differ in baseline values and their post-treatment ratings revealed significant improvement on virtually all the scales. Perceived self-efficacy and social support from friends and significant others at baseline as well as their changes over time were the best predictors of the QOL in the short and long terms. The study's limitations are noted.

CONCLUSIONS

The beneficial effects on the QOL were associated with improvement in the psychosocial parameters and a reduction in buprenorphine-related side effects and psychological distress. This study could stimulate research to compare the QOL related to buprenorphine and methadone treatment and serve as a basis on which a controlled study should be performed.

Quality of life and substance use: concepts and recent tendencies

PURPOSE OF REVIEW

Quality of life (QoL) has become an important clinical and research outcome in clinical drug and alcohol studies. Yet, further advancement in this field is hindered by the lack of a consensual definition of QoL in that often investigators use the constructs of health status and QoL interchangeably. This article reviews the conceptual definitions of QoL as a researchable construct. It also presents the most commonly used questionnaires to evaluate QoL in the context of substance use.

RECENT FINDINGS

In the area of substance use research, the evaluation of QoL has been conducted mainly via generic instruments. Most of the studies reporting results of QoL measurements have obtained their data from opiate users receiving different treatment modalities at various healthcare agencies. Recent studies have used the Injection Drug User QoL Scale as a specific assessment tool. Specific QoL instruments have also been developed in the area of alcohol and nicotine dependence.

SUMMARY

QoL is an important clinical and research outcome in the context of substance use. However, the indiscriminate use of nonspecific measurement tools may produce questionable results. A new generation of specific tools takes into particular consideration the life areas that have a greater influence on the QoL of substance users. It is hoped that the new impetus toward a specific QoL assessment in the context of substance use will promote further scientific advancement in this area.

Retention rate and substance use in methadone and buprenorphine maintenance therapy and predictors of outcome: results from a randomized study

This was a 6-month, randomized, flexible-dose study comparing the effects of methadone (Meth) and buprenorphine (Bup) on retention rate and substance use in a sample of 140 opioid-dependent, primarily heroin-addicted, patients who had been without opioid substitution therapy in the 4 weeks prior to the study. The major aims were to compare the efficacy of Bup and Meth in a flexible dosing regimen and to identify possible predictors of outcome. There were no major inhomogeneities between treatment groups. All patients also received standardized psychosocial interventions. Mean daily dosages after the induction phase were 44-50 mg for Meth and 9-12 mg for Bup. Results from this study indicate a favourable outcome, with an overall retention rate of 52.1% and no significant differences between treatment groups (55.3% vs. 48.4%). Substance use decreased significantly over time in both groups and was non-significantly lower in the Bup group. Predictors of outcome were length of continuous opioid use and age at onset of opioid use, although these were only significant in the Bup group. Mean dosage and other parameters were not significant predictors of outcome. Overall, the results of this study give further evidence that substitution treatment is a safe and effective treatment for drug dependence. Meth and Bup are equally effective. Duration of continuous opioid use and age at onset were found to have predictive value for negative outcome. The intensity of withdrawal symptoms showed the strongest correlation with drop-out. Future studies are warranted to further address patient profiles and outcome under different substitution regimens.

Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence

BACKGROUND

Buprenorphine has been reported as an alternative to methadone for maintenance treatment of opioid dependence, but differing results are reported concerning its relative effectiveness indicating the need for an integrative review.

OBJECTIVES

To evaluate the effects of buprenorphine maintenance against placebo and methadone maintenance in retaining patients in treatment and in suppressing illicit drug use.

SEARCH STRATEGY

We searched the following databases up to October 2006: Cochrane Drugs and Alcohol Review Group Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, Current Contents, Psychlit, CORK , Alcohol and Drug Council of Australia, Australian Drug Foundation, Centre for Education and Information on Drugs and Alcohol, Library of Congress databases, reference lists of identified studies and reviews, authors were asked about any other published or unpublished relevant RCT.

SELECTION CRITERIA

Randomised clinical trials of buprenorphine maintenance versus placebo or methadone maintenance.

DATA COLLECTION AND ANALYSIS

Authors separately and independently evaluated the papers and extracted data for meta-analysis.

MAIN RESULTS

Twenty four studies met the inclusion criteria (4497 participants), all were randomised clinical trials, all but six were double-blind. The method of allocation concealment was not clearly described in the majority (20) of the studies, but where it was reported the methodological quality was good. Buprenorphine was statistically significantly superior to placebo medication in retention of patients in treatment at low doses (RR=1.50; 95% CI: 1.19 - 1.88), medium (RR=1.74; 95% CI: 1.06 - 2.87), and high doses (RR=1.74; 95% CI: 1.02 - 2.96). The high statistical heterogeneity prevented the calculation of a cumulative estimate. However, only medium and high dose buprenorphine suppressed heroin use significantly above placebo. Buprenorphine given in flexible doses was statistically significantly less effective than methadone in retaining patients in treatment (RR= 0.80; 95% CI: 0.68 - 0.95), but no different in suppression of opioid use for those who remained in treatment. Low dose methadone is more likely to retain patients than low dose buprenorphine (RR= 0.67; 95% CI: 0.52 - 0.87). Medium dose buprenorphine does not retain more patients than low dose methadone, but may suppress heroin use better. There was no advantage for medium dose buprenorphine over medium dose methadone in retention (RR=0.79; 95% CI:0.64 - 0.99) and medium dose buprenorphine was inferior in suppression of heroin use.

AUTHORS' CONCLUSIONS

Buprenorphine is an effective intervention for use in the maintenance treatment of heroin dependence, but it is less effective than methadone delivered at adequate dosages.