Cognitive-behavioral therapy and buprenorphine for opioid use disorder: A systematic review and meta-analysis of randomized controlled trials

Commentary on Cochran et al.: Meeting people where they are in addictions research

In addiction treatment, it’s important to ‘meet people where they are’. However, in research, we commonly ask participants to meet us where we are in the interventions we develop. Cochran et al. report on a patient navigation intervention for pregnant and postpartum people with opioid use disorder. Their study illustrates a delicate balance reached between the research need to maximize scientific rigor and the clinical need to ‘meet people where they are’.

"I Just Don't Feel Heard": A Case Study on Opioid Use Disorder and Pain Management

The nation's opioid epidemic requires a paradigm shift in the way patients with co-occurring opioid use disorder are treated during episodes of acute pain. Patients are often introduced to prescription opioids after an extremity fracture or sprain or resulting from musculoskeletal back, abdominal, or dental pain. Opioid naive patients who receive their first opioid prescription on discharge from the emergency department may be more likely to develop chronic opioid use compared to patients receiving non-opioid pain medications. This case report will highlight one patient's journey including initial prescription opioid use, escalation into illicit opioids, entry to a recovery and treatment program, discussions with her physician about alternative therapies, and barriers to satisfactory pain relief. A shared decision-making model will be explored.

Caring for Our Patients With Opioid Use Disorder in the Perioperative Period: A Guide for the Anesthesiologist

Opioid use disorder (OUD) is a rising public health crisis, impacting millions of individuals and families worldwide. Anesthesiologists can play a key role in improving morbidity and mortality around the time of surgery by informing perioperative teams and guiding evidence-based care and access to life-saving treatment for patients with active OUD or in recovery. This article serves as an educational resource for the anesthesiologist caring for patients with OUD and is the second in a series of articles published in Anesthesia & Analgesia on the anesthetic and analgesic management of patients with substance use disorders. The article is divided into 4 sections: (1) background to OUD, treatment principles, and the anesthesiologist; (2) perioperative considerations for patients prescribed medications for OUD (MOUD); (3) perioperative considerations for patients with active, untreated OUD; and (4) nonopioid and nonpharmacologic principles of multimodal perioperative pain management for patients with untreated, active OUD, or in recovery. The article concludes with a stepwise approach for the anesthesiologist to support OUD treatment and recovery. The anesthesiologist is an important leader of the perioperative team to promote these suggested best practices and help save lives.

Management of opioid use disorder, opioid withdrawal, and opioid overdose prevention in hospitalized adults: A systematic review of existing guidelines

BACKGROUND

Hospitalizations related to the consequences of opioid use are rising. National guidelines directing in-hospital opioid use disorder (OUD) management do not exist. OUD treatment guidelines intended for other treatment settings could inform in-hospital OUD management.

OBJECTIVE

Evaluate the quality and content of existing guidelines for OUD treatment and management.

DATA SOURCES

OVID MEDLINE, PubMed, Ovid PsychINFO, EBSCOhost CINHAL, ERCI Guidelines Trust, websites of relevant societies and advocacy organizations, and selected international search engines.

STUDY SELECTION

Guidelines published between January 2010 to June 2020 addressing OUD treatment, opioid withdrawal management, opioid overdose prevention, and care transitions among adults.

DATA EXTRACTION

We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.

DATA SYNTHESIS

Nineteen guidelines met the selection criteria. Most recommendations were based on observational studies or expert consensus. Guidelines recommended the use of nonstigmatizing language among patients with OUD; to assess patients with unhealthy opioid use for OUD using the Diagnostic Statistical Manual of Diseases-5th Edition criteria; use of methadone or buprenorphine to treat OUD and opioid withdrawal; use of multimodal, nonopioid therapy, and when needed, short-acting opioid analgesics in addition to buprenorphine or methadone, for acute pain management; ensuring linkage to ongoing methadone or buprenorphine treatment; referring patients to psychosocial treatment; and ensuring access to naloxone for opioid overdose reversal.

CONCLUSIONS

Included guidelines were informed by studies with various levels of rigor and quality. Future research should systematically study buprenorphine and methadone initiation and titration among people using fentanyl and people with pain, especially during hospitalization.

A Personalized, Interactive, Cognitive Behavioral Therapy-Based Digital Therapeutic (MODIA) for Adjunctive Treatment of Opioid Use Disorder: Development Study

BACKGROUND

Opioid use disorder (OUD) is characterized by the inability to control opioid use despite attempts to stop use and negative consequences to oneself and others. The burden of opioid misuse and OUD is a national crisis in the United States with substantial public health, social, and economic implications. Although medication-assisted treatment (MAT) has demonstrated efficacy in the management of OUD, access to effective counseling and psychosocial support is a limiting factor and a significant problem for many patients and physicians. Digital therapeutics are an innovative class of interventions that help prevent, manage, or treat diseases by delivering therapy using software programs. These applications can circumvent barriers to uptake, improve treatment adherence, and enable broad delivery of evidence-based management strategies to meet service gaps. However, few digital therapeutics specifically targeting OUD are available, and additional options are needed.

OBJECTIVE

To this end, we describe the development of the novel digital therapeutic MODIA.

METHODS

MODIA was developed by an international, multidisciplinary team that aims to provide effective, accessible, and sustainable management for patients with OUD. Although MODIA is aligned with principles of cognitive behavioral therapy, it was not designed to present any 1 specific treatment and uses a broad range of evidence-based behavior change techniques drawn from cognitive behavioral therapy, mindfulness, acceptance and commitment therapy, and motivational interviewing.

RESULTS

MODIA uses proprietary software that dynamically tailors content to the users' responses. The MODIA program comprises 24 modules or "chats" that patients are instructed to work through independently. Patient responses dictate subsequent content, creating a "simulated dialogue" experience between the patient and program. MODIA also includes brief motivational text messages that are sent regularly to prompt patients to use the program and help them transfer therapeutic techniques into their daily routines. Thus, MODIA offers individuals with OUD a custom-tailored, interactive digital psychotherapy intervention that maximizes the personal relevance and emotional impact of the interaction.

CONCLUSIONS

As part of a clinician-supervised MAT program, MODIA will allow more patients to begin psychotherapy concurrently with opioid maintenance treatment. We expect access to MODIA will improve the OUD management experience and provide sustainable positive outcomes for patients.

Comparative benefits of social housing and buprenorphine on wheel running depressed by morphine withdrawal in rats

RATIONALE

Social support and opioid replacement therapy are commonly used to treat opioid withdrawal.

OBJECTIVE

The present study tested the hypothesis that social housing and buprenorphine administration can restore wheel running depressed by morphine withdrawal in rats.

RESULTS

Experiment 1 assessed disruptive side effects of buprenorphine and found that administration of low doses (3.2, 10, & 32 µg/kg, s.c.) had no impact on voluntary wheel running. Experiment 2 assessed the impact of social housing and acute buprenorphine administration (10 µg/kg) on morphine withdrawal. Two 75 mg morphine pellets were implanted for 3 days to induce dependence. Removal of the morphine pellets caused a decrease in body weight, increase in wet dog shakes, and depression of wheel running during the normally active dark phase of the circadian cycle. Social housing restored wheel running and reduced the number of wet dog shakes but did not affect body weight. Administration of buprenorphine restored wheel running depressed by morphine withdrawal for 2 days in individually housed rats and produced time-dependent changes in socially housed rats: Depression of wheel running in the 3 h following administration and restoration of running subsequently compared to saline-treated controls.

CONCLUSIONS

The impact of buprenorphine and social housing to reduce the effect of morphine withdrawal in rats is consistent with the use of opioid substitution therapy and psychotherapy/social support to treat opioid withdrawal in humans. These data provide further validation for the clinical relevance for the use of wheel running to assess spontaneous opioid withdrawal.

Collaborative care in the treatment of opioid use disorder and mental health conditions in primary care: A clinical study protocol

BACKGROUND

People with opioid use disorder (OUD) often have a co-occurring psychiatric disorder, which elevates the risk of morbidity and mortality. Promising evidence supports the use of collaborative care for treating people with OUD in primary care. Whether collaborative care interventions that treat both OUD and psychiatric disorders will result in better outcomes is presently unknown.

METHODS

The Whole Health Study is a 3-arm randomized controlled trial designed to test collaborative care treatment for OUD and the psychiatric disorders that commonly accompany OUD. Approximately 1200 primary care patients aged ≥18 years with OUD and depression, anxiety, or PTSD will be randomized to one of three conditions: (1) Augmented Usual Care, which consists of a primary care physician (PCP) waivered to prescribe buprenorphine and an addiction psychiatrist to consult on medication-assisted treatment; (2) Collaborative Care, which consists of a waivered PCP, a mental health care manager trained in psychosocial treatments for OUD and psychiatric disorders, and an addiction psychiatrist who provides consultation for OUD and mental health; or (3) Collaborative Care Plus, which consists of all the elements of the Collaborative Care arm plus a Certified Recovery Specialist to help with treatment engagement and retention. Primary outcomes are six-month rates of opioid use and six-month rates of remission of co-occurring psychiatric disorders.

DISCUSSION

The Whole Health Study will investigate whether collaborative care models that address OUD and co-occurring depression, anxiety, or PTSD will result in better patient outcomes. The results will inform clinical care delivery during the current opioid crisis.

CLINICAL TRIALS REGISTRATION

www.clinicaltrials.gov registration: NCT04245423.

Opioid Use Disorder: Treatments and Barriers

Over the last decade, opioid use around the world has risen considerably and is projected to continue to rise at an alarming rate. As opioid use rises, so too does the number of people who suffer from opioid use disorder (OUD) and opioid overdose-related deaths. As science and medicine progresses, new medications and therapies have arisen in order to help treat patients suffering from addiction. Treatment can be split into two main domains: pharmacological and non-pharmacological. Buprenorphine and methadone, currently the most prescribed medications for patients suffering from OUD, have been shown to be extremely effective in clinical trials but have significant real-world limitations. Geographical disparities between various locations, physician stigma with prescribing these medications, and training required to prescribe medication can make access to these treatments difficult for patients. Non-pharmacological interventions have also been shown to help with limited efficacy when combined with pharmacological interventions. However, the time and resources required to implement these strategies may be a difficult barrier to overcome. In this review, we assess pharmacological interventions, non-pharmacological treatments, examine barriers to treatment for patients, and propose solutions to bypass these barriers.