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Ivasiy R, Madden LM, Meteliuk A, Machavariani E, Ahmad B, Zelenev A, Desai MM, Bromberg DJ, Polonsky M, Galvez de Leon SJ, Farnum SO, Islam Z, Altice FL. The impact of emergency guidance to the COVID-19 pandemic on treatment entry, retention and mortality among patients on methadone in Ukraine. Addiction 2024; 119:1585-1596. [PMID: 38807448 DOI: 10.1111/add.16565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/24/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND AND AIMS Ukraine's Ministry of Health released urgent COVID-19 guidelines, allowing for early implementation of take-home dosing (THD) for opioid agonist therapies (OAT) such as methadone. Enrollment in OAT and retention in the program are the most effective HIV prevention strategies for people who inject drugs (PWID). This study aimed to evaluate the impact of Ukraine's COVID-19 emergency guidance on OAT treatment enrollment, retention on treatment and mortality. DESIGN AND SETTING Using Ukraine's national OAT registry for 252 governmental clinics across 25 regions, we conducted a 12-month comparative prospective cohort survival analysis. This study compared newly enrolled methadone patients within the initial 6 months following the COVID-19 guidance (COVID) with patients from the preceding year (pre-COVID) in a country with high adult HIV prevalence (1.2%) that is concentrated in PWID. PARTICIPANTS In the nation-wide sample of newly enrolled PWID in Ukraine, comprising 2798 individuals, 1423 were in the COVID cohort and 1375 were in the pre-COVID cohort. The majority were male (86.7%), with an average age of 39.3 years. MEASUREMENTS Primary outcomes were average monthly enrollment per cohort, treatment retention and mortality, with internal time-dependent predictors, including THD and optimal (> 85 mg) methadone dosing. RESULTS Relative to the pre-COVID period, the monthly average patient enrollment was statistically significantly higher during the COVID period (283.7 versus 236.0; P < 0.0001), where patients were more likely to transition to THD and achieve optimal dosing earlier. Significant differences were observed in the proportions of person-months on THD (41 versus 13%, P < 0.0001) and optimal dosing (38 versus 31%, P < 0.0001) between the COVID and pre-COVID cohorts. Predictors of treatment retention, expressed as adjusted hazard ratios (aHR), included early THD [aHR = 1.90, 95% confidence interval (CI) = 1.47-2.45], early optimal dosing (aHR = 1.71, 95% CI = 1.37-2.13) and prior methadone treatment (aHR = 1.39, 95% CI = 1.15-1.68). These factors persisted, respectively, in the pre-COVID (aHR = 2.28, 95% CI = 1.41-3.70; aHR = 1.84, 95% CI = 1.32-2.56; and aHR = 1.36, 95% CI = 1.06-1.74) and COVID (aHR = 1.91, 95% CI = 1.40-2.59; aHR = 1.61, 95% CI = 1.20-2.16; and aHR = 1.49, 95% CI = 1.08-1.94) cohorts. Survival did not differ significantly between the two prospective cohorts. CONCLUSION Ukraine's prompt adoption of early take-home dosing for opioid agonist therapies, such as methadone, following the emergency COVID-19 guidance appears to have increased enrollment into methadone and improved treatment retention for people who inject drugs without adverse effects on patient survival.
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Affiliation(s)
- Roman Ivasiy
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Lynn M Madden
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
- APT Foundation, New Haven, CT, USA
| | | | - Eteri Machavariani
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | | | - Alexei Zelenev
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Mayur M Desai
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Daniel J Bromberg
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
| | - Maxim Polonsky
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Frederick L Altice
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
- APT Foundation, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
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Freet CS, Evans B, Brick TR, Deneke E, Wasserman EJ, Ballard SM, Stankoski DM, Kong L, Raja-Khan N, Nyland JE, Arnold AC, Krishnamurthy VB, Fernandez-Mendoza J, Cleveland HH, Scioli AD, Molchanow A, Messner AE, Ayaz H, Grigson PS, Bunce SC. Ecological momentary assessment and cue-elicited drug craving as primary endpoints: study protocol for a randomized, double-blind, placebo-controlled clinical trial testing the efficacy of a GLP-1 receptor agonist in opioid use disorder. Addict Sci Clin Pract 2024; 19:56. [PMID: 39061093 PMCID: PMC11282646 DOI: 10.1186/s13722-024-00481-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 06/07/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Despite continuing advancements in treatments for opioid use disorder (OUD), continued high rates of relapse indicate the need for more effective approaches, including novel pharmacological interventions. Glucagon-like peptide 1 receptor agonists (GLP-1RA) provide a promising avenue as a non-opioid medication for the treatment of OUD. Whereas GLP-1RAs have shown promise as a treatment for alcohol and nicotine use disorders, to date, no controlled clinical trials have been conducted to determine if a GLP-1RA can reduce craving in individuals with OUD. The purpose of the current protocol was to evaluate the potential for a GLP-1RA, liraglutide, to safely and effectively reduce craving in an OUD population in residential treatment. METHOD This preliminary study was a randomized, double-blinded, placebo-controlled clinical trial designed to test the safety and efficacy of the GLP-1RA, liraglutide, in 40 participants in residential treatment for OUD. Along with taking a range of safety measures, efficacy for cue-induced craving was evaluated prior to (Day 1) and following (Day 19) treatment using a Visual Analogue Scale (VAS) in response to a cue reactivity task during functional near-infrared spectroscopy (fNIRS) and for craving. Efficacy of treatment for ambient craving was assessed using Ecological Momentary Assessment (EMA) prior to (Study Day 1), across (Study Days 2-19), and following (Study Days 20-21) residential treatment. DISCUSSION This manuscript describes a protocol to collect clinical data on the safety and efficacy of a GLP-1RA, liraglutide, during residential treatment of persons with OUD, laying the groundwork for further evaluation in a larger, outpatient OUD population. Improved understanding of innovative, non-opioid based treatments for OUD will have the potential to inform community-based interventions and health policy, assist physicians and health care professionals in the treatment of persons with OUD, and to support individuals with OUD in their effort to live a healthy life. TRIAL REGISTRATION ClinicalTrials.gov: NCT04199728. Registered 16 December 2019, https://clinicaltrials.gov/study/NCT04199728?term=NCT04199728 . PROTOCOL VERSION 10 May 2023.
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Affiliation(s)
- Christopher S Freet
- Department of Psychiatry and Behavioral Health, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Brianna Evans
- Department of Neural and Behavioral Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Timothy R Brick
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
- Institute for Computational and Data Sciences, The Pennsylvania State University, University Park, PA, USA
| | - Erin Deneke
- Fran and Doug Tieman Center for Research, Caron Treatment Centers, Wernersville, PA, USA
| | - Emily J Wasserman
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Sarah M Ballard
- Department of Neural and Behavioral Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Dean M Stankoski
- Fran and Doug Tieman Center for Research, Caron Treatment Centers, Wernersville, PA, USA
| | - Lan Kong
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Nazia Raja-Khan
- Department of Psychiatry and Behavioral Health, The Pennsylvania State University College of Medicine, Hershey, PA, USA
- Department of Medicine, The Pennsylvania State University College of Medicine, Hershey, PA, USA
- Department of Obstetrics & Gynecology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Jennifer E Nyland
- Department of Neural and Behavioral Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Amy C Arnold
- Department of Neural and Behavioral Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Venkatesh Basappa Krishnamurthy
- Department of Medicine and Psychiatry, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Julio Fernandez-Mendoza
- Department of Psychiatry and Behavioral Health, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - H Harrington Cleveland
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
| | - Adam D Scioli
- Fran and Doug Tieman Center for Research, Caron Treatment Centers, Wernersville, PA, USA
| | | | | | - Hasan Ayaz
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, USA
| | - Patricia S Grigson
- Department of Neural and Behavioral Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Scott C Bunce
- Department of Psychiatry and Behavioral Health, The Pennsylvania State University College of Medicine, Hershey, PA, USA.
- Penn State University College of Medicine, Milton S. Hershey Medical Center, H073, 500 University Drive, Hershey, PA, 17033-0850, USA.
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Pedersen CN, Yang F, Ita S, Xu Y, Akunuri R, Trampari S, Neumann CMT, Desdorf LM, Schiøtt B, Salvino JM, Mortensen OV, Nissen P, Shahsavar A. Cryo-EM structure of the dopamine transporter with a novel atypical non-competitive inhibitor bound to the orthosteric site. J Neurochem 2024. [PMID: 39010681 DOI: 10.1111/jnc.16179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/28/2024] [Accepted: 07/01/2024] [Indexed: 07/17/2024]
Abstract
The regulation of dopamine (DA) removal from the synaptic cleft is a crucial process in neurotransmission and is facilitated by the sodium- and chloride-coupled dopamine transporter DAT. Psychostimulant drugs, cocaine, and amphetamine, both block the uptake of DA, while amphetamine also triggers the release of DA. As a result, they prolong or even amplify neurotransmitter signaling. Atypical inhibitors of DAT lack cocaine-like rewarding effects and offer a promising strategy for the treatment of drug use disorders. Here, we present the 3.2 Å resolution cryo-electron microscopy structure of the Drosophila melanogaster dopamine transporter (dDAT) in complex with the atypical non-competitive inhibitor AC-4-248. The inhibitor partially binds at the central binding site, extending into the extracellular vestibule, and locks the transporter in an outward open conformation. Our findings propose mechanisms for the non-competitive inhibition of DAT and attenuation of cocaine potency by AC-4-248 and provide a basis for the rational design of more efficacious atypical inhibitors.
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Affiliation(s)
- Clara Nautrup Pedersen
- DANDRITE, Nordic EMBL Partnership for Molecular Medicine, Department of Molecular Biology and Genetics, Aarhus University, Aarhus, Denmark
| | - Fuyu Yang
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Samantha Ita
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Yibin Xu
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Sofia Trampari
- DANDRITE, Nordic EMBL Partnership for Molecular Medicine, Department of Molecular Biology and Genetics, Aarhus University, Aarhus, Denmark
| | - Caroline Marie Teresa Neumann
- DANDRITE, Nordic EMBL Partnership for Molecular Medicine, Department of Molecular Biology and Genetics, Aarhus University, Aarhus, Denmark
| | | | - Birgit Schiøtt
- Department of Chemistry, Aarhus University, Aarhus, Denmark
| | | | - Ole Valente Mortensen
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Poul Nissen
- DANDRITE, Nordic EMBL Partnership for Molecular Medicine, Department of Molecular Biology and Genetics, Aarhus University, Aarhus, Denmark
| | - Azadeh Shahsavar
- DANDRITE, Nordic EMBL Partnership for Molecular Medicine, Department of Molecular Biology and Genetics, Aarhus University, Aarhus, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
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Choi SA, Yan CH, Gastala NM, Touchette DR, Stranges PM. Cost-effectiveness of full and partial opioid agonists for opioid use disorder in outpatient settings: United States healthcare sector perspective. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 160:209237. [PMID: 38061629 DOI: 10.1016/j.josat.2023.209237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/30/2023] [Accepted: 11/30/2023] [Indexed: 01/07/2024]
Abstract
INTRODUCTION Studies show that medications for opioid use disorder (MOUD) reduce illicit opioid use, emergency healthcare services, opioid-related overdose, and death. However, few studies have investigated the long-term cost-effectiveness of MOUD in office-based opioid treatment (OBOT) and opioid treatment program (OTP) settings. We aimed to estimate the cost, utility, quality-adjusted life years gained (QALYs), and incremental cost-effectiveness ratios (ICERs) of three MOUD compared to each other and counseling without medication from a US healthcare sector perspective. METHODS Our study developed a Markov model to conduct a cost-effectiveness analysis of counseling and three MOUD in the OBOT and OTP settings: sublingual buprenorphine/naloxone (BUPNX), buprenorphine extended-release (XR-BUP) injection, and oral methadone. The model included five health states representing combinations of receiving or off treatment while either using or not actively using illicit opioids, and death. The cycle length was one month; the time-horizon was ten years. The study obtained model inputs from systematic reviews of published literature and public data. A 3 % annual discount rate was applied to cost and utility calculation. The primary outcomes included total costs, life-years (LYs), QALYs, and ICERs. We also conducted a scenario analysis using a hypothetical OBOT outpatient setting with methadone. RESULTS In the base-case OBOT setting, the total costs and QALYs, respectively, were counseling $22,848, 5.60; BUPNX $29,875, 5.82; and XR-BUP $63,936, 5.87. ICERs were $32,345/QALY (BUPNX vs. counseling) and $625,858/QALY (XR-BUP vs BUPNX). In the OTP setting, the total costs of counseling, methadone, BUPNX, and XR-BUP were $20,124, $27,000, $33,500, and $75,272, respectively. QALYs of methadone were 5.86. QALYs of counseling, BUPNX, and XR-BUP remained the same as in the OBOT setting. Incremental ICERs were $26,714/QALY (methadone vs counseling) and $3,337,623/QALY (XR-BUP vs methadone). BUPNX was dominated by methadone. In the scenario analysis, BUPNX was also dominated by methadone. CONCLUSIONS Outpatient MOUD resulted in important gains in quality of life and life expectancy. In both OBOT and OTP settings, XR-BUP was not cost-effective. BUPNX was cost-effective in the OBOT setting, while it was dominated by methadone in the OTP setting. The cost-effectiveness of BUPNX and XR-BUP could be enhanced if the costs of these medications were reduced.
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Affiliation(s)
- Sun A Choi
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood Street MC 871, Chicago, IL 60612, USA.
| | - Connie H Yan
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood Street MC 871, Chicago, IL 60612, USA.
| | - Nicole M Gastala
- Department of Family Medicine, Mile Square Health Centers, University of Illinois Hospital and Health Science Systems, 1220 S. Wood St., 60608 Chicago, IL, USA.
| | - Daniel R Touchette
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood Street MC 871, Chicago, IL 60612, USA.
| | - Paul M Stranges
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, 833 South Wood Street Rm C-300, Chicago, IL 60612, USA.
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Trammel CJ, Whitley J, Kelly JC. Pharmacotherapy for opioid use disorder in pregnancy. Curr Opin Obstet Gynecol 2024; 36:74-80. [PMID: 38193300 DOI: 10.1097/gco.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW Opioid use disorder (OUD) in pregnancy has significantly increased in the last decade, impacting 8.2 per 1000 deliveries. OUD carries significant risk of morbidity and mortality for both the birthing person and neonate, but outcomes for both are improved with opioid agonist treatment (OAT). Here, we describe the recommended forms of OAT in pregnancy, updates to the literature, and alternate OAT strategies, and share practical peripartum considerations for patients on OAT. RECENT FINDINGS Recent studies comparing buprenorphine and methadone have reaffirmed previous findings that buprenorphine is associated with superior outcomes for the neonate, without clear differences in morbidity or mortality for the birthing person. Optimal initiation and dosing of OAT remains unclear, with several recent studies evaluating methods of initiation, as well as a potential role for higher and more rapid dosing in the fentanyl era. Alternative products such as buprenorphine-naloxone and extended-release buprenorphine are of significant research interest, though randomized prospective data are not yet available. SUMMARY Buprenorphine and methadone are standard of care for treatment of OUD during pregnancy, and multiple patient factors impact the optimal choice. Insufficient data exist to recommend alternative agents as a primary strategy currently. All patients with OUD in pregnancy should be counseled regarding OAT. VIDEO http://links.lww.com/COOG/A94.
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Affiliation(s)
- Cassandra J Trammel
- Washington University in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, St. Louis, Missouri, USA
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MacLean RR, Spinola S, Pittman B, Meyerovich J, Szollosy SK, Wolkowicz NR, Minnix S, Sofuoglu M. The relationship of pain intensity and opioid craving with delayed methadone dose: A preliminary study of individuals with opioid use disorder. Br J Clin Pharmacol 2024. [PMID: 38439592 DOI: 10.1111/bcp.16027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/26/2023] [Accepted: 01/06/2024] [Indexed: 03/06/2024] Open
Abstract
AIMS Despite a strong theoretical link between opioid craving and pain, little is known about the temporal relationship between pain and craving and the acute experience of pain in the context of methadone treatment. Using a cross-over design, the current study evaluated the time course of pain and craving and objective experience of pain as a function of the last methadone dose. METHODS Participants (n = 20) presented for the study in the morning and either received methadone dose as scheduled or delayed dose until the afternoon. During the 4-h study visit, participants completed a series of tasks, including repeated assessment of pain and craving at 0, +40, +70, +130, +160 and +240 min and a cold pressor test (CPT) at +15 and +220 min. RESULTS Separate mixed model results demonstrated no effect of dosing condition on craving; however, there was a significant dosing condition by time interaction (F(5,209) = 3.38, P = .006) such that pain increased over time in the delayed methadone condition but decreased in time in the scheduled methadone condition. A mixed model predicting self-reported pain revealed a three-way interaction between dosing condition, craving and time (F(5,197) = 2.39, P = .039) explained by a positive association between craving and pain at each time point (except 240 min) in delayed condition (P-range = .004-.0001). A separate mixed model on CPT data indicated a significant condition by time interaction such that pain threshold decreased in the delayed, but not scheduled, condition (F(1,57) = 4.01, P = .050). CONCLUSIONS These preliminary findings highlight the potential for increased risks after even a short delay in receiving a methadone dose.
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Affiliation(s)
- R Ross MacLean
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Suzanne Spinola
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Brian Pittman
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Sara K Szollosy
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Noah R Wolkowicz
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Stacy Minnix
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mehmet Sofuoglu
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
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Langmann GA, Childers J, Merlin JS. Caring for Patients With Opioid Misuse or Substance Use Disorders in Hospice: A National Survey. J Palliat Med 2024; 27:209-215. [PMID: 37824806 PMCID: PMC11074426 DOI: 10.1089/jpm.2023.0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 10/14/2023] Open
Abstract
Background: Opioid misuse and substance use disorders (SUDs) including opioid use disorder (OUD) are common and negatively impact quality of life. Hospice clinicians' experiences with these conditions have not been well described. Objectives: We sought to explore hospice clinicians' knowledge, practices, and comfort caring for patients with opioid misuse (e.g., a pattern of unsanctioned opioid use escalation, or concurrent illicit substance use) and SUDs. Design: We recruited hospice clinicians in the United States via national hospice and palliative care organizations to complete an online survey designed by the study authors and pilot tested with an interdisciplinary group of current/former hospice clinicians. Results: One hundred seventy-five clinicians (40% nurses, 40% physicians, 16% nurse practitioners) responded to the survey; most had cared for two or more hospice patients with opioid misuse or SUD in the past month. The majority felt confident identifying opioid misuse (94%) and taking SUD histories (79%). Most (62%) felt it is their role to treat hospice patients for SUD, though 56% lacked comfort in using buprenorphine for OUD treatment. While the majority felt it is their role to treat pain in hospice patients with SUDs (94%) and that hospice can help patients with SUDs (94%), many were not comfortable managing pain in patients taking buprenorphine (45%) or naltrexone (49%) for SUDs. Most felt comfortable managing pain in patients taking methadone for SUD (73%). Conclusions: Opioid misuse and SUD are common in hospice. Though clinicians are comfortable taking relevant histories, they feel less comfortable managing patients' opioid misuse or SUD, or these patients' pain.
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Affiliation(s)
- Gabrielle A. Langmann
- Supportive and Palliative Care Program, Division of General Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jessica S. Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Guerra-Alejos BC, Kurz M, Min JE, Dale LM, Piske M, Bach P, Bruneau J, Gustafson P, Hu XJ, Kampman K, Korthuis PT, Loughin T, Maclure M, Platt RW, Siebert U, Socías ME, Wood E, Nosyk B. Comparative effectiveness of urine drug screening strategies alongside opioid agonist treatment in British Columbia, Canada: a population-based observational study protocol. BMJ Open 2023; 13:e068729. [PMID: 37258082 PMCID: PMC10255039 DOI: 10.1136/bmjopen-2022-068729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/26/2023] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION Urine drug tests (UDTs) are commonly used for monitoring opioid agonist treatment (OAT) responses, supporting the clinical decision for take-home doses and monitoring potential diversion. However, there is limited evidence supporting the utility of mandatory UDTs-particularly the impact of UDT frequency on OAT retention. Real-world evidence can inform patient-centred approaches to OAT and improve current strategies to address the ongoing opioid public health emergency. Our objective is to determine the safety and comparative effectiveness of alternative UDT monitoring strategies as observed in clinical practice among OAT clients in British Columbia, Canada from 2010 to 2020. METHODS AND ANALYSIS We propose a population-level retrospective cohort study of all individuals 18 years of age or older who initiated OAT from 1 January 2010 to 17 March 2020. The study will draw on eight linked health administrative databases from British Columbia. Our primary outcomes include OAT discontinuation and all-cause mortality. To determine the effectiveness of the intervention, we will emulate a 'per-protocol' target trial using a clone censoring approach to compare fixed and dynamic UDT monitoring strategies. A range of sensitivity analyses will be executed to determine the robustness of our results. ETHICS AND DISSEMINATION The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. Results will be disseminated to local advocacy groups and decision-makers, national and international clinical guideline developers, presented at international conferences and published in peer-reviewed journals electronically and in print.
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Affiliation(s)
- B Carolina Guerra-Alejos
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Megan Kurz
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Laura M Dale
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Micah Piske
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Paxton Bach
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Julie Bruneau
- Department of Family Medicine and Emergency Medicine, University of Montreal, Montreal, Québec, Canada
- Research Center, Centre hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Paul Gustafson
- Department of Statistics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - X Joan Hu
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Kyle Kampman
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - P Todd Korthuis
- School of Public Health, OHSU-PSU, Portland, Oregon, USA
- Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Tom Loughin
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert W Platt
- Departments of Epidemiology, Biostatistics, and Occupational Health and of Pediatrics, McGill University, Montreal, Québec, Canada
| | - U Siebert
- Center for Health Decision Science, Department of Health Policy and Management, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of Public Health, Health Services Research and Health Technology Assessment, Private University of Health Sciences Medical Informatics and Technology Hall/Tyrol Institute for Health Information Systems, Hall in Tirol, Austria
| | - M Eugenia Socías
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Evan Wood
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Racha S, Patel SM, Bou Harfouch LT, Berger O, Buresh ME. Safety of rapid inpatient methadone initiation protocol: A retrospective cohort study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 148:209004. [PMID: 36931605 DOI: 10.1016/j.josat.2023.209004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/01/2022] [Accepted: 02/27/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Current methadone titration guidelines recommend low initial doses (15-40 mg) and slow increases (10-20 mg every 3 to 7 days) to prevent dose accumulation and oversedation until reaching a target therapeutic dose between 60 and 120 mg. These guidelines were created primarily for outpatient settings in the pre-fentanyl era. Methadone initiations are becoming more common in hospitals, but no titration guidelines exist specific to this treatment setting, which has capacity for increased monitoring. Our objective was to assess the safety of rapid inpatient methadone initiation with regard to mortality, overdose, and serious adverse outcomes both in-hospital and postdischarge. METHODS This is a retrospective, observational, cohort study conducted at an urban, academic medical center in the United States. We queried our electronic medical record for hospitalized adults with moderate to severe opioid use disorder admitted between July 1, 2018, and November 30, 2021. Included patients were rapidly initiated on methadone with 30 mg as the initial dose and 10 mg increases daily until reaching 60 mg. The study extracted thirty-day post-discharge opioid overdose and mortality data from the CRISP database. RESULTS Twenty-five hospitalized patients received rapid methadone initiation during the study period. The study had no major adverse events including in-hospital or thirty-day post-discharge overdoses or deaths. The study did have two instances of sedation, but neither led to methadone dose holds. There were no instances of QTc prolongation. The study had one patient-directed discharge. CONCLUSIONS This study demonstrated that a small subset of hospitalized patients tolerated rapid methadone initiation. More rapid titrations can be utilized in a monitored inpatient setting to retain patients in the hospital and allow providers to account for increased tolerance in the fentanyl era. Guidelines should be updated to reflect the capabilities of inpatient settings to safely initiate and rapidly titrate methadone. Further work should determine optimal methadone initiation protocols in the fentanyl era.
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Affiliation(s)
- Savitha Racha
- Department of Medicine, Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America.
| | - Sapan M Patel
- Department of Medicine, Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Johns Hopkins University, Krieger School of Arts and Sciences, United States of America.
| | - Layal T Bou Harfouch
- Department of Medicine, Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Johns Hopkins University, Krieger School of Arts and Sciences, United States of America.
| | - Olivia Berger
- Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States of America.
| | - Megan E Buresh
- Department of Medicine, Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
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Colledge-Frisby S, Jones N, Degenhardt L, Hickman M, Padmanathan P, Santo T, Farrell M, Gisev N. Incidence of suicide and self-harm among people with opioid use disorder and the impact of opioid agonist treatment: A retrospective data linkage study. Drug Alcohol Depend 2023; 246:109851. [PMID: 37028102 PMCID: PMC10225170 DOI: 10.1016/j.drugalcdep.2023.109851] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/07/2023] [Accepted: 03/14/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Rates of suicide and self-harm are elevated among people with opioid use disorder (OUD). This study examined incidence of self-harm and suicide among people who have entered OAT and assessed the impact of different OAT exposure periods on these events. METHOD We conducted a retrospective population-based cohort study of all OAT recipients (N = 45,664) in New South Wales, Australia (2002-2017), using linked administrative data. Incidence rates of self-harm hospitalisations and suicide deaths were estimated per 1000 person-years (PY). The first 28 days of an OAT episode, ≥ 29 days on OAT, the first 28 days off OAT, and ≥ 29 days off OAT (maximum four years post-OAT) were exposure periods. Poisson regression models with generalised estimating equations estimated the adjusted incidence rate ratios (ARR) of self-harm and suicide by OAT exposure periods, adjusting for covariates. RESULTS There were 7482 hospitalisations (4148 individuals) for self-harm and 556 suicides, equating to incidence rates of 19.2 (95% confidence intervals [CI]=18.8-19.7) and 1.0 (95%CI=0.9-1.1) per 1000 PY, respectively. Opioid overdose was implicated in 9.6% of suicides and 28% of self-harm hospitalisations. Compared to ≥ 29 days on OAT, the incidence rate of suicide was elevated in the 28 days following OAT cessation (ARR=17.4 [95%CI=11.7-25.9]), and the rate of self-harm hospitalisations was elevated during the first 28 days of OAT (ARR=2.2 [95%CI=1.9-2.6]) and the 28 days after leaving OAT (ARR=2.7 [95%CI=2.3-3.2]). CONCLUSIONS OAT may reduce suicide and self-harm risk among people with OUD; however, OAT initiation and cessation are critical periods for targeting self-harm and suicide prevention interventions.
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Affiliation(s)
- Samantha Colledge-Frisby
- National Drug Research Institute, Curtin University, Perth, Australia; National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia; The Burnet Institute, Melbourne, Australia.
| | - Nicola Jones
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Prianka Padmanathan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Thomas Santo
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
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Carl A, Pasman E, Broman MJ, Lister JJ, Agius E, Resko SM. Experiences of Healthcare and Substance Use Treatment Provider-based Stigma Among Patients Receiving Methadone. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 6:100138. [PMID: 36994374 PMCID: PMC10040326 DOI: 10.1016/j.dadr.2023.100138] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 01/14/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023]
Abstract
Background Medications for Opioid Use Disorder (MOUD) are efficacious, however only one-third of individuals with an opioid use disorder (OUD) enter into treatment. Low rates of MOUD utilization are partially due to stigma. This study examines provider-based stigma toward MOUD and identifies factors associated with experiencing stigma related to MOUD from substance use treatment and healthcare providers among people receiving methadone. Methods Clients receiving MOUD at an opioid treatment program (N = 247) were recruited to complete a cross-sectional computer-based survey assessing socio-demographics, substance use, depression and anxiety symptoms, self-stigma, and recovery supports/barriers. Logistic regression was used to examine factors associated with hearing negative comments about MOUD from substance use treatment and healthcare providers. Results 27.9% and 56.7% of respondents reported they sometimes/often hear negative comments about MOUD from substance use treatment and healthcare providers, respectively. Logistic regression results indicate that individuals who experience more negative consequences resulting from their OUD (OR=1.09, p=.019) had greater odds of hearing negative comments from substance use treatment providers. Age (OR=0.966, p=.017) and treatment stigma (OR=1.42, p=.030) were associated with greater odds of hearing negative comments from healthcare providers. Conclusions Stigma can be a deterrent to seeking substance use treatment, healthcare, and recovery support. Understanding factors associated with experiencing stigma from substance use treatment providers and healthcare providers is important as these individuals may act as advocates for those with OUD. This study highlights individual factors associated with hearing negative comments about methadone and other MOUD and point to areas for targeted education.
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Affiliation(s)
- Alexis Carl
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, USA
| | - Emily Pasman
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, USA
| | - Michael J. Broman
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, USA
| | - Jamey J. Lister
- School of Social Work, Rutgers University – New Brunswick, 120 Albany Street, Tower One, New Brunswick, NJ 08901, USA
| | - Elizabeth Agius
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, USA
| | - Stella M. Resko
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, USA
- Merrill Palmer Skillman Institute, Wayne State University, 71 E Ferry St, Detroit, MI 48202, USA
- Corresponding author.
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12
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Calcaterra SL, Martin M, Bottner R, Englander H, Weinstein Z, Weimer MB, Lambert E, Herzig SJ. Management of opioid use disorder and associated conditions among hospitalized adults: A Consensus Statement from the Society of Hospital Medicine. J Hosp Med 2022; 17:744-756. [PMID: 35880813 PMCID: PMC9474708 DOI: 10.1002/jhm.12893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 01/14/2023]
Abstract
Hospital-based clinicians frequently care for patients with opioid withdrawal or opioid use disorder (OUD) and are well-positioned to identify and initiate treatment for these patients. With rising numbers of hospitalizations related to opioid use and opioid-related overdose, the Society of Hospital Medicine convened a working group to develop a Consensus Statement on the management of OUD and associated conditions among hospitalized adults. The guidance statement is intended for clinicians practicing medicine in the inpatient setting (e.g., hospitalists, primary care physicians, family physicians, advanced practice nurses, and physician assistants) and is intended to apply to hospitalized adults at risk for, or diagnosed with, OUD. To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines and composed a draft statement based on extracted recommendations. Next, the working group obtained feedback on the draft statement from external experts in addiction medicine, SHM members, professional societies, harm reduction organizations and advocacy groups, and peer reviewers. The iterative development process resulted in a final Consensus Statement consisting of 18 recommendations covering the following topics: (1) identification and treatment of OUD and opioid withdrawal, (2) perioperative and acute pain management in patients with OUD, and (3) methods to optimize care transitions at hospital discharge for patients with OUD. Most recommendations in the Consensus Statement were derived from guidelines based on observational studies and expert consensus. Due to the lack of rigorous evidence supporting key aspects of OUD-related care, the working group identified important issues necessitating future research and exploration.
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Affiliation(s)
- Susan L. Calcaterra
- Department of Medicine, Division of General Internal Medicine and Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Marlene Martin
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA, USA
| | - Richard Bottner
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, TX, USA
| | - Honora Englander
- Department of Medicine, Section of Addiction Medicine and Division of Hospital Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Zoe Weinstein
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Eugene Lambert
- Harvard Medical School and Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
| | - Shoshana J. Herzig
- Harvard Medical School and Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Carswell N, Angermaier G, Castaneda C, Delgado F. Management of opioid withdrawal and initiation of medications for opioid use disorder in the hospital setting. Hosp Pract (1995) 2022; 50:251-258. [PMID: 35837678 DOI: 10.1080/21548331.2022.2102776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Opioid use disorder (OUD) has become increasingly prevalent among hospitalized patients in the United States and globally. As its prevalence increases, this provides a valuable opportunity for clinicians in the hospital setting to engage and initiate management and treatment of OUD. This article aims to provide hospitalists and other clinicians working in the hospital with a narrative review of the management of opioid withdrawal and the initiation of medications for opioid use disorder (MOUD) in the hospital and provide an update on a novel low dose approach to buprenorphine induction (also commonly referred to as the "microinduction" method). Management can initially include treating withdrawal symptoms with opioids as well as with a combination of non-opioid medications such as alpha 2 agonists, benzodiazepines, and/or antiemetics as needed. Besides simply managing withdrawal symptoms, clinicians can further improve the care of patients with OUD through initiating maintenance treatment with MOUD, ideally with opioids used in the initial management of withdrawal. Opioid detoxification is an inferior method of primary treatment and is associated with relapse and poor outcomes. In contrast, treatment with MOUD using methadone or buprenorphine is associated with superior treatment outcomes and reduced relapse compared to detoxification alone. Treatment with MOUD using methadone or buprenorphine can be successfully used in the hospital setting. A novel low dose approach to buprenorphine induction may be useful in minimizing precipitated withdrawals in patients who have recently used or received opioids, which makes this an attractive option in the hospital where patients are frequently on opioids for acutely painful conditions. The hospital setting also provides a valuable opportunity for clinicians to address harm reduction in patients with OUD. Finally, clinicians can improve the long-term outcomes of patients with OUD by ensuring a smooth discharge with adequate and timely follow-up.
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Affiliation(s)
- Nico Carswell
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Giselle Angermaier
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Christopher Castaneda
- Department of Psychiatry, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Fabrizzio Delgado
- Department of Psychiatry, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
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Jones NR, Hickman M, Nielsen S, Larney S, Dobbins T, Ali R, Degenhardt L. The impact of opioid agonist treatment on fatal and non-fatal drug overdose among people with a history of opioid dependence in NSW, Australia, 2001-2018: Findings from the OATS retrospective linkage study. Drug Alcohol Depend 2022; 236:109464. [PMID: 35523111 DOI: 10.1016/j.drugalcdep.2022.109464] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND There are critical periods of mortality risk at onset and cessation of opioid agonist treatment. We aim to determine whether non-fatal overdose followed the same pattern as fatal overdose, comparing the first 4 weeks of treatment and treatment cessation and the remainder time off treatment, with the remainder treatment time, to determine intervention markers. METHODS Retrospective cohort study of people with a history of opioid agonist treatment using linked New South Wales data. The incidence of non-fatal overdose hospitalization; emergency department presentation; and fatal overdose from national death records were compared. Rates were calculated using generalized estimating equations adjusting for demographics, year, and recent health and incarceration events. RESULTS The remainder time in OAT had the lowest incidence of overdose for all outcomes and is the reference level for the adjusted incident rate ratios (aIRR). Fatal overdose was lowest in treatment and highest in the first four weeks out of treatment, aIRR of 12.83 (95% CI 10.0-16.4). Whereas the highest overdose rate for non-fatal opioid overdose was in the first four weeks in treatment, aIRR of 3.11 (95% CI 2.19-4.42). CONCLUSIONS Retention on opioid agonist treatment is protective against drug related overdose. There is elevated risk of non-fatal overdose at treatment initiation that is not evident for fatal overdose, but the first month of treatment cessation is a critical period for both non-fatal and fatal overdose. These findings emphasize the importance of treatment retention and interventions for polysubstance overdose at cessation.
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Affiliation(s)
- Nicola R Jones
- National Drug and Alcohol Research Centre, University of NSW, Sydney, NSW 2052, Australia
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS2 8DZ, UK
| | - Suzanne Nielsen
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Sarah Larney
- Department of Family Medicine and Emergency Medicine, Université de Montréal and Centre de Recherche du, Centre Hospitalier de l'Université de Montréal (CRCHUM), Canada
| | - Timothy Dobbins
- National Drug and Alcohol Research Centre, University of NSW, Sydney, NSW 2052, Australia; School of Public Health and Community Medicine, UNSW, Sydney, Australia
| | - Robert Ali
- School of Medicine, The University of Adelaide, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of NSW, Sydney, NSW 2052, Australia.
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Buresh M, Nahvi S, Steiger S, Weinstein ZM. Adapting methadone inductions to the fentanyl era. J Subst Abuse Treat 2022; 141:108832. [DOI: 10.1016/j.jsat.2022.108832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/11/2022] [Accepted: 06/18/2022] [Indexed: 10/17/2022]
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Methadone treatment and patient-directed hospital discharges among patients with opioid use disorder: Observations from general medicine services at an urban, safety-net hospital. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 3:100066. [PMID: 36845982 PMCID: PMC9949313 DOI: 10.1016/j.dadr.2022.100066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/13/2022] [Accepted: 05/11/2022] [Indexed: 11/22/2022]
Abstract
Introduction People with opioid use disorder (OUD) have high rates of discharge against medical advice from the hospital. Interventions for addressing these patient-directed discharges (PDDs) are lacking. We sought to explore the impact of methadone treatment for OUD on PDD. Methods Using electronic record and billing data from an urban safety-net hospital, we retrospectively examined the first hospitalization on a general medicine service for adults with OUD from January 2016 through June 2018. Associations with PDD compared to planned discharge were examined using multivariable logistic regression. Administration patterns of maintenance therapy versus new in-hospital initiation of methadone were examined using bivariate tests. Results During the study time period, 1,195 patients with OUD were hospitalized. 60.6% of patients received medication for OUD, of which 92.8% was methadone. Patients who received no treatment for OUD had a 19.1% PDD rate while patients initiated on methadone in-hospital had a 20.5% PDD rate and patients on maintenance methadone during the hospitalization had a 8.6% PDD rate. In multivariable logistic regression, methadone maintenance was associated with lower odds of PDD compared to no treatment (aOR 0.53, 95% CI 0.34-0.81), while methadone initiation was not (aOR 0.89, 95% CI 0.56-1.39). About 60% of patients initiated on methadone received 30 mg or less per day. Conclusions In this study sample, maintenance methadone was associated with nearly a 50% reduction in the odds of PDD. More research is needed to assess the impact of higher hospital methadone initiation dosing on PDD and if there is an optimal protective dose.
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McCombe G, Swan D, Lambert JS, O'Connor E, Ward Z, Vickerman P, Avramovic G, Crowley D, Tinago W, Mafirakureva N, Cullen W. Integrating Hepatitis C Care for opioid substitution treatment patients attending general practice: Feasibility, Clinical and Cost Effectiveness (Preprint). Interact J Med Res 2021; 11:e35300. [PMID: 35998029 PMCID: PMC9449831 DOI: 10.2196/35300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/31/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background Objective Methods Results Conclusions
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Affiliation(s)
- Geoff McCombe
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Davina Swan
- School of Medicine, University College Dublin, Dublin, Ireland
| | - John S Lambert
- School of Medicine, University College Dublin, Dublin, Ireland
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Eileen O'Connor
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Zoe Ward
- Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Peter Vickerman
- Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Gordana Avramovic
- School of Medicine, University College Dublin, Dublin, Ireland
- Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Willard Tinago
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Nyashadzaishe Mafirakureva
- Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Walter Cullen
- School of Medicine, University College Dublin, Dublin, Ireland
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Elvir-Lazo OL, White PF, Cruz Eng H, Yumul F, Chua R, Yumul R. Impact of chronic medications in the perioperative period -anesthetic implications (Part II). Postgrad Med 2021; 133:920-938. [PMID: 34551658 DOI: 10.1080/00325481.2021.1982298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: This review article discusses the pharmacodynamic effects of the most commonly used chronic medications by patients undergoing elective surgical procedures, namely cardiovascular drugs (e.g., beta blockers, alpha-2 agonist, calcium channel blockers, ACE inhibitors, diuretics, etc.), lipid-lowering drugs, gastrointestinal medications (H2-blockers, proton pump inhibitors), pulmonary medications (inhaled β-agonists, anticholinergics,), antibiotics (tetracyclines, clindamycin and macrolide, linezolid.), opioids and non-opioids analgesics (NSAIDs, COX-2 inhibitors, acetaminophen), gabapentanoids, erectile dysfunction (ED) drugs, psychotropic drugs (tricyclic antidepressants [TCAs], monoamine oxidase inhibitors [MAOI], selective serotonin reuptake inhibitors [SSRIs], serotonin norepinephrine reuptake inhibitors [SNRIs], and cannabinol-containing drugs). In addition, the potential adverse drug-interactions between these chronic medications and commonly used anesthetic drugs during the perioperative period will be reviewed. Finally, recommendations regarding the management of chronic medications during the preoperative period will be provided.Materials and Methods: An online search was conducted from January 2000 through February 2021 with the Medline database through PubMed and Google Scholar using the following search terms/keywords: "chronic medications in the perioperative period", and "chronic medications and anesthetic implications." In addition, we searched for anesthetic side effects associated with the major drug groups.Results and Conclusions: An understanding of the pharmacodynamic effects of most used chronic medications is important to avoid untoward outcomes in the perioperative period. These drug interactions may result in altered efficacy and toxicity of the anesthetic medications administered during surgery. These drug-drug interactions can also affect the morbidity, mortality, recovery time of surgical patients and acute relapse of chronic illnesses which could lead to last minute cancellation of surgical procedures. Part II of this two-part review article focuses on the reported interactions between most commonly taken chronic medications by surgical patients and anesthetic and analgesic drugs, as well as recommendations regarding the handling these chronic medications during the perioperative period.
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Affiliation(s)
| | - Paul F White
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,The White Mountain Institute, The Sea Ranch, CA, USA
| | - Hillenn Cruz Eng
- Adena Health System, department of anesthesiology, Chillicothe, OH, US
| | - Firuz Yumul
- Department of family medicine, Skagit Regional Health, Family Medicine, Arlington, WA, USA
| | - Raissa Chua
- Department of Internal Medicine, Huntington Hospital, Prasadena, CA, USA
| | - Roya Yumul
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,David Geffen School of Medicine-UCLA, Charles R, Drew University of Medicine and Science, Los Angeles, CA, USA
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The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med 2021; 14:1-91. [PMID: 32511106 DOI: 10.1097/adm.0000000000000633] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Mammana G, Bertolino M, Bruera E, Orellana F, Vega F, Peirano G, Bunge S, Armesto A, Dran G. First-line methadone for cancer pain: titration time analysis. Support Care Cancer 2021; 29:6335-6341. [PMID: 33880639 DOI: 10.1007/s00520-021-06211-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/07/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Methadone is a low-cost, strong opioid that is increasingly used as a first-line treatment for pain in palliative care (PC). Its long and unpredictable half-life and slow elimination phase can make titration challenging. Evidence for titration modalities is scarce. OBJECTIVE To describe the titration phase of the treatment with low-dose first-line methadone and the use of methadone for breakthrough pain. METHODS Prospective study with strong opioid-naïve patients with moderate to severe cancer pain followed at a tertiary PC unit in Argentina. Starting methadone dose was 2.5-5 mg/day every 8, 12, or 24 h. Titration allowed daily dose increases from day 1, and prescription of oral methadone 2.5 mg every 2 h with a maximum of 3 rescue doses/day for breakthrough pain. Pain control, methadone stabilization dose, and adverse effects, among other variables, were daily assessed over the first 7 days (T0-T7). RESULTS Sixty-two patients were included. Initial median (IQR) methadone dose was 5 (2.5) mg/day. Pain intensity decreased from a median (IQR) of 8 (2.3) at T0 to 4 (2.3) at T1 and remained ≤ 4 until T7 (all p < 0.0001 compared to T0). Similar results were obtained through the categorical and tolerability scales for pain. Fifty patients (81%) reached pain control, 66% in the first 48 h. Methadone daily doses at T2 and T7 were higher than that at T0: 7.5 (3) and 6.7 (5.5) versus 5 (2.5), respectively (all p < 0.05). The opioid escalation index at T7 was 1.7%. The median (IQR) number of rescues, stabilization dose, and time for stabilization was 0 (1), 5(4.5) mg, and 3(2) days, respectively. Two patients were discontinued due to delirium. All other side effects were mild. CONCLUSIONS First-line, low-dose methadone using rescue methadone resulted in a pronounced and rapid decrease in pain, with minimal need for titration and for breakthrough doses, and no evidence of accumulation or sedation by the end of the week.
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Affiliation(s)
- Guillermo Mammana
- Unidad de Cuidados Paliativos - Fundación FEMEBA, Hospital de Agudos Dr. E. Tornú, Buenos Aires, Argentina
| | - Mariela Bertolino
- Unidad de Cuidados Paliativos - Fundación FEMEBA, Hospital de Agudos Dr. E. Tornú, Buenos Aires, Argentina
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, & Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Fernando Orellana
- Unidad de Cuidados Paliativos - Fundación FEMEBA, Hospital de Agudos Dr. E. Tornú, Buenos Aires, Argentina
| | - Fanny Vega
- Unidad de Cuidados Paliativos - Fundación FEMEBA, Hospital de Agudos Dr. E. Tornú, Buenos Aires, Argentina
| | - Gabriela Peirano
- Unidad de Cuidados Paliativos - Fundación FEMEBA, Hospital de Agudos Dr. E. Tornú, Buenos Aires, Argentina
| | - Sofía Bunge
- Unidad de Cuidados Paliativos - Fundación FEMEBA, Hospital de Agudos Dr. E. Tornú, Buenos Aires, Argentina.,Facultad de Ciencias de la Salud, UNICEN, Buenos Aires, Argentina
| | - Arnaldo Armesto
- Cátedra de Farmacología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Graciela Dran
- Programa de Bioética, Facultad Latinoamericana de Ciencias Sociales (FLACSO), Buenos Aires, Argentina. .,Consejo Nacional de Investigación Científica y Tecnológica (CONICET), Buenos Aires, Argentina.
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21
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Errico S, Bedocchi D, Drommi M, Barranco R, Bonsignore A, Ventura F. Forensic pathological study of methadone-related deaths in the Genoa (Italy) district: A six-year study. J Forensic Leg Med 2021; 79:102149. [PMID: 33667794 DOI: 10.1016/j.jflm.2021.102149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 11/30/2022]
Abstract
Methadone is a synthetic opioid, a pure agonist of the μ receptor. It is used for opioid maintenance therapy in heroin addiction. In recent years, Italian studies of incidence and prevalence have indicated an increase in the illegal sales of methadone and, consequently, an increase in deaths due to acute methadone intoxication as well. The present review is a prospective-observational study regarding epidemiological and toxicological analyses of methadone-related deaths recorded in the district of Genoa (Italy) from 2013 to 2018. The study includes a list of twenty-six people that have died from methadone toxicity: twenty-two males and four females. The concentration of methadone in the blood samples ranged from 181 to 4058.53 ng/mL, with an average of 964.29 ng/mL. Six subjects tested positive for methadone alone; twenty cases, however, presented drugs or substances in different concentrations in the blood samples. Illegal sales and consumption of methadone have a negative impact on the self-administration therapy of opioid addiction, inducing patients to increase their dosage or sell methadone in order to purchase illegal drugs. As shown in our study, this behaviour is associated with an increase in methadone-related deaths. Accordingly, careful monitoring of dosage administrated to patients is required in order to render the system safer.
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Affiliation(s)
- Stefano Errico
- Department of Forensic and Legal Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Davide Bedocchi
- Department of Forensic and Legal Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Martina Drommi
- Department of Forensic and Legal Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Rosario Barranco
- Department of Forensic and Legal Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Alessandro Bonsignore
- Department of Forensic and Legal Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Francesco Ventura
- Department of Forensic and Legal Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy.
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22
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Nunes EV, Levin FR, Reilly MP, El-Bassel N. Medication treatment for opioid use disorder in the age of COVID-19: Can new regulations modify the opioid cascade? J Subst Abuse Treat 2020; 122:108196. [PMID: 33221125 PMCID: PMC7666540 DOI: 10.1016/j.jsat.2020.108196] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/15/2020] [Accepted: 11/10/2020] [Indexed: 01/15/2023]
Abstract
The temporary loosening of regulations governing methadone and buprenorphine treatment for opioid use disorder (OUD) in the U.S., instituted to prevent the spread of COVID-19, has created an opportunity to explore the effectiveness of new models of care for people with OUD. The opioid cascade describes the current status of the treatment system, where only a fraction of people with OUD initiate effective medication treatment for OUD (MOUD), and of those only a fraction is retained in treatment. Regulatory changes—such as availability of larger take-home supplies of methadone and buprenorphine initiated via telemedicine (e.g., no initial in person visit; telemedicine buprenorphine permitted across state lines)—could modify the cascade, by reducing the burden and increasing the attractiveness, availability, and feasibility of MOUD both for people with OUD and for providers. We review examples of more liberal MOUD regimens, including the implementation of buprenorphine in France in the 1990s, primary care–based methadone in Canada, and low-threshold buprenorphine models. Research is needed to document whether new models implemented in the U.S. in the wake of COVID-19 are successful, and whether safety concerns, such as diversion and misuse, emerge. We discuss barriers to implementation, including racial and ethnic health disparities, and lack of knowledge and reluctance among potential providers of MOUD. We suggest that the urgency and public spiritedness of the response to COVID-19 be harnessed to make gains on the opioid cascade, inspiring prescribers, health systems, and communities to embrace the delivery of MOUD to meet the needs of an increasingly vulnerable population. The COVID-19 epidemic has prompted regulatory changes to support medication treatments for opioid use disorder. Loosened regulations governing methadone and buprenorphine present an opportunity to expand treatment. Models of lower threshold availability of buprenorphine and methadone have succeeded in other countries and settings.
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Affiliation(s)
- Edward V Nunes
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States of America; Columbia Center for Healing of Opioid and Other Substance Use Disorders - Enhancing Intervention Development and Implementation (CHOSEN), Riverside Drive, New York, NY 10032, United States of America; Columbia University Irving Medical Center, West 168th Street, New York, NY 10032, United States of America.
| | - Frances R Levin
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States of America; Columbia Center for Healing of Opioid and Other Substance Use Disorders - Enhancing Intervention Development and Implementation (CHOSEN), Riverside Drive, New York, NY 10032, United States of America; Columbia University Irving Medical Center, West 168th Street, New York, NY 10032, United States of America
| | - Muredach P Reilly
- Columbia Center for Healing of Opioid and Other Substance Use Disorders - Enhancing Intervention Development and Implementation (CHOSEN), Riverside Drive, New York, NY 10032, United States of America; Columbia University Irving Medical Center, West 168th Street, New York, NY 10032, United States of America; Irving Institute for Clinical and Translational Research, West 168th Street, New York, NY 10032, United States of America
| | - Nabila El-Bassel
- Columbia Center for Healing of Opioid and Other Substance Use Disorders - Enhancing Intervention Development and Implementation (CHOSEN), Riverside Drive, New York, NY 10032, United States of America; Columbia School of Social Work, 1255 Amsterdam Ave, New York, NY 10027, United States of America
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23
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Medication-Assisted Treatment for Opioid Use Disorder in Pregnancy: Practical Applications and Clinical Impact. Obstet Gynecol Surv 2020; 75:175-189. [PMID: 32232496 DOI: 10.1097/ogx.0000000000000744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Opioid use disorder is increasingly common in the United States and affects many pregnancies. Given the rise in pregnancies complicated by opioid use, providers should understand the diagnosis and management of opioid use disorder in pregnancy. Objective This article focuses on screening for opioid misuse, selecting appropriate treatment for patients, initiating medication-assisted treatment in the inpatient setting, and providing appropriate peripartum care. Evidence Acquisition A PubMed search was undertaken using the following search terms: "opioid use disorder", "pregnancy," "medication assisted treatment," "buprenorphine," "methadone," "heroin," "addiction," "neonatal abstinence syndrome," and "detoxification." The search was limited to the English language publications, with most being published after 2000. Results All women should be screened for opioid use disorder during pregnancy. Opioid use has profound effects on the mother and infant. Medication-assisted treatment is the standard of care for pregnant women with opioid use disorder. Patients will require a multidisciplinary approach to management in the intrapartum and postpartum period. Conclusions Conclusions Opioid use disorder is a common, chronic condition with significant implications during pregnancy. Recognition and appropriate treatment of this disorder can optimize maternal and fetal outcomes. Conclusions Obstetricians are increasingly being challenged to manage pregnancies complicated by opioid use disorder and should be proficient in providing safe and effective care.
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24
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Perioperative Pain Control in the Opioid-Dependent Patient: Just Bite the Bullet? CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00425-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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25
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Gibson R, MacLeod N, Donaldson LJ, Williams H, Hibbert P, Parry G, Bhatt J, Sheikh A, Carson-Stevens A. A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales. Addiction 2020; 115:2066-2076. [PMID: 32149443 DOI: 10.1111/add.15039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/24/2019] [Accepted: 03/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Opioid substitution treatment is used in many countries as an effective harm minimization strategy. There is a need for more information about patient safety incidents and the resulting harm relating to this treatment. We aimed to characterize patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care by: (i) identifying the sources and nature of harm and (ii) describing and interpreting themes to identify priorities to focus future improvement work. DESIGN Mixed-methods study examining patient safety incident reports involving opioid substitution treatment with either methadone or buprenorphine in community-based care. SETTING Data submitted between 2005 and 2015 from the National Reporting and Learning System (NRLS), a national repository of patient safety incident reports from across England and Wales. PARTICIPANTS A total of 2284 reports were identified involving patients receiving community-based opioid substitution treatment. MEASUREMENTS Incident type, contributory factors, incident outcome and severity of harm. Analysis involved data coding, processing and iterative generation of data summaries using descriptive statistical and thematic analysis. FINDINGS Most risks of harm from opioid substitution treatment came from failure in one of four processes of care delivery: prescribing opioid substitution (n = 151); supervised dispensing (n = 248); non-supervised dispensing (n = 318); and monitoring and communication (n = 1544). Most incidents resulting in harm involved supervised or non-supervised dispensing (n = 91 of 127, 72%). Staff- (e.g. slips during task execution, not following protocols) and organization-related (e.g. poor working conditions or poor continuity of care between services) contributory factors were identified for more than half of incidents. CONCLUSIONS Risks of harm in delivering opioid substitute treatment in England and Wales appear to arise out of failures in four processes: prescribing opioid substitution, supervised dispensing, non-supervised dispensing and monitoring and communication.
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Affiliation(s)
| | | | - Liam J Donaldson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Gareth Parry
- Harvard Medical School and Institute for Healthcare Improvement, Boston, MA, USA
| | - Jay Bhatt
- The American Hospital Association, Chicago, IL, USA
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Shapira B, Rosca P, Berkovitz R, Gorjaltsan I, Neumark Y. The switch from one substance-of-abuse to another: illicit drug substitution behaviors in a sample of high-risk drug users. PeerJ 2020; 8:e9461. [PMID: 32742781 PMCID: PMC7370931 DOI: 10.7717/peerj.9461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/10/2020] [Indexed: 01/07/2023] Open
Abstract
Background Substitution can be defined as the consciously motivated choice to use one drug, either licit or illicit, instead of another, due to perceptions of cost, availability, safety, legality, substance characteristics, and substance attributions. Substitution represents a potential risk to drug users, mainly when substitutes are of higher potency and toxicity. This study offers a basic conceptualization of illicit substitution behavior and describes substitution patterns among users of two highly prevalent drugs of abuse-heroin and cannabis. Methods Here, 592 high-risk drug users undergoing pharmacological and psycho-social treatment were interviewed. Patients were asked questions about current drug use, lifetime substitution, and substitution patterns. Descriptive statistics, chi-square tests of independence, and multinomial logistic regressions were used to identify and test correlates of substitution patterns for heroin and cannabis. Results Of the 592 drug users interviewed, 448 subjects (75.7%) reported having substituted their preferred drug for another illicit substance. Interviews yielded a total of 275 substitution events reported by users of cannabis, and 351 substitution events reported by users of heroin. The most frequently reported substitution substances for responders who preferred heroin were illicit non-prescribed "street" methadone (35.9%), followed by oral and transdermal prescription opioids (17.7%). For responders who preferred cannabis, substitution for synthetic cannabinoid receptor agonists (33.5%) followed by alcohol (16.0%) were the most commonly reported. Age at onset-of-use (p < 0.005), population group (p = 0.008), and attending treatment for the first time (p = 0.026) were significantly associated with reported lifetime substitution. Past-year use of stimulants, heroin, hallucinogens, methylenedioxymethamphetamine (MDMA), and novel psychoactive substances were-at the 95% confidence level-also significantly associated with reported lifetime substitution. In multivariate analysis, the odds for methadone substitution among heroin users were significantly affected by age at onset-of-use, type of treatment center, and education. Odds for substitution for synthetic cannabinoid receptor agonists among cannabis users were significantly affected by age, population group, type of treatment center, and education. Conclusion Self-substitution behavior should be considered by clinicians and policymakers as a common practice among most drugusers. Substitution for street methadone provides evidence for the ongoing diversion of this substance from Opioid Maintenance Treatment Centers, while the prominence of substitution of synthetic cannabinoids among dual-diagnosis patients should be regarded as an ongoing risk to patients that needs to be addressed by clinicians. Analysis of additional substitution patterns should provide further valuable insights into the behavior of drugusers.
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Affiliation(s)
- Barak Shapira
- Braun School of Public Health and Community Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Division of Enforcement and Inspection, Israel Ministry of Health, Jerusalem, Israel
| | - Paola Rosca
- Department for the Treatment of Substance Abuse, Israel Ministry of Health, Jerusalem, Israel
| | - Ronny Berkovitz
- Division of Enforcement and Inspection, Israel Ministry of Health, Jerusalem, Israel
| | | | - Yehuda Neumark
- Braun School of Public Health and Community Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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27
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Oviedo-Joekes E, Palis H, Guh D, Marsh DC, MacDonald S, Harrison S, Brissette S, Anis AH, Schechter MT. Adverse Events During Treatment Induction With Injectable Diacetylmorphine and Hydromorphone for Opioid Use Disorder. J Addict Med 2020; 13:354-361. [PMID: 30747750 PMCID: PMC6791495 DOI: 10.1097/adm.0000000000000505] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 01/08/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The present study aims to describe a 3-day induction protocol for injectable hydromorphone (HDM) and diacetylmorphine (DAM) used in 3 Canadian studies and examine rates of opioid-related overdose and somnolence during this induction phase. METHODS The induction protocol and associated data on opioid-related overdose and somnolence are derived from 2 clinical trials and one cohort study conducted in Vancouver and Montreal (2005-2008; 2011-2014; 2014-2018). In this analysis, using the Medical Dictionary for Regulatory Activities coding system we report somnolence (ie, drowsiness, sleepiness, grogginess) and opioid overdose as adverse events. Overdoses requiring intervention with naloxone are coded as severe adverse events. RESULTS Data from the 3 studies provides a total of 1175 induction injections days, with 700 induction injection days for DAM, and 475 induction injection days for HDM. There were 34 related somnolence and adverse event (AE) overdoses (4.899 per 100 injection days) in DAM and 6 (1.467 per 100 days) in HDM. Four opioid overdoses requiring naloxone (0.571 per 100 injection days) were registered in DAM and 1 in HDM (0.211 per 100 injection days), all safely mitigated onsite. The first week maximum daily dose patients received were on average 433.62 mg [standard deviation (SD) = 137.92] and 223.26 mg (SD = 68.06) for DAM and HDM, respectively. CONCLUSIONS A 3-day induction protocol allowed patients to safely reach high doses of injectable hydromorphone and diacetylmorphine in a timely manner. These findings suggest that safety is not an evidence-based barrier to the implementation of treatment with injectable hydromorphone and diacetylmorphine.
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Affiliation(s)
- Eugenia Oviedo-Joekes
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital (EOJ, HP, DG, AHA, MTS); School of Population and Public Health, University of British Columbia, Vancouver, BC (EOJ, HP, AHA, MTS); Northern Ontario School of Medicine, Sudbury, ON (DCM); Canadian Addiction Treatment Centres, Markham, ON (DCM); Providence Health Care, Providence Crosstown Clinic, Vancouver, BC (SH, SM); Centre Hospitalier de l'Université de Montréal, Hôpital Saint-Luc, CHUM Montréal, Montréal, QC, Canada (SB)
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28
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Shah K, Stout B, Caskey H. Tramadol for the Management of Opioid Withdrawal: A Systematic Review of Randomized Clinical Trials. Cureus 2020; 12:e9128. [PMID: 32789069 PMCID: PMC7417126 DOI: 10.7759/cureus.9128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/11/2020] [Indexed: 11/05/2022] Open
Abstract
The increase in the prescription of opioid medications has resulted in a wildfire of misuse of opioids, both for medical and non-medical reasons, with over 1.7 million people in the United States (US) suffering from distinct disorders owing to opioid use. While various medications, such as methadone, buprenorphine, and naloxone, among others, have been used in treating opioid withdrawal symptoms, concerns of the potential abuse of these drugs, the cost of procurement, legislations, and prescription policies have risen. In recent times, tramadol has been considered a viable replacement for some of these treatment regimes. Tramadol is a synthetic analgesic that acts centrally, possessing opioid-like effects due to the binding of its metabolite with the mu (µ)-opioid receptor, yet with low potential for abuse. Several clinical studies conducted in the past ten years have identified the effects of tramadol in opioid withdrawal cases. The results showed that it exhibits better efficacy and tolerance with fewer side effects in specific clinical scenarios as compared to existing available detox management. We aim to examine the properties of tramadol in opioid withdrawal through this systematic review of clinical studies on humans.
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Affiliation(s)
- Kaushal Shah
- Psychiatry, Griffin Memorial Hospital, Norman, USA
| | - Billy Stout
- Psychiatry and Behavioral Sciences, The Recovery Center, Oklahoma City, USA
| | - Hunter Caskey
- Psychiatry and Behavioral Sciences, Griffin Memorial Hospital, Norman, USA
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29
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Talal AH, Ding Y, Venuto CS, Chakan LM, McLeod A, Dharia A, Morse GD, Brown LS, Markatou M, Kharasch ED. Toward precision prescribing for methadone: Determinants of methadone deposition. PLoS One 2020; 15:e0231467. [PMID: 32302325 PMCID: PMC7164646 DOI: 10.1371/journal.pone.0231467] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/24/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Despite the World Health Organization listing methadone as an essential medication, effective dose selection is challenging, especially in racial and ethnic minority populations. Subtherapeutic doses can result in withdrawal symptoms while supratherapeutic doses can result in overdose and death. Although CYP3A4 was conventionally considered the principal methadone metabolizing enzyme, more recent data have identified CYP2B6 as the principal enzyme. CYP2B6 has ethnically-associated polymorphisms that affect the metabolic rate. Our objective was to investigate the effects of genetic and nongenetic factors on methadone metabolism. METHODS We measured trough plasma methadone levels in 100 participants with opioid use disorder. We assessed methadone metabolism by calculating the metabolite ratio (major metabolite: 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine [EDDP] divided by methadone concentration). We assessed hepatic fibrosis and steatosis by transient elastography and CYP2B6 alleles, principally responsible for methadone metabolism. Mixed effects models modeled the data in 97 participants. RESULTS Participants were largely male (58%), minority (61% African American) and non-Hispanic (68%). Forty percent were HCV mono-infected, 40% were uninfected, and 20% were HCV/HIV co-infected. Female sex had significant effects on (R)- and (S)-methadone metabolism (p = 0.016 and p = 0.044, respectively). CYP2B6 loss of function (LOF) alleles significantly affected (S)-methadone metabolism (p = 0.012). Body mass index (BMI) significantly affected (R)-methadone metabolism (p = 0.034). Methadone metabolism appeared to be lower in males, in individuals with LOF alleles, and elevated BMI. CONCLUSIONS Genetic analysis, especially in minority populations, is essential to delivering individualized treatments. Although the principal methadone metabolizing enzyme remains controversial, our results suggest that sex, CYP2B6 genotype, and BMI should be incorporated into multivariate models to create methadone dosing algorithms. Methadone dosing algorithms should facilitate medication delivery, improve patient satisfaction, and diminish overdose potential.
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Affiliation(s)
- Andrew H. Talal
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States of America
| | - Yuxin Ding
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States of America
| | - Charles S. Venuto
- Department of Neurology, University of Rochester, Rochester, NY, United States of America
| | - Lindsay M. Chakan
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States of America
| | - Anthony McLeod
- START Treatment & Recovery Centers, Brooklyn, NY, United States of America
| | - Arpan Dharia
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States of America
| | - Gene D. Morse
- NYS Center of Excellence in Bioinformatics and Life Sciences, University at Buffalo, Buffalo, NY, United States of America
| | - Lawrence S. Brown
- START Treatment & Recovery Centers, Brooklyn, NY, United States of America
| | - Marianthi Markatou
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States of America
| | - Evan D. Kharasch
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, United States of America
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30
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O'Connor A, Bowling N. Initial Management of Incarcerated Pregnant Women With Opioid Use Disorder. JOURNAL OF CORRECTIONAL HEALTH CARE 2020; 26:17-26. [PMID: 31960750 DOI: 10.1177/1078345819897063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The epidemic of opioid and other drug use and related arrests are a growing public health crisis in the United States. The national prevalence of pregnant women with opioid use disorder (OUD) has increased dramatically from 1.5 per 1,000 delivery hospitalizations in 1999 to 6.5 in 2014. The combination of these factors has led to an increased frequency of pregnant women with OUDs in the correctional health care system. This protocol provides evidence-based treatment recommendations including the initiation of methadone and buprenorphine in the inpatient or jail setting. It also explores many of the nuances around caring for this vulnerable patient population and discusses ways in which the medical and correctional health care teams can efficiently collaborate to improve patient outcomes.
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Affiliation(s)
- Alane O'Connor
- Maine-Dartmouth Family Medicine Residency, Maine General Medical Center, Waterville, ME, USA
| | - Nathaniel Bowling
- Maine-Dartmouth Family Medicine Residency, Maine General Medical Center, Waterville, ME, USA
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31
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Hermann GM, Iovoli AJ, Platek AJ, Wang C, Miller A, Attwood K, Bourgeois DJ, Singh AK. A single-institution, randomized, pilot study evaluating the efficacy of gabapentin and methadone for patients undergoing chemoradiation for head and neck squamous cell cancer. Cancer 2019; 126:1480-1491. [PMID: 31869451 DOI: 10.1002/cncr.32676] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 11/14/2019] [Accepted: 11/17/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND The objective of the current study was to compare the safety and efficacy between 2 analgesic regimens for patients with head and neck cancer (HNC) undergoing definitive chemoradiation (CRT). METHODS The current study was a prospective, single-institution, 2-arm, randomized pilot study. Patients with American Joint Committee on Cancer seventh edition stage II to stage IV squamous cell carcinoma of the head and neck who were undergoing CRT were randomized to either arm 1, which entailed high-dose gabapentin (2700 mg daily) with the institutional standard of care (hydrocodone and/or acetaminophen progressing to fentanyl as needed), or arm 2, which comprised low-dose gabapentin (900 mg daily) with methadone. The primary endpoints were safety and toxicity. Secondary endpoints were pain, opioid requirement, and quality of life (QOL). Differences between the treatment arms at multiple time points were compared using a generalized linear mixed regression model with Sidak correction. RESULTS A total of 60 patients (31 in arm 1 and 29 in arm 2) were enrolled from April 2015 to August 2017. There was no difference between the treatment arms with regard to adverse events or serious adverse events. Pain was not found to be different between the treatment arms. More patients in arm 1 did not require an opioid during treatment (42% vs 7%; P = .002). Patients in arm 2 experienced significantly better QOL outcomes across multiple domains, including overall health (P = .05), physical functioning (P = .04), role functioning (P = .01), and social functioning (P = .01). CONCLUSIONS High-dose prophylactic gabapentin increased the percentage of patients who required no opioid during treatment. Methadone may improve QOL compared with a regimen of short-acting opioids and fentanyl. However, pain was found to significantly worsen throughout treatment regardless of treatment arm, necessitating further studies to identify a more optimal regimen.
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Affiliation(s)
- Gregory M Hermann
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Austin J Iovoli
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Alexis J Platek
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Chong Wang
- Department of Biostatistics, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Austin Miller
- Department of Biostatistics, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Kristopher Attwood
- Department of Biostatistics, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Daniel J Bourgeois
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York.,Radiation Oncology, Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana
| | - Anurag K Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
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Edmonds KP, Saunders IM, Willeford A, Ajayi TA, Atayee RS. Emerging Challenges to the Safe and Effective Use of Methadone for Cancer-Related Pain in Paediatric and Adult Patient Populations. Drugs 2019; 80:115-130. [PMID: 31820362 DOI: 10.1007/s40265-019-01234-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Methadone continues to be an important medication for the treatment of paediatric and adult cancer-related pain. Appropriate patient selection to ensure safe and effective treatment by a team of clinicians who appreciate and are familiar with methadone and its unique pharmacology is crucial. Unlike morphine and other more common opioids, methadone is purported to have involvement with delta-opioid receptor and higher affinity as an N-methyl-D-aspartate-receptor antagonist. Clinically this gives it the advantage of being effective for both nociceptive and neuropathic pain, but also may be useful in the setting of tolerance to other opioids. Methadone also comes in multiple available formulations that can be administrated through a variety of routes beyond the oral route. Challenges with methadone in treating cancer-related pain include drug interactions specifically as it relates to new targeted cancer therapies. Recent guidelines recommend electrocardiogram monitoring with methadone and there is potential for additive cardiac toxicity in the oncology setting. Appropriate dosing of methadone for pain management given age, organ dysfunction, and patients who are on methadone maintenance therapy are also key factors. This article aims to provide clinicians with evidence and clinical practice guidelines for safe and appropriate use of methadone including indication, initiation, and monitoring given its complexity for management of pain in the dynamic oncology setting.
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Affiliation(s)
- Kyle P Edmonds
- Doris A. Howell Palliative Care Teams, University of California San Diego, La Jolla, CA, 92093, USA
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
| | - Ila M Saunders
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA
| | - Andrew Willeford
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA
| | - Toluwalase A Ajayi
- Digital Medicine, Scripps Research Translational Institute, La Jolla, CA, 92037, USA
| | - Rabia S Atayee
- Doris A. Howell Palliative Care Teams, University of California San Diego, La Jolla, CA, 92093, USA.
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA.
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA.
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Mamat R, Nasrulddin NAA, Yusoff NAM. Continued Use of Illicit Substance among Methadone Treatment Patients in Primary Health Care Clinics in East Coast Region of Malaysia. ALCOHOLISM TREATMENT QUARTERLY 2019. [DOI: 10.1080/07347324.2019.1672600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Ruzmayuddin Mamat
- Kuantan Health District Office, Ministry of Health Malaysia, Pejabat Kesihatan Daerah, Kuantan
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Koehl JL, Zimmerman DE, Bridgeman PJ. Medications for management of opioid use disorder. Am J Health Syst Pharm 2019; 76:1097-1103. [DOI: 10.1093/ajhp/zxz105] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Purpose
The use of buprenorphine, methadone, and long-acting naltrexone for treatment of opioid use disorder (OUD) is discussed, including a review of current literature detailing treatment approaches and action steps to optimize treatment in acute care and office-based settings.
Summary
The U.S. epidemic of opioid-related deaths has been driven by misuse of prescription opioids and, increasingly, illicit drugs such as heroin, fentanyl, and fentanyl analogs, necessitating a refocusing of treatment efforts on expanding access to life-saving, evidence-based OUD pharmacotherapy. Inpatient treatment of opioid withdrawal includes acute symptom control through a combination of nonopioid medications and long-term pharmacotherapy to lessen opioid craving and facilitate stabilization and recovery. Methadone and buprenorphine reduce opioid craving, increase treatment retention, reduce illicit opioid use, and increase overall survival. Buprenorphine has logistical advantages over methadone, such as greater flexibility of treatment setting and less risk of adverse effects. Studies have shown the efficacy of long-acting injectable naltrexone to be comparable to that of buprenorphine if patients are detoxified prior to initiation of therapy; however, patients with active OUD are often not able to complete the week-long period of opioid abstinence needed prior to initiation of naltrexone injections. Although buprenorphine is preferred by many patients and can be prescribed in office-based settings, there remains a paucity of physicians certified to prescribe it.
Conclusion
Buprenorphine has become the medication of choice for many patients with OUD, but its use is limited by the low number of physicians certified to prescribe the agent. Other agents studied for treatment of OUD include methadone and naltrexone.
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Affiliation(s)
- Jennifer L Koehl
- Department of Pharmacy Practice, Massachusetts General Hospital, Boston, MA
| | - David E Zimmerman
- Department of Pharmacy Practice, Duquesne University, Pittsburgh, PA
| | - Patrick J Bridgeman
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ
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Bruneau J, Ahamad K, Goyer MÈ, Poulin G, Selby P, Fischer B, Wild TC, Wood E. Management of opioid use disorders: a national clinical practice guideline. CMAJ 2019; 190:E247-E257. [PMID: 29507156 DOI: 10.1503/cmaj.170958] [Citation(s) in RCA: 265] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Julie Bruneau
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Keith Ahamad
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Marie-Ève Goyer
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Ginette Poulin
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Peter Selby
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Benedikt Fischer
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - T Cameron Wild
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Evan Wood
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
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Exploring Slow Release Oral Morphine (SROM) As a Transition Bridge for Medium to High Doses of Methadone Conversion to Buprenorphine/Naloxone Sublingual: A Calgary Concept and Approach. CANADIAN JOURNAL OF ADDICTION 2019. [DOI: 10.1097/cxa.0000000000000050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Lister JJ, Brown S, Greenwald MK, Ledgerwood DM. Gender-specific predictors of methadone treatment outcomes among African Americans at an urban clinic. Subst Abus 2019; 40:185-193. [PMID: 30888262 DOI: 10.1080/08897077.2018.1547810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background: African American patients with opioid use disorder (OUD) have demonstrated poorer methadone maintenance treatment (MMT) outcomes compared with white patients. This issue is further complicated in urban settings, where African Americans experience high rates of poverty and publicly funded treatment. Despite interrelated factors that disadvantage African Americans, the literature focusing on this population is scant. To address this shortcoming, we conducted the first investigation of gender differences and gender-specific MMT outcome predictors among African Americans (or any racial minority population). This study provides gender-specific findings to improve African American MMT outcomes. Methods: We studied 211 African American patients (male: n = 137, 64.9%) at an urban, university-affiliated MMT clinic. We used existing intake data to assess baseline demographic, substance use, mental health, and interpersonal factors. Primary outcomes were 3-month drug+ (positive) urine drug screen (UDS) results and treatment retention. Results: Women were more likely (than men) to endorse histories of interpersonal violence, substance abuse in their social network, and mental health problems. Men reported a greater likelihood (than women) for early opioid-use onset and a lack of prior MMT. There were no gender differences in 3-month drug+ UDS or treatment retention. In multivariable analyses among women, no baseline factors predicted 3-month opioid+ UDS and physical abuse history predicted a higher proportion of 3-month cocaine+ UDS. Among men, primary injection opioid use and older age best predicted a higher proportion of 3-month cocaine+ UDS and parent substance abuse predicted shorter retention. In both gender-stratified analyses, higher proportions of 3-month opioid+ UDS and cocaine+ UDS predicted shorter retention. Conclusions: This study offers an analysis of gender differences in risk factors, MMT outcomes, and gender-specific predictors among African American patients. MMT clinics should tailor assessment and treatment protocols to address gender-specific needs.
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Affiliation(s)
- Jamey J Lister
- School of Social Work, Wayne State University , Detroit , Michigan , USA.,Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine , Detroit , Michigan , USA
| | - Suzanne Brown
- School of Social Work, Wayne State University , Detroit , Michigan , USA
| | - Mark K Greenwald
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine , Detroit , Michigan , USA.,Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University , Detroit , Michigan , USA
| | - David M Ledgerwood
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine , Detroit , Michigan , USA
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Duber HC, Barata IA, Cioè-Peña E, Liang SY, Ketcham E, Macias-Konstantopoulos W, Ryan SA, Stavros M, Whiteside LK. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department. Ann Emerg Med 2018; 72:420-431. [PMID: 29880438 PMCID: PMC6613583 DOI: 10.1016/j.annemergmed.2018.04.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/09/2018] [Accepted: 04/11/2018] [Indexed: 01/03/2023]
Abstract
Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the focus within the emergency medicine community has been on opioid prescribing-specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment-interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.
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Affiliation(s)
- Herbert C Duber
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Isabel A Barata
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Eric Cioè-Peña
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Stephen Y Liang
- Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine, St. Louis, MO
| | - Eric Ketcham
- San Juan Regional Medical Center, Farmington, NM
| | | | - Shawn A Ryan
- Department of Emergency Medicine, University of Cincinnati, and BrightView, Cincinnati, OH
| | - Mark Stavros
- Department of Emergency Medicine, Florida State University, Tallahassee, FL
| | - Lauren K Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
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39
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Kharasch ED. Current Concepts in Methadone Metabolism and Transport. Clin Pharmacol Drug Dev 2018; 6:125-134. [PMID: 28263461 DOI: 10.1002/cpdd.326] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 11/07/2016] [Indexed: 12/17/2022]
Abstract
Methadone is a cornerstone therapy for opioid addiction and a public health strategy for HIV/AIDS and hepatitis C reduction. Methadone is also used for acute and chronic pain. As use for chronic pain has grown, so too have adverse events. Constitutive and acquired (drug interactions) inter- and intraindividual variability in methadone pharmacokinetics and pharmacodynamics confounds reliable clinical use. Identification of enzymes and transporters responsible for methadone disposition has been a long-sought ideal. Initial in vitro studies identified CYP3A4 as metabolizing methadone. Subsequently, by extrapolation, CYP3A4 was long assumed to be responsible for clinical methadone disposition. However, CYP2B6 is also a major catalyst of methadone metabolism in vitro. It has now been unequivocally established that CYP2B6, not CYP3A4, is the principal determinant of methadone metabolism, clearance, elimination, and plasma concentrations in humans. Methadone disposition is susceptible to inductive and inhibitory drug interactions. CYP2B6 genetics also influences methadone metabolism and clearance, which were diminished in CYP2B6*6 carriers and increased in CYP2B6*4 carriers. CYP2B6 genetics can explain, in part, interindividual variability in methadone metabolism and clearance. Thus, both constitutive variability due to CYP2B6 genetics, and CYP2B6-mediated drug interactions, can alter methadone disposition, clinical effect, and drug safety. Methadone is not a substrate for major influx or efflux transporters.
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Affiliation(s)
- Evan D Kharasch
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA.,Department of Biochemistry and Biophysics, Washington University in St. Louis, St. Louis, MO, USA.,The Center for Clinical Pharmacology, St. Louis College of Pharmacy and Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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40
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Parpouchi M, Moniruzzaman A, Rezansoff SN, Russolillo A, Somers JM. The effect of Housing First on adherence to methadone maintenance treatment. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 56:73-80. [DOI: 10.1016/j.drugpo.2018.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/08/2018] [Accepted: 03/13/2018] [Indexed: 11/28/2022]
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Schuster M, Bayer O, Heid F, Laufenberg-Feldmann R. Opioid Rotation in Cancer Pain Treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:135-142. [PMID: 29563006 PMCID: PMC5876542 DOI: 10.3238/arztebl.2018.0135] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 07/11/2016] [Accepted: 11/14/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Rotating several different WHO level III opioid drugs is a therapeutic option for patients with chronic cancer-related pain who suffer from inadequate analgesia and/or intolerable side effects. The evidence favoring opioid rotation is controversial, and the current guidelines in Germany and other countries contain only weak recommendations for it. METHODS This review is based on pertinent publications retrieved by a systematic review of the literature on opioid rotation for adult patients with chronic cancerrelated pain who are regularly taking WHO level III opioids by the oral or trans - dermal route. RESULTS 9 individual studies involving a total of 725 patients were included in the analysis, and 3 previous systematic reviews of studies involving a total of 2296 patients were also analyzed. Morphine, oxycodone, fentanyl, hydromorphone, and buprenorphine were used as first-line opioid drugs, and hydromorphone, bupre - norphine, tapentadol, fentanyl, morphine, oxymorphone, and methadone were used as second-line opioid drugs. In all of the studies, pain control was achieved for 14 days after each rotation. In most of them, the dose of the new drug introduced in each rotation needed to be increased above the dose initially calculated from a rotation ratio, with the exception of rotations to methadone. The frequency of side effects was only rarely lessened, but patients largely considered the result of opioid rotation to be positive. No particular opioid drug was found to be best. CONCLUSION Opioid rotation can improve analgesia and patient satisfaction. The success of opioid rotation appears to depend on the magnitude of the initial dose, among other factors. Tables of equianalgesic doses should be considered no more than a rough guide for determining the dose of the new drug. Rotations to methadone should be carried out under clinical supervision in experienced hands.
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Affiliation(s)
| | - Oliver Bayer
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Hospital Mainz
| | - Florian Heid
- Department of Anesthesiology, University Hospital Mainz
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Leaving Hospital Against Medical Advice After Methadone Discontinuation in the Intensive Care Unit: A Case Report. CANADIAN JOURNAL OF ADDICTION 2018. [DOI: 10.1097/cxa.0000000000000010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dematteis M, Auriacombe M, D’Agnone O, Somaini L, Szerman N, Littlewood R, Alam F, Alho H, Benyamina A, Bobes J, Daulouede JP, Leonardi C, Maremmani I, Torrens M, Walcher S, Soyka M. Recommendations for buprenorphine and methadone therapy in opioid use disorder: a European consensus. Expert Opin Pharmacother 2017; 18:1987-1999. [DOI: 10.1080/14656566.2017.1409722] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Maurice Dematteis
- Department of Addiction Medicine, Grenoble Alpes University Hospital, Grenoble, France
- Faculty of Medicine, Grenoble Alpes University, Grenoble, France
| | - Marc Auriacombe
- Université de Bordeaux, Bordeaux, France
- Addiction Psychiatry Team, SANPsy CNRS USR, Bordeaux, France
- Pôle Addictologie, CH Ch. Perrens and CHU Bordeaux, Bordeaux, France
| | - Oscar D’Agnone
- Faculty of Medical and Human Sciences, Institute of Brain Behaviour and Mental Health, University of Manchester, Manchester, UK
| | | | - Néstor Szerman
- Department of Psychiatry, Hospital Universitario Gregorio Marañon, Madrid, Spain
| | | | - Farrukh Alam
- Divisional Medical Director, Central & North West London NHS Foundation Trust, London, UK
| | - Hannu Alho
- Abdominal Center, University Hospital and University of Helsinki, Helsinki, Finland
| | - Amine Benyamina
- Centre d’Enseignement, de Recherche et de Traitement des Addictions, AP-HP, Paris-Sud University Hospital Group, Paul Brousse site, Paris-Sud University, Villejuif, France
| | - Julio Bobes
- Department of Psychiatry, University of Oviedo-CIBERSAM, Oviedo, Spain
| | - Jean Pierre Daulouede
- Université de Bordeaux, Bordeaux, France
- Addiction Psychiatry Team, SANPsy CNRS USR, Bordeaux, France
- Centre d׳Addictologie, BIZIA and CH Bayonne, Bayonne, France
| | - Claudio Leonardi
- Drug Addiction Department, Local Public Health ASL Rome 2, Rome, Italy
| | - Icro Maremmani
- Santa Chiara University Hospital, University of Pisa, Pisa, Italy
| | - Marta Torrens
- Department of Psychiatry and Legal Medicine, Universidad Autonoma de Barcelona, Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, IMIM (Hospital del Mar Medical Research Institut), Barcelona, Spain
| | | | - Michael Soyka
- Department of Psychiatry, Ludwig Maximilian University, Munich, Germany
- Medical Park Ciemseeblick, Bernau-Felden, Germany
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Abstract
Our goal consisted of describing the 4-year prevalence, contributors, and interventions for long QTc's in methadone maintenance treatment. Cardiologists' diagnosis of long QTc defined case-ness in 62 patients. Long QTc categories, drawn from epidemiological reports, encompassed 440 to 469 (borderline), 470 to 499 (moderate), and 500+ milliseconds (severe). Data collection included electrocardiograms, demographic characteristics, contributors to long QTc, and interventions-plus-outcomes (defined by resolution of long QTc). Of 62 patients, 21 had 39 long QTc episodes-a 4-year case prevalence of 34%, and an annual episode incidence of 15.7 per 100. Contributing factors identified in 36 of 39 episodes consisted of medication management (n = 19), illicit drug use (n = 11), and other factors (n = 6). Long QTc reverted to normal in 38 of 39 episodes. Of 21 patients, 12 (57%) experienced one or two recurrences. Methadone maintenance treatment physicians normalized most episodes as outpatients, often in collaboration with patients' primary care physicians. One fifth of episodes required hospitalization and other specialty care. Lack of timely QTc normalization may have accounted for one sudden death.
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Trujols J, González-Saiz F, Manresa MJ, Alcaraz S, Batlle F, Duran-Sindreu S, Pérez de Los Cobos J. Patient perception of methadone dose adequacy in methadone maintenance treatment: The role of perceived participation in dosage decisions. PATIENT EDUCATION AND COUNSELING 2017; 100:981-986. [PMID: 27988071 DOI: 10.1016/j.pec.2016.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 11/13/2016] [Accepted: 12/10/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE In clinical practice, methadone maintenance treatment (MMT) entails tailoring the methadone dose to the patient's specific needs, thereby individualizing treatment. The aim of this study was to identify the independent factors that may significantly explain methadone dose adequacy from the patient's perspective. METHOD Secondary analysis of data collected in a treatment satisfaction survey carried out among a representative sample of MMT patients (n=122) from the region of La Rioja (Spain). As part of the original study protocol, participants completed a comprehensive battery to assess satisfaction with MMT, psychological distress, opinion of methadone as a medication, participation in dosage decisions, and perception of dose adequacy. RESULTS Multivariate binary logistic regression showed that the only variable independently associated with the likelihood of a patient perceiving methadone dose as inadequate was the variable perceived-participation in methadone dosage decisions (OR=0.538, 95% CI=0.349-0.828). CONCLUSION Patient participation in methadone dosage decisions was predictive of perceived adequacy of methadone dose beyond the contribution of other socio-demographic, clinical, and MMT variables. PRACTICE IMPLICATIONS Patient participation in methadone dosage decision-making is valuable for developing a genuinely patient-centred MMT.
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Affiliation(s)
- Joan Trujols
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain; Biomedical Research Networking Center on Mental Health (CIBERSAM), Barcelona, Spain.
| | - Francisco González-Saiz
- Community Mental Health Unit of Villamartín, Mental Health Clinical Management Unit of Hospital de Jerez de la Frontera, Northern Area Health Management of Cádiz, Andalusian Health Service, Spain; Addictive Disorders Network (RTA), Granada, Spain
| | - María José Manresa
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Saul Alcaraz
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Francesca Batlle
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain; Department of Psychiatry and Forensic Medicine, School of Medicine, Autonomous University of Barcelona (UAB), Bellaterra, Spain
| | - Santiago Duran-Sindreu
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain; Biomedical Research Networking Center on Mental Health (CIBERSAM), Barcelona, Spain
| | - José Pérez de Los Cobos
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain; Biomedical Research Networking Center on Mental Health (CIBERSAM), Barcelona, Spain; Department of Psychiatry and Forensic Medicine, School of Medicine, Autonomous University of Barcelona (UAB), Bellaterra, Spain
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46
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Lister JJ, Greenwald MK, Ledgerwood DM. Baseline risk factors for drug use among African-American patients during first-month induction/stabilization on methadone. J Subst Abuse Treat 2017; 78:15-21. [PMID: 28554598 DOI: 10.1016/j.jsat.2017.04.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 04/09/2017] [Accepted: 04/11/2017] [Indexed: 12/17/2022]
Abstract
Drug use during methadone induction/stabilization negatively influences later methadone-maintenance-treatment [MMT] outcomes (retention, abstinence). Our study examined the association of baseline risk factors to drug use during the first month of methadone treatment as well as longer-term treatment retention. We conducted these analyses among a race/ethnic minority group at high risk for worse MMT outcomes. African-American MMT patients (N=212) were interviewed at intake to assess clinical (drug use history), psychosocial (close family member substance abuse, psychosocial problems), and demographic factors. Outcomes were first-month opioid+ and cocaine+ urine drug screen [UDS] results and retention (days in treatment). In bivariate analyses, co-occurring cocaine abuse/dependence was associated with worse outcomes for opioid+ UDS, cocaine+ UDS, and retention. Being a primary injection opioid user and residing farther from the clinic were associated with a higher proportion of cocaine+ UDS and shorter retention, respectively. Patients with a significant other substance abuse history provided a higher proportion of both opioid+ and cocaine+ UDS. Sibling and parent substance abuse histories were associated with a higher proportion of opioid+ UDS and shorter retention. Psychosocial problems (economic, housing) were associated with a higher proportion of cocaine+ UDS. In multivariate analyses, co-occurring cocaine abuse/dependence and primary injection opioid use best accounted for first-month opioid+ and cocaine+ UDS, respectively. A higher proportion of first-month opioid+ and cocaine+ UDS and living farther from the clinic accounted for retention. African-American patients reporting baseline risk factors (particularly clinical) experience worse short- and long-term MMT outcomes. Recommendations for improving standards of care are discussed.
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Affiliation(s)
- Jamey J Lister
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA; School of Social Work, Wayne State University, Detroit, MI, USA.
| | - Mark K Greenwald
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA; Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| | - David M Ledgerwood
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA.
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47
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Peles E, Sason A, Schreiber S, Adelson M. Newborn birth-weight of pregnant women on methadone or buprenorphine maintenance treatment: A national contingency management approach trial. Am J Addict 2017; 26:167-175. [PMID: 28191917 DOI: 10.1111/ajad.12508] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 01/09/2017] [Accepted: 01/28/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Methadone maintenance treatment (MMT) is the gold standard for pregnant women with opioid use disorders. Still, low birth-weights were reported, in particular of mothers who became pregnant before admission to MMT. We studied whether an escalating incentive contingency-management approach may contribute to better newborn birth-weights. METHODS A nationwide controlled randomized trial among all Israeli methadone/buprenorphine maintenance treatment (MBMT), newly or already in treatment pregnant women was performed. A modified contingency-management protocol with coupons of escalating value depending upon reduction of drug use, cigarette smoking, and alcohol consumption was compared to standard care arm. Drugs in urine, smoking (Fagerstrom score), alcohol use, and depression were monitored. RESULTS Thirty-five women had 46 pregnancies. In their first pregnancy, 19 from the contingency-management and 16 from the standard care arms were studied. Contingency-management group as compared to the standard care arm included more newly admitted women (36.8% vs. 6.3%, p = .05), with benzodiazepine and cannabis onset at a younger age, and higher proportion of any drug abuse while pregnant (100% vs. 68.8%, p = .01). Fifteen of the contingency-management and 14 of the control arm gave birth (78.9% vs. 87.5%, p = .3) with similar proportions of normal (>2,500 g) birth-weight (71.4% vs. 61.5%, p = .8). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Newborns' birth-weight was comparable among the two study arms indicating no contribution of the contingency-management approach. Small sample and baseline differences between arms might have influenced results. Intensive intervention should be evaluated on a larger scale of participants. (Am J Addict 2017;26:167-175).
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Affiliation(s)
- Einat Peles
- Dr Miriam and Sheldon G. Adelson Clinic for Drug Abuse, Treatment and Research, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Anat Sason
- Dr Miriam and Sheldon G. Adelson Clinic for Drug Abuse, Treatment and Research, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shaul Schreiber
- Dr Miriam and Sheldon G. Adelson Clinic for Drug Abuse, Treatment and Research, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.,Department of Psychiatry, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Miriam Adelson
- Dr Miriam and Sheldon G. Adelson Clinic for Drug Abuse, Treatment and Research, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
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Some Additional Considerations Regarding the American Society of Addiction Medicine National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. J Addict Med 2017; 10:140-2. [PMID: 27223833 DOI: 10.1097/adm.0000000000000219] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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49
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Donroe JH, Holt SR, Tetrault JM. Caring for patients with opioid use disorder in the hospital. CMAJ 2016; 188:1232-1239. [PMID: 27647616 PMCID: PMC5135493 DOI: 10.1503/cmaj.160290] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Joseph H Donroe
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, Conn.
| | - Stephen R Holt
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Jeanette M Tetrault
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, Conn
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Marienfeld C, Liu P, Wang X, Schottenfeld R, Zhou W, Chawarski MC. Evaluation of an implementation of methadone maintenance treatment in China. Drug Alcohol Depend 2015; 157:60-7. [PMID: 26601934 PMCID: PMC4663107 DOI: 10.1016/j.drugalcdep.2015.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 08/24/2015] [Accepted: 10/01/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Methadone maintenance treatment (MMT) reduces the harms of opioid use disorder and is being rapidly scaled-up in China. This study evaluated the real-world implementation of MMT system in Wuhan, China. METHODS Data extracted from electronic medical records collected in 2010 on 8811 patients were used to compute for each patient indices of the prescribed and consumed daily methadone doses, an adherence index, dose adjustments following missed doses, the rates of opiate positive urine tests, self-reported drug use, injection drug use (IDU), and the duration of MMT exposure. FINDINGS The modal daily doses prescribed were 60 mg and above for 68.5% of patients. Adherence was variable: 51% of patients attended less than 60% and 26% attended 80-100% of their treatment days; and patients with long MMT exposure had significantly higher adherence rates than patients with short MMT exposure. The differences between doses dispensed immediately before and after the interruption in dosing days ranged from 0 to 7 mg, independently of the length of the interruption or the prescribed dosing level. The overall rate of opiate positive tests was 20%; 45% of patients had at least one opiate positive test; 29% reported past month drug use and 53% of them reported past month IDU. Adherence and MMT exposure duration correlated significantly with the proportion of opiate negative urine tests (r=0.355, p<0.001; r=0.351, p<0.001, respectively). Treatment for males and females was comparable. CONCLUSIONS Provision of safe methadone dosing after absences and improving daily attendance are identified as priority improvement areas.
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Affiliation(s)
- Carla Marienfeld
- Yale School of Medicine, Department of Psychiatry, 34 Park Street, New Haven, CT 06519, United States
| | - Pulin Liu
- Wuhan Centers for Disease Prevention and Control, 24 Jianghan North Road, Wuhan, PR China; Tongji Medical College, School of Public Health, Huazhong University of Science & Technology, 13 Hangkong Road, Wuhan, PR China
| | - Xia Wang
- Wuhan Centers for Disease Prevention and Control, 24 Jianghan North Road, Wuhan, PR China
| | - Richard Schottenfeld
- Yale School of Medicine, Department of Psychiatry, 34 Park Street, New Haven, CT 06519, United States
| | - Wang Zhou
- Wuhan Centers for Disease Prevention and Control, 24 Jianghan North Road, Wuhan, PR China.
| | - Marek C Chawarski
- Yale School of Medicine, Department of Psychiatry, 34 Park Street, New Haven, CT 06519, United States.
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