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Hammerslag LR, Talbert J, Slavova S, Lei F, Freeman PR, Marks KR, Fanucchi LC, Walsh SL, Lofwall MR. Utilization of long-acting injectable monthly depot buprenorphine for opioid use disorder (OUD) in Kentucky, before and after COVID-19 related buprenorphine access policy changes. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 164:209391. [PMID: 38740189 DOI: 10.1016/j.josat.2024.209391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 04/15/2024] [Accepted: 05/06/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Long-acting injectable buprenorphine (LAI-bup) formulations have advantages over transmucosal buprenorphine (TM-bup), but barriers may limit their utilization. Several policies shifted during the COVID-19 pandemic to promote buprenorphine access. The federal government expanded telemedicine treatment for opioid use disorder and Kentucky (KY) Medicaid lifted prior authorization requirements (PAs) for LAI-bup (i.e., Sublocade®). This retrospective cohort study evaluated changes in LAI-bup access, utilization, and retention before and after these policy changes in KY. METHODS Individual-level TM-bup and LAI-bup dispensing record data from KY's prescription drug monitoring program examined LAI-bup utilization and retention, without a >30-day gap in coverage, for patients starting a new episode of LAI-bup treatment. Two key time periods were examined: pre-policy changes (Apr 1, 2019 - Dec 31, 2019) and post-policy changes (Apr 1, 2020 - Dec 31, 2020). Data on PA requests among Medicaid managed care organizations and availability of LAI-bup Risk Evaluation and Mitigation Strategy (REMS)-certified pharmacies were also obtained. A multivariable Cox proportional hazard regression model analysis compared pre- versus post-policy period treatment discontinuation. RESULTS The number of patients initiating LAI-bup increased from 211 to 481 over the two periods. By the end of the post-policy period, 24.3 % of eligible patients were retained on LAI-bup, versus 12.5 % in the pre-policy change period. The adjusted hazard ratio, comparing discontinuation during the post- versus pre-policy change periods, was 0.70 (95 % confidence interval: 0.55-0.89). There were also more REMS-certified pharmacies and providers in the post-policy change period. CONCLUSIONS LAI-bup access, utilization, and retention increased after several policy changes.
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Affiliation(s)
- Lindsey R Hammerslag
- Institute for Biomedical Informatics, College of Medicine, University of Kentucky, United States of America; Department of Internal Medicine, College of Medicine, University of Kentucky, United States of America.
| | - Jeffery Talbert
- Institute for Biomedical Informatics, College of Medicine, University of Kentucky, United States of America; Department of Internal Medicine, College of Medicine, University of Kentucky, United States of America
| | - Svetla Slavova
- Department of Biostatistics, College of Public Health, University of Kentucky, United States of America
| | - Feitong Lei
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, United States of America
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, United States of America
| | - Katherine R Marks
- Department of Behavioral Science, College of Medicine, University of Kentucky, United States of America
| | - Laura C Fanucchi
- Department of Internal Medicine, College of Medicine, University of Kentucky, United States of America; Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, United States of America
| | - Sharon L Walsh
- Department of Behavioral Science, College of Medicine, University of Kentucky, United States of America; Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, United States of America
| | - Michelle R Lofwall
- Department of Behavioral Science, College of Medicine, University of Kentucky, United States of America; Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, United States of America
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Christine PJ, Chahine RA, Kimmel SD, Mack N, Douglas C, Stopka TJ, Calver K, Fanucchi LC, Slavova S, Lofwall M, Feaster DJ, Lyons M, Ezell J, Larochelle MR. Buprenorphine Prescribing Characteristics Following Relaxation of X-Waiver Training Requirements. JAMA Netw Open 2024; 7:e2425999. [PMID: 39102264 DOI: 10.1001/jamanetworkopen.2024.25999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024] Open
Abstract
Importance Local-level data are needed to understand whether the relaxation of X-waiver training requirements for prescribing buprenorphine in April 2021 translated to increased buprenorphine treatment. Objective To assess whether relaxation of X-waiver training requirements was associated with changes in the number of clinicians waivered to and who prescribe buprenorphine for opioid use disorder and the number of patients receiving treatment. Design, Setting, and Participants This serial cross-sectional study uses an interrupted time series analysis of 2020-2022 data from the HEALing Communities Study (HCS), a cluster-randomized, wait-list-controlled trial. Urban and rural communities in 4 states (Kentucky, Massachusetts, New York, and Ohio) with a high burden of opioid overdoses that had not yet received the HCS intervention were included. Exposure Relaxation of X-waiver training requirements (ie, allowing training-exempt X-waivers) on April 28, 2021. Main Outcomes and Measures The monthly number of X-waivered clinicians, X-waivered buprenorphine prescribers, and patients receiving buprenorphine were each summed across communities within a state. Segmented linear regression models to estimate pre- and post-policy change by state were used. Results The number of individuals in 33 participating HCS communities included 347 863 in Massachusetts, 815 794 in Kentucky, 971 490 in New York, and 1 623 958 in Ohio. The distribution of age (18-35 years: range, 29.4%-32.4%; 35-54 years: range, 29.9%-32.5%; ≥55 years: range, 35.7%-39.3%) and sex (female: range, 51.1%-52.6%) was similar across communities. There was a temporal increase in the number of X-waivered clinicians in the pre-policy change period in all states, which further increased in the post-policy change period in each state except Ohio, ranging from 5.2% (95% CI, 3.1%-7.3%) in Massachusetts communities to 8.4% (95% CI, 6.5%-10.3%) in Kentucky communities. Only communities in Kentucky showed an increase in the number of X-waivered clinicians prescribing buprenorphine associated with the policy change (relative increase, 3.2%; 95% CI, 1.5%-4.9%), while communities in other states showed no change or a decrease. Similarly, only communities in Massachusetts experienced an increase in patients receiving buprenorphine associated with the policy change (relative increase, 1.7%; 95% CI, 0.8%-2.6%), while communities in other states showed no change. Conclusions and Relevance In this serial cross-sectional study, relaxation of X-waiver training requirements was associated with an increase in the number of X-waivered clinicians but was not consistently associated with an increase in the number of buprenorphine prescribers or patients receiving buprenorphine. These findings suggest that training requirements may not be the primary barrier to expanding buprenorphine treatment.
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Affiliation(s)
- Paul J Christine
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
- Department of General Internal Medicine, Denver Health and Hospital Authority, Denver, Colorado
| | - Rouba A Chahine
- Social, Statistical, and Environmental Sciences, Research Triangle Institute, Research Triangle Park, North Carolina
| | - Simeon D Kimmel
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Nicole Mack
- Social, Statistical, and Environmental Sciences, Research Triangle Institute, Research Triangle Park, North Carolina
| | - Christian Douglas
- Social, Statistical, and Environmental Sciences, Research Triangle Institute, Research Triangle Park, North Carolina
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Katherine Calver
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Laura C Fanucchi
- Division of Infectious Diseases, College of Medicine, University of Kentucky, Lexington
- Center on Drug and Alcohol Research, University of Kentucky, Lexington
| | - Svetla Slavova
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington
- Kentucky Injury Prevention Research Center, University of Kentucky, Lexington
| | - Michelle Lofwall
- Center on Drug and Alcohol Research, University of Kentucky, Lexington
- Department of Behavioral Science and Psychiatry, University of Kentucky, Lexington
| | - Daniel J Feaster
- Division of Health Services Research and Policy, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Michael Lyons
- Department of Emergency Medicine, College of Medicine, The Ohio State University, Columbus
| | - Jerel Ezell
- Division of Community Health Sciences, School of Public Health, University of California, Berkeley
| | - Marc R Larochelle
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts
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Braun HM, Taylor JL, Axelrath S. Buprenorphine/naloxone - one formulation that doesn't fit all: a case report. Harm Reduct J 2024; 21:143. [PMID: 39080714 PMCID: PMC11287853 DOI: 10.1186/s12954-024-01054-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 07/03/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND Sublingual buprenorphine, approved for treatment of opioid use disorder since 2002, is most commonly available in co-formulation with naloxone. Naloxone is an opioid antagonist minimally absorbed when sublingual (SL) buprenorphine/naloxone is taken as prescribed; it is thought to reduce potential for misuse via intravenous administration. However, growing data and clinical experience demonstrate that previously accepted assumptions about the pharmacokinetics of these medications may not apply to all patients. CASE PRESENTATION We present a patient whose adverse post-administration side effects on SL buprenorphine/naloxone resolved with transition to SL buprenorphine monoproduct. DISCUSSION Naloxone can be detected in nearly all patients taking SL buprenorphine/naloxone, though with apparent variability in clinical effect. In a minority of patients, naloxone can contribute to adverse and potentially treatment-limiting side effects. Furthermore, the naloxone component is commonly misunderstood by patients and providers and can foster mistrust in the therapeutic relationship if providers are perceived to be withholding a more tolerable formulation. Prescribers should have a low threshold to offer buprenorphine alone when clinically appropriate.
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Affiliation(s)
- Hannan M Braun
- Division of General Internal Medicine, Denver Health and Hospital Authority, 301 W 6th Ave, Denver, 80204, CO, USA.
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Jessica L Taylor
- General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, USA
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Jain L, Meeks TW, Blazes CK. Reconsidering the usefulness of long-term high-dose buprenorphine. Front Psychiatry 2024; 15:1401676. [PMID: 39114740 PMCID: PMC11303732 DOI: 10.3389/fpsyt.2024.1401676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 07/04/2024] [Indexed: 08/10/2024] Open
Abstract
Buprenorphine has been successfully used for decades in the treatment of opioid use disorder, yet there are complexities to its use that warrant attention to maximize its utility. While the package insert of the combination product buprenorphine\naloxone continues to recommend a maximum dose of 16 mg daily for maintenance, the emergence of fentanyl and synthetic analogs in the current drug supply may be limiting the effectiveness of this standard dose. Many practitioners have embraced and appropriately implemented novel practices to mitigate the sequelae of our current crisis. It has become common clinical practice to stabilize patients with 24 - 32 mg of buprenorphine daily at treatment initiation. Many of these patients, however, are maintained on these high doses (>16 mg/d) indefinitely, even after prolonged stability. Although this may be a necessary strategy in the short term, there is little evidence to support its safety and efficacy, and these high doses may be exposing patients to more complications and side effects than standard doses. Commonly known side effects of buprenorphine that are likely dose-related include hyperhidrosis, sedation, decreased libido, constipation, and hypogonadism. There are also complications related to the active metabolite of buprenorphine (norbuprenorphine) which is a full agonist at the mu opioid receptor and does not have a ceiling on respiratory suppression. Such side effects can lead to medical morbidity as well as decreased medication adherence, and we, therefore, recommend that after a period of stabilization, practitioners consider a trial of decreasing the dose of buprenorphine toward standard dose recommendations. Some patients' path of recovery may never reach this stabilization phase (i.e., several months of adherence to medications, opioid abstinence, and other clinical indicators of stability). Side effects of buprenorphine may not have much salience when patients are struggling for survival and safety, but for those who are fortunate enough to advance in their recovery, the side effects become more problematic and can limit quality of life and adherence.
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Affiliation(s)
- Lakshit Jain
- Department of Psychiatry, University of Connecticut, Farmington, CT, United States
| | - Thomas W. Meeks
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
| | - Christopher K. Blazes
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
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Mariottini C, Häkkinen M, Kriikku P, Ojanperä I. Buprenorphine deaths confirmed by toxicology reveal a low proportion of opioid agonist treatment before death in Finland. Int J Legal Med 2024:10.1007/s00414-024-03273-5. [PMID: 38910139 DOI: 10.1007/s00414-024-03273-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 06/13/2024] [Indexed: 06/25/2024]
Abstract
We studied opioid agonist treatment (OAT) status before buprenorphine-related death in Finland, where buprenorphine is the principal OAT medicine and also the most misused opioid, through a retrospective population-based study using medico-legal cause-of-death investigation and OAT patient records. The study included all death cases (N = 570) between 2018 and 2020 with a buprenorphine or norbuprenorphine finding in post-mortem toxicology and with known drug misuse history or concomitant findings of illicit drugs. Of the deceased, 10% had received OAT in the year before death. Less than 1% of individuals < 25 years had received OAT, whereas the proportion in individuals ≥ 25 years was 13% (p < 0.001). There were significantly more females and more fatal poisonings (p < 0.001) among those < 25 years than among those ≥ 25 years. OAT medication at the time of death was sublingual buprenorphine-naloxone in 74% and subcutaneous buprenorphine in 23%. Except for significantly fewer benzodiazepine findings among those receiving OAT, minimal differences were found in terms of age, gender, cause and manner of death, or concomitant substance use between the deceased in and outside of OAT. Concomitant misuse of benzodiazepines, psychostimulants, alcohol, and gabapentinoids was frequent both in and outside of OAT and likely contributed to the death. These results suggest that access to OAT especially for young people and treatment of multiple addictions should be improved. Comprehensive information from medico-legal cause-of-death investigation as a starting point, combined with subsequent ante-mortem patient records, proved to be a successful approach to shed light on the Finnish scene of buprenorphine mortality.
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Affiliation(s)
- Claudia Mariottini
- Department of Forensic Medicine, University of Helsinki, P.O. Box 21(Haartmaninkatu 3), Helsinki, 00014, Finland.
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 30, Helsinki, 00271, Finland.
| | - Margareeta Häkkinen
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 30, Helsinki, 00271, Finland
- A-Clinic Ltd, Kuortaneenkatu 2, Helsinki, 00510, Finland
| | - Pirkko Kriikku
- Department of Forensic Medicine, University of Helsinki, P.O. Box 21(Haartmaninkatu 3), Helsinki, 00014, Finland
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 30, Helsinki, 00271, Finland
| | - Ilkka Ojanperä
- Department of Forensic Medicine, University of Helsinki, P.O. Box 21(Haartmaninkatu 3), Helsinki, 00014, Finland
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 30, Helsinki, 00271, Finland
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D'Aunno T, Neighbors CJ. Innovation in the Delivery of Behavioral Health Services. Annu Rev Public Health 2024; 45:507-525. [PMID: 37871139 DOI: 10.1146/annurev-publhealth-071521-024027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Several factors motivate the need for innovation to improve the delivery of behavioral health services, including increased rates of mental health and substance use disorders, limited access to services, inconsistent use of evidence-based practices, and persistent racial and ethnic disparities. This narrative review identifies promising innovations that address these challenges, assesses empirical evidence for the effectiveness of these innovations and the extent to which they have been adopted and implemented, and suggests next steps for research. We review five categories of innovations: organizational models, including a range of novel locations for providing services and new ways of organizing services within and across sites; information and communication technologies; workforce; treatment technologies; and policy and regulatory changes. We conclude by discussing the need to strengthen and accelerate the contributions of implementation science to close the gap between the launch of innovative behavioral health services and their widespread use.
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Affiliation(s)
- Thomas D'Aunno
- Wagner Graduate School of Public Service, New York University, New York, NY, USA;
| | - Charles J Neighbors
- Department of Population Health, Grossman School of Medicine, New York University, New York, NY, USA
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Walsh SL, Comer SD, Zdovc JA, Sarr C, Björnsson M, Strandgården K, Hjelmström P, Tiberg F. Pharmacokinetic-pharmacodynamic analysis of drug liking blockade by buprenorphine subcutaneous depot (CAM2038) in participants with opioid use disorder. Neuropsychopharmacology 2024; 49:1050-1057. [PMID: 38200140 PMCID: PMC11039630 DOI: 10.1038/s41386-023-01793-z] [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: 11/09/2022] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024]
Abstract
Buprenorphine is used to treat opioid use disorder (OUD). Weekly and monthly subcutaneous long-acting buprenorphine injections (CAM2038) provide more stable buprenorphine plasma levels and reduce the treatment burden, misuse, and diversion associated with sublingual transmucosal buprenorphine formulations. To characterize the pharmacokinetic/pharmacodynamic (PK/PD) relationship, a maximum inhibition (Imax) model was developed relating CAM2038 buprenorphine plasma concentration to drug liking maximum effect (Emax) visual analog scale (VAS; bipolar) score after intramuscular hydromorphone administration. Data included time-matched observations of buprenorphine plasma concentration and drug liking Emax VAS score after hydromorphone 18 mg administration in 47 non-treatment-seeking adults with moderate to severe OUD in a phase 2 study. Analysis used non-linear mixed-effects modeling (NONMEM®). The final Imax model adequately described the PK/PD relationship between buprenorphine plasma concentration and drug liking Emax VAS score. Simulations showed drug liking was effectively blocked at low buprenorphine plasma concentrations (0.4 ng/mL) where the upper 95% confidence interval of the drug liking Emax VAS score was below the pre-defined 11-point complete blockade threshold. The buprenorphine plasma concentration required to achieve 90% of the maximal effect (IC90) of drug liking was 0.675 ng/mL. Interindividual variability in responses to buprenorphine was observed; some participants experienced fluctuating responses, and a few did not achieve drug liking blockade even with higher buprenorphine plasma concentrations. This affirms the need to individualize treatment and titrate doses for optimal treatment outcomes. PK/PD models were also developed for desire to use VAS and Clinical Opiate Withdrawal Scale (COWS) scores, with results aligned to those for drug liking.
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Affiliation(s)
- Sharon L Walsh
- Behavioral Science, Pharmacology, Psychiatry and Pharmaceutical Sciences Departments, University of Kentucky College of Medicine and Pharmacy, Kentucky, KY, USA
| | - Sandra D Comer
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | | | | | | | - Peter Hjelmström
- Camurus AB, Lund, Sweden
- Uppsala Monitoring Centre, Uppsala, Sweden
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Johnson B, Monwell B, Capusan AJ. Long-acting injectable depot buprenorphine from a harm reduction perspective in patients with ongoing substance use and multiple psychiatric comorbidities: a qualitative interview study. Harm Reduct J 2024; 21:68. [PMID: 38528531 DOI: 10.1186/s12954-024-00984-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/07/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Long-acting injectable depot buprenorphine may increase access to opioid agonist treatment (OAT) for patients with opioid use disorder in different treatment phases. The aim of this study was to explore the experiences of depot buprenorphine among Swedish patients with ongoing substance use and multiple psychiatric comorbidities. METHOD Semi-structured qualitative interviews were conducted with OAT patients with experience of depot buprenorphine. Recruitment took place at two OAT clinics with a harm reduction focus, specializing in the treatment of patients with ongoing substance use and multiple comorbidities. Nineteen participants were included, 12 men and seven women, with a mean age of 41 years (range 24-56 years), and a mean of 21 years (5-35 years) of experience with illicit substance use. All participants had ongoing substance use and psychiatric comorbidities such as ADHD, anxiety, mood, psychotic and eating disorders. Interviews were transcribed verbatim. Thematic content analysis was conducted both manually and using qualitative data analysis software. RESULTS Participants reported social benefits and positive changes in self-perception and identity. In particular, depot buprenorphine contributed to a realization that it was possible to make life changes and engage in activities not related to substance use. Another positive aspect that emerged from the interviews was a noticeable relief from perceived pressure to divert OAT medication, while some expressed the lack of income from diverted oral/sublingual OAT medication as a negative, but still acceptable, consequence of the depot buprenorphine. Many participants considered that the information provided prior to starting depot buprenorphine was insufficient. Also, not all patients found depot buprenorphine suitable, and those who experienced coercion exhibited particularly negative attitudes towards the medication. CONCLUSIONS OAT patients with ongoing substance use and multiple psychiatric comorbidities reported clear benefits of depot buprenorphine, including changes in self-perception which has been theorized to play an important role in recovery. Clinicians should consider the specific information needs of this population and the extensive diversion of traditional OAT medications in this population to improve the treatment experience and outcomes. Overall, depot buprenorphine is a valuable treatment option for a population in need of harm reduction and may also contribute to psychological changes that may facilitate recovery in those with the greatest need.
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Affiliation(s)
- Björn Johnson
- School of Social Work, Lund University, Lund, Sweden.
| | - Bodil Monwell
- Department of Psychiatry, County Hospital Jönköping, Jönköping, Sweden
- Department of Social Work, Jönköping University, Jönköping, Sweden
| | - Andrea Johansson Capusan
- Department of Psychiatry in Linköping, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Fursman H, Finch E, Xiao L, Lefrançois E, Gupta A, Bartlett M, Latimer J, Chadwick S, Roux C, Morelato M. A snapshot of injecting drug consumption from the analysis of used syringes within the Medically Supervised Injecting Centre in Sydney, Australia. Drug Alcohol Rev 2024; 43:787-798. [PMID: 38145366 DOI: 10.1111/dar.13803] [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: 09/03/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION The administration of illicit drugs by injection is associated with considerable harm, including an increased risk of overdose. The chemical analysis of used syringes can enhance knowledge on injecting drug consumption beyond traditional data sources (self-report surveys). This additional information may be useful during significant global events like the COVID-19 pandemic. This study aimed to examine a snapshot of the drugs injected at the Medically Supervised Injecting Centre (MSIC) in Sydney, Australia, in 2019-2020. METHODS Used syringes were collected from MSIC across three periods throughout 2019 and 2020 (February 2019, March-April 2020 and June-September 2020). Drug residues were extracted from used syringes using methanol before detection by gas chromatography-mass spectrometry and ultra-performance liquid chromatography-tandem mass spectrometry. The chemical analysis results were compared to self-report data obtained from MSIC clients. RESULTS Heroin (46-53%), methamphetamine (24-34%) and pharmaceutical opioids (15-27%) were the most common drug residues detected. The chemically detected drugs had declining coherence with the drugs self-reported by MSIC clients across the time periods examined. DISCUSSION AND CONCLUSIONS There was no significant change in the drugs injected (heroin, methamphetamine and pharmaceutical opioids) across the three periods collected throughout varying COVID-19 lockdown restrictions. Changes in the frequency of other drugs injected and discrepancies between chemical analysis and self-report were potentially related to regulatory changes, degradation or misinformed sales. Routine chemical analysis of used syringes has provided an alternative information source to promote awareness of current drug trends and aid harm reduction.
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Affiliation(s)
- Harrison Fursman
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
| | - Eleanor Finch
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
| | - Linda Xiao
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
| | - Elodie Lefrançois
- School of Criminal Justice, Faculty of Law, Criminal Justice and Public Administration, University of Lausanne, Lausanne, Switzerland
| | - Anjali Gupta
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
| | - Mark Bartlett
- Uniting Medically Supervised Injecting Centre, Sydney, Australia
| | - Julie Latimer
- Uniting Medically Supervised Injecting Centre, Sydney, Australia
| | - Scott Chadwick
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
| | - Claude Roux
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
| | - Marie Morelato
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
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McPherson SM, Smith CL, Hall L, Miguel AQ, Bowden T, Keever A, Schmidt A, Olson K, Rodin N, McDonell MG, Roll JM, LeBrun J. Mobile Medication Adherence Platform for Buprenorphine (MAP4BUP): A Phase I feasibility, usability and efficacy pilot randomized clinical trial. Drug Alcohol Depend 2024; 256:111099. [PMID: 38306822 PMCID: PMC10923156 DOI: 10.1016/j.drugalcdep.2024.111099] [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: 05/29/2023] [Revised: 01/05/2024] [Accepted: 01/11/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND/AIM Poor medication adherence is one of the main barriers to the long-term efficacy of buprenorphine/naloxone (BUP/NAL). The aims of this pilot investigation were to examine if a Bluetooth-enabled pill cap and mobile application is a feasible, usable tool for increasing BUP/NAL adherence among people with an opioid use disorder. METHODS This pilot randomized clinical trial (RCT; total n = 41) lasted 12 weeks and was conducted in two office-based BUP/NAL provider locations in Spokane, WA and Coeur d'Alene, ID from January 2020 to September of 2021 with an 11-month gap due to COVID-19. Patients receiving BUP/NAL who consented to participate were randomized to receive the pill cap device (PLY group; n = 19) or a service as usual (SAU group; n = 22) group that included an identical but inactive cap for their bottle. The PLY group received reminders via text and voice, and the support of a "helper" (e.g., friend) to monitor pill cap openings. RESULTS Most participants in PLY group found the device both feasible (92.86 %) and usable (78.57 %). Most participants liked using the device (92.86 %) and were satisfied with the device (85.71 %). While not statistically different from one another, medication adherence per the Medication Possession Ratio was 75 % in the SAU group and 84 % in the PLY group. Pill cap openings were significantly higher in the PLY group with an average of 91.8 openings versus the SAU group's average of 56.7 (p < 0.05). CONCLUSION The devices was feasible, usable, and patients had high levels of satisfaction. The device was associated with increased pill openings.
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Affiliation(s)
- Sterling M McPherson
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States; Analytics and PsychoPharmacology Laboratory (APPL), Washington State University, Spokane, WA, United States; Program of Excellence in Addiction Research (PEAR), Washington State University, Spokane, WA, United States.
| | - Crystal L Smith
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States; Analytics and PsychoPharmacology Laboratory (APPL), Washington State University, Spokane, WA, United States; Program of Excellence in Addiction Research (PEAR), Washington State University, Spokane, WA, United States
| | - Luke Hall
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States; Analytics and PsychoPharmacology Laboratory (APPL), Washington State University, Spokane, WA, United States; Program of Excellence in Addiction Research (PEAR), Washington State University, Spokane, WA, United States
| | - André Q Miguel
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States; Analytics and PsychoPharmacology Laboratory (APPL), Washington State University, Spokane, WA, United States; Program of Excellence in Addiction Research (PEAR), Washington State University, Spokane, WA, United States
| | - Theresa Bowden
- Analytics and PsychoPharmacology Laboratory (APPL), Washington State University, Spokane, WA, United States; Program of Excellence in Addiction Research (PEAR), Washington State University, Spokane, WA, United States; College of Nursing, Washington State University, Spokane, WA, United States
| | - Abigail Keever
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States; Analytics and PsychoPharmacology Laboratory (APPL), Washington State University, Spokane, WA, United States; Program of Excellence in Addiction Research (PEAR), Washington State University, Spokane, WA, United States
| | - Alex Schmidt
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States; Analytics and PsychoPharmacology Laboratory (APPL), Washington State University, Spokane, WA, United States; Program of Excellence in Addiction Research (PEAR), Washington State University, Spokane, WA, United States
| | | | - Nicole Rodin
- Analytics and PsychoPharmacology Laboratory (APPL), Washington State University, Spokane, WA, United States; Program of Excellence in Addiction Research (PEAR), Washington State University, Spokane, WA, United States; College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, United States
| | - Michael G McDonell
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States; Program of Excellence in Addiction Research (PEAR), Washington State University, Spokane, WA, United States
| | - John M Roll
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States; Program of Excellence in Addiction Research (PEAR), Washington State University, Spokane, WA, United States
| | - Jeff LeBrun
- Optimize Health, 5601 22nd Ave NW #200, Seattle, WA, United States
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11
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Bontemps AP, Chana SM, Hawes ES, Rawi YA, Cenczyk CE, Atkins LR, Li L, Cropsey KL. Predictors of MOUD referral among persons with involvement in the criminal legal system. J Opioid Manag 2024; 20:97-102. [PMID: 38700390 DOI: 10.5055/jom.0831] [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: 05/05/2024]
Abstract
INTRODUCTION Opioid use disorder (OUD) is a significant cause of opioid-related fatality, and while medications to treat OUD (MOUD) are effective, disparities remain in the access and uptake of such medications. This study investigated factors that may influence referral to and initiation of MOUD treatment. METHODS Data from electronic medical records of 677 patients with a history of criminal legal system involvement in a recovery program were used to examine the flow of MOUD referral. RESULTS Among patients identified as potentially eligible for MOUD treatment, about 38.0 percent were referred and 18.8 percent were confirmed to initiate MOUD treatment. Logistic regression analyses highlighted female gender and unemployment due to incarceration as positive and negative predictors of referral, respectively. The Chi-square test revealed that women and uninsured patients were more likely to initiate referred MOUD treatment. CONCLUSIONS Data highlight the need for greater connection between referral agencies and MOUD treatment providers, considering factors that may influence referral.
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Affiliation(s)
- Andrew P Bontemps
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, Alabama. ORCID: https://orcid.org/0000-0003-1902-3045
| | - Sofia Mildrum Chana
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth S Hawes
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yoser Al Rawi
- Cahaba Family Medicine Residency, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christina E Cenczyk
- Substance Abuse Division, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lindsey R Atkins
- Substance Abuse Division, University of Alabama at Birmingham, Birmingham, Alabama
| | - Li Li
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Karen L Cropsey
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, Alabama
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12
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Burstin H, Clark KJ, Duff N, Dopp AL, Bentley E, Wattenberg S, Sandbrink F, Beale RR, Ling SM, Eaton E, Freiling E, Salman A. Integrating Telehealth and Traditional Care in Chronic Pain Management and Substance Use Disorder Treatment: An Action Agenda for Building the Future State of Hybrid Care. NAM Perspect 2023; 2023:202310b. [PMID: 38784634 PMCID: PMC11114598 DOI: 10.31478/202310b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
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13
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Tay Wee Teck J, Gittins R, Zlatkute G, Oteo Pérez A, Galea-Singer S, Baldacchino A. Developing a Theoretically Informed Implementation Model for Telemedicine-Delivered Medication for Opioid Use Disorder: Qualitative Study With Key Informants. JMIR Ment Health 2023; 10:e47186. [PMID: 37851506 PMCID: PMC10620637 DOI: 10.2196/47186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/16/2023] [Accepted: 09/02/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Telemedicine-delivered medication for opioid use disorder (TMOUD) has become more prevalent during the COVID-19 pandemic, particularly in North America. This is considered a positive development as TMOUD has the potential to increase access to evidence-based treatment for a population heavily affected by the opioid crisis and consequent rising mortality and morbidity rates in relation to opioid use disorder. Despite the increase in the use of TMOUD, there are no established service- and process-focused models to guide the implementation of this intervention. OBJECTIVE This study aims to develop a process- and service-focused implementation model in collaboration with key stakeholders and bring together peer-reviewed literature, practice-based knowledge, and expert opinions. METHODS The simple rules for evidence translation in complex systems framework was applied to guide the development of a 6-step qualitative study. The steps were definition of the scope and objectives of the model, identification of evidence, stakeholder engagement, draft model development, key informant consultation, and final model specification. RESULTS The final specification for the TMOUD implementation model incorporated key strategic priorities, service delivery prerequisites, service design elements, stakeholder identification and engagement, key process domains, and iterative cycles of evaluation and improvement. CONCLUSIONS Through stakeholder engagement and key informant consultation, we produced a process- and service-focused TMOUD implementation model. The model is modifiable to different contexts and settings while also in keeping with the current evidence base and national and international standards of high-quality opioid use disorder care.
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Affiliation(s)
- Joseph Tay Wee Teck
- Digital Health Interventions in Addiction Services Project, Population and Behavioural Science, School of Medicine, University of St Andrews, St Andrews, United Kingdom
| | | | - Giedre Zlatkute
- Digital Health Interventions in Addiction Services Project, Population and Behavioural Science, School of Medicine, University of St Andrews, St Andrews, United Kingdom
| | - Alberto Oteo Pérez
- Digital Health Interventions in Addiction Services Project, Population and Behavioural Science, School of Medicine, University of St Andrews, St Andrews, United Kingdom
| | | | - Alexander Baldacchino
- Digital Health Interventions in Addiction Services Project, Population and Behavioural Science, School of Medicine, University of St Andrews, St Andrews, United Kingdom
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14
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Björnsson M, Acharya C, Strandgården K, Tiberg F. Population Pharmacokinetic Analysis Supports Initiation Treatment and Bridging from Sublingual Buprenorphine to Subcutaneous Administration of a Buprenorphine Depot (CAM2038) in the Treatment of Opioid Use Disorder. Clin Pharmacokinet 2023; 62:1427-1443. [PMID: 37584841 PMCID: PMC10520114 DOI: 10.1007/s40262-023-01288-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND OBJECTIVE In treating opioid use disorder (OUD), subcutaneous (SC) extended-release buprenorphine (BPN) depots, e.g., CAM2038, have been shown to provide smaller and less frequent fluctuations in BPN plasma concentrations and pharmacodynamic responses, improve outcomes, reduce treatment burden, and lower risks of misuse and diversion compared to daily sublingual (SL) BPN. This analysis characterized the pharmacokinetics (PK) of BPN following intravenous and SL administration, and administration of SC CAM2038 weekly and monthly. METHODS Pharmacokinetic data from two Phase 1 and two Phase 2 trials in healthy participants and participants with OUD, respectively, were used to develop a population PK model using non-linear mixed effects modelling. The analysis included data from 252 participants and 10,658 BPN observations. RESULTS The disposition of BPN was best described by a three-compartment model with first-order elimination, and absorption of SL BPN and SC CAM2038 weekly and monthly by dual parallel absorption pathways. Model diagnostics indicated good predictive performance of BPN concentrations. Buprenorphine plasma concentration-time profiles were simulated for treatment initiation, switching from SL BPN to CAM2038 weekly and monthly, and tapering after interrupting treatment with CAM2038. Simulations predicted CAM2038 weekly and monthly doses that provided BPN plasma maximum concentration (Cmax) and trough concentration (Ctrough) values at steady state within those observed following SL BPN administration. CONCLUSIONS This population PK model supports the use of CAM2038 doses as individualized treatment for OUD across different treatment stages, including initiation, switching from SL BPN according to established dose conversion schedules, and tapering. TRIAL REGISTRATIONS ISRCTN41550730 (05/19/2014), ISRCTN24987553 (07/29/2014), NCT02611752 (11/23/2015), NCT02710526 (03/16/2016).
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15
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McNicholas M, Scully M, Keenan E. An overview of recent advances in opioid agonist treatment (OAT). Ir J Psychol Med 2023; 40:535-537. [PMID: 34585651 DOI: 10.1017/ipm.2021.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- M McNicholas
- The HSE National Drug Treatment Centre, Dublin, Ireland
| | - M Scully
- The HSE National Drug Treatment Centre, Dublin, Ireland
| | - E Keenan
- HSE National Social Inclusion Office, Stewart's Hospital, Dublin, Ireland
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16
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Bormann NL, Gout A, Kijewski V, Lynch A. Case Report: Buprenorphine-precipitated fentanyl withdrawal treated with high-dose buprenorphine. F1000Res 2023; 11:487. [PMID: 37767082 PMCID: PMC10521070 DOI: 10.12688/f1000research.120821.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/29/2023] Open
Abstract
Background: Buprenorphine, a partial agonist of the mu-opioid receptor, is an increasingly prescribed medication for maintenance treatment of opioid use disorder. When this medication is taken in the context of active opioid use, precipitated withdrawal can occur, leading to acute onset of opioid withdrawal symptoms. Fentanyl complicates use of buprenorphine, as it slowly releases from body stores and can lead to higher risk of precipitated withdrawal. Objectives: Describe the successful management of buprenorphine precipitated opioid withdrawal from fentanyl with high doses of buprenorphine. We seek to highlight how no adverse effects occurred in this patient and illustrate his stable transition to outpatient treatment. Case report: We present the case of a patient with severe opioid use disorder who presented in moderately severe opioid withdrawal after taking non-prescribed buprenorphine-naloxone which precipitated opioid withdrawal from daily fentanyl use. He was treated with high doses of buprenorphine, 148 mg over the first 48 hours, averaging 63 mg per day over four days. The patient reported rapid improvement in withdrawal symptoms without noted side effects and was able to successfully taper to 16 mg twice daily by discharge. Conclusions: This case demonstrates the safety and effectiveness of buprenorphine at high doses for treatment of precipitated withdrawal. While other options include symptomatic withdrawal management, initiating methadone or less researched options like ketamine, utilizing buprenorphine can preserve or re-establish confidence in this life-saving medication. This case also increases the previously documented upper boundary on buprenorphine dosing for withdrawal and should provide additional confidence in its use.
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Affiliation(s)
- Nicholas L. Bormann
- Psychiatry, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Antony Gout
- Psychiatry, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
- Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Vicki Kijewski
- Psychiatry, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
- Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Alison Lynch
- Psychiatry, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
- Family Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
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17
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Hsu ZS, Warnick JA, Harkins TR, Sylvester BE, Bharati NK, Eley LB, Nichols SD, McCall K, Piper BJ. An analysis of patterns of distribution of buprenorphine in the United States using ARCOS, Medicaid, and Medicare databases. Pharmacol Res Perspect 2023; 11:e01115. [PMID: 37485957 PMCID: PMC10364307 DOI: 10.1002/prp2.1115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 05/23/2023] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
Opioid overdose remains a problem in the United States despite pharmacotherapies, such as buprenorphine, in the treatment of opioid use disorder. This study characterized changes in buprenorphine use. Using the Drug Enforcement Administration's ARCOS, Medicaid, and Medicare claims databases, patterns in buprenorphine usage in the United States from 2018 to 2020 were analyzed by examining percentage changes in total grams distributed and changes in grams per 100 K people in year-to-year usage based on ZIP code and state levels. For ARCOS from 2018 to 2019 and 2019 to 2020, total buprenorphine distribution in grams increased by 16.2% and 12.6%, respectively. South Dakota showed the largest statewide percentage increase in both 2018-2019 (66.1%) and 2019-2020 (36.7%). From 2018 to 2019, the ZIP codes ND-577 (156.4%) and VA-222 (-82.1%) had the largest and smallest percentage changes, respectively. From 2019 to 2020, CA-932 (250.2%) and IL-603 (-36.8%) were the largest and smallest, respectively. In both 2018-2019 and 2019-2020, PA-191 had the second highest increase in grams per 100K while OH-452 was the only ZIP code to remain in the top three largest decreases in grams per 100K in both periods. Among Medicaid patients in 2018, there was a nearly 2000-fold difference in prescriptions per 100k Medicaid enrollees between Kentucky (12 075) and Nebraska (6). Among Medicare enrollees in 2018, family medicine physicians and other primary care providers were the top buprenorphine prescribers. This study not only identified overall increases in buprenorphine availability but also pronounced state-level differences. Such geographic analysis can be used to discern which public policies and regional factors impact buprenorphine access.
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Affiliation(s)
- Zhi-Shan Hsu
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Justina A Warnick
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Tice R Harkins
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Briana E Sylvester
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Neal K Bharati
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - leTausjua B Eley
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Stephanie D Nichols
- Department of Pharmacy Practice, University of New England, Portland, Maine, USA
| | - Kenneth McCall
- Department of Pharmacy Practice, Binghamton University, Binghamton, New York, USA
| | - Brian J Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
- Center for Pharmacy Innovation and Outcomes, Geisinger Precision Heath Center, Pennsylvania, USA
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18
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Ghosh A, Mahintamani T, Kathiravan S, Swer SB, Basu D, Mattoo SK, B N S, Singh A. Does Prescription Length of Buprenorphine Influence Treatment Outcomes in Opioid Use Disorder? A Retrospective Cohort Study from North India. Subst Use Misuse 2023; 58:1620-1624. [PMID: 37469041 DOI: 10.1080/10826084.2023.2236196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Buprenorphine (BUP) effectively suppresses non-prescription opioid use and increases treatment retention in opioid use disorder (OUD). However, short prescription length may interfere with treatment retention and recovery. We wanted to examine whether the outcomes of BUP treatment differ in high (HPL up to 4 wk) and low-prescription (LPL 1-2 wk) length groups. METHODS We compared time to treatment discontinuation (TD), non-prescription opioid-positive urine screen, buprenorphine-negative urine screen, and self-reported non-prescription opioid use between two different cohorts of LPL (case record: June 2018 to August 2019; n = 105; observation endpoint: 31 October 2019) and HPL groups (case record: June 2020 to Aug 2021; n = 133; observation endpoint: 31 October 2021). We used Kaplan-Meier survival analysis and log-rank tests for between-group comparisons. We used Cox regression analysis to adjust for age, opioid potency, comorbidities, family income, and marital status. RESULTS Subjects' age and buprenorphine dose were significantly lower, and the percentage of high-potency opioid users was significantly higher in the LPL group. In the unadjusted survival analysis, the median time to BUP discontinuation in the HPL was longer than that of the LPL [LPL= 22.4 ± 4.3 wk; HPL = 33.1 ± 8.5 wk; χ2(1)= 5.7; p=.02]. The survival distributions of other outcomes did not differ between groups. When adjusted for covariates, neither the prescription length nor other covariates independently predicted any treatment outcome. CONCLUSION Higher prescription length might be associated with longer treatment retention. We provide preliminary evidence to support greater flexibility in BUP treatment, enhancing its scalability and attractiveness.
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Affiliation(s)
- Abhishek Ghosh
- Drug Deaddiction and Treatment Centre & Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, UTIndia
| | - Tathagata Mahintamani
- Drug Deaddiction and Treatment Centre & Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, UTIndia
- Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, India
| | - Sanjana Kathiravan
- Drug Deaddiction and Treatment Centre & Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, UTIndia
| | - Sankie B Swer
- Drug Deaddiction and Treatment Centre & Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, UTIndia
| | - Debasish Basu
- Drug Deaddiction and Treatment Centre & Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, UTIndia
| | - S K Mattoo
- Newcastle North East Community Treatment Team, Tyne and Wear NHS Foundation Trust, Molineux NHS Centre, Cumbria, United Kingdom of Great Britain and Northern Ireland
| | - Subodh B N
- Drug Deaddiction and Treatment Centre & Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, UTIndia
| | - Ajaypal Singh
- Drug Deaddiction and Treatment Centre & Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, UTIndia
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19
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Nosyk B, Kurz M, Guerra-Alejos BC, Piske M, Dale L, Min JE. Incremental expenditures attributable to daily dispensation and witnessed ingestion for opioid agonist treatment in British Columbia: 2014-20. Addiction 2023; 118:1376-1380. [PMID: 36772838 PMCID: PMC11025638 DOI: 10.1111/add.16160] [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: 07/27/2022] [Accepted: 01/20/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND AND AIM While daily witnessed opioid agonist treatment (OAT) ingestion is common in British Columbia (BC), Canada, and elsewhere, sparse evidence supports this resource-intensive practice. Many settings across North America relaxed restrictions for take-home dosing during the COVID-19 pandemic and have reported consistent or improved patient outcomes. This study measured excess expenditures attributed to daily witnessed pharmacy dispensing compared with weekly or biweekly dispensation schedules. DESIGN, SETTING AND PARTICIPANTS This study was a population-level retrospective analysis. We included all methadone, buprenorphine/naloxone and slow-release oral morphine dispensations in BC from 1 January 2014 to 30 December 2020. A total of 24 357 107 OAT dispensations among 51 195 unique individuals with 122 793 person-years of follow-up were included during the study period. MEASUREMENTS Total expenditures for each person-week of OAT with an estimated expenditure under two scenarios are as follows: (1) a weekly dispensation scenario and (2) a biweekly dispensation scenario. FINDINGS We estimated excess expenditures attributable to current dispensing practices of between $38 million (2014) and $47.4 million (2018) compared with a hypothetical weekly dispensing schedule, and $43.9 million (2014) to $54.9 million (2018) compared with biweekly dispensing. The majority of these expenditures (58-64%) were attributed to pharmacy dispensing fees ($23 million in 2014 to $30 million in 2018 compared with weekly dispensing; $26.6 million in 2014 to $34.7 million in 2018 compared with biweekly dispensing). CONCLUSION Daily witnessed opioid agonist treatment ingestion results in more than $30 million in excess expenditures annually in the province of British Columbia, Canada compared with the costs of weekly or biweekly dispensation schedules.
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Affiliation(s)
- Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital; Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University; Burnaby, British Columbia, Canada
| | - Megan Kurz
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital; Vancouver, British Columbia, Canada
| | | | - Micah Piske
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital; Vancouver, British Columbia, Canada
| | - Laura Dale
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital; Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital; Vancouver, British Columbia, Canada
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20
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Riblet NB, Young-Xu Y, Shiner B, Schnurr PP, Watts BV. The efficacy and safety of buprenorphine for the treatment of depression: A systematic review and meta-analysis. J Psychiatr Res 2023; 161:393-401. [PMID: 37019069 PMCID: PMC10149594 DOI: 10.1016/j.jpsychires.2023.03.037] [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: 01/09/2023] [Revised: 03/01/2023] [Accepted: 03/27/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Depressive disorders are common. Many patients with major depression do not achieve remission with available treatments. Buprenorphine has been raised as a potential treatment for depression as well as suicidal behavior but may pose certain risks. METHODS A meta-analysis comparing the efficacy, tolerability, and safety of buprenorphine (or combinations such as buprenorphine/samidorphan) versus control in improving symptoms in patients with depression. Medline, Cochrane Database, PsycINFO, Excerpta Medica Database and The Cumulative Index to Nursing and Allied Health Literature were searched from inception through January 2, 2022. Depressive symptoms were pooled using Hedge's g with 95% Confidence Intervals (CI). Tolerability, safety, suicide outcomes were summarized qualitatively. RESULTS 11 studies (N = 1699) met inclusion criteria. Buprenorphine had a small effect on depressive symptoms (Hedges' g 0.17, 95%CI: 0.05-0.29). Results were driven by six trials of buprenorphine/samidorphan (N = 1,343, Hedges's g 0.17, 95%CI: 0.04-0.29). One study reported significant improvement in suicidal thoughts (Least Squares Mean Change: -7.1, 95%CI: -12.0 - 2.3). Most studies found buprenorphine was well-tolerated with no evidence of abuse behavior or dependency. CONCLUSIONS Buprenorphine may have a small benefit for depressive symptoms. Future research should clarify the dose response relationship between buprenorphine and depression.
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Affiliation(s)
- Natalie B Riblet
- Veterans Affairs Medical Center, Mental Health Service, 215 North Main Street, White River Junction, VT, 05009, USA; Geisel School of Medicine at Dartmouth, Department of Psychiatry and Dartmouth Institute, 1 Rope Ferry Road, Hanover, NH, 03755, USA.
| | - Yinong Young-Xu
- Veterans Affairs Medical Center, Mental Health Service, 215 North Main Street, White River Junction, VT, 05009, USA; Geisel School of Medicine at Dartmouth, Department of Psychiatry, 1 Rope Ferry Road, Hanover, NH, 03755, USA
| | - Brian Shiner
- Veterans Affairs Medical Center, Mental Health Service, 215 North Main Street, White River Junction, VT, 05009, USA; Geisel School of Medicine at Dartmouth, Department of Psychiatry and Dartmouth Institute, 1 Rope Ferry Road, Hanover, NH, 03755, USA; National Center for PTSD, 215 North Main Street, White River Junction, VT, 05009, USA
| | - Paula P Schnurr
- Geisel School of Medicine at Dartmouth, Department of Psychiatry, 1 Rope Ferry Road, Hanover, NH, 03755, USA; National Center for PTSD, 215 North Main Street, White River Junction, VT, 05009, USA
| | - Bradley V Watts
- Veterans Affairs Medical Center, Mental Health Service, 215 North Main Street, White River Junction, VT, 05009, USA; Geisel School of Medicine at Dartmouth, Department of Psychiatry, 1 Rope Ferry Road, Hanover, NH, 03755, USA; Veterans Rural Health Resource Center, White River Junction VA Medical Center, White River Junction, VT, 05009, USA
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21
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Alvarez-Perez B, Poras H, Maldonado R. The inhibition of enkephalin catabolism by dual enkephalinase inhibitor: A novel possible therapeutic approach for opioid use disorders. Br J Pharmacol 2023; 180:879-893. [PMID: 34378790 DOI: 10.1111/bph.15656] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/14/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022] Open
Abstract
Despite the increasing impact of opioid use disorders on society, there is a disturbing lack of effective medications for their clinical management. An interesting innovative strategy to treat these disorders consists in the protection of endogenous opioid peptides to activate opioid receptors, avoiding the classical opioid-like side effects. Dual enkephalinase inhibitors (DENKIs) physiologically activate the endogenous opioid system by inhibiting the enzymes responsible for the breakdown of enkephalins, protecting endogenous enkephalins and increasing their half-lives and physiological actions. The activation of opioid receptors by the increased enkephalin levels, and their well-demonstrated safety, suggests that DENKIs could represent a novel analgesic therapy and a possible effective treatment for acute opioid withdrawal, as well as a promising alternative to opioid substitution therapy minimizing side effects. This new pharmacological class of compounds could bring effective and safe medications avoiding the major limitations of exogenous opioids, representing a novel approach to overcome the problem of opioid use disorders. LINKED ARTICLES: This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.
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Affiliation(s)
- Beltran Alvarez-Perez
- Laboratory of Neuropharmacology, Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain
| | | | - Rafael Maldonado
- Laboratory of Neuropharmacology, Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain
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22
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Kline A, Williams JM, Steinberg ML, Mattern D, Chesin M, Borys S, Chaguturu V. Predictors of opioid overdose during the COVID-19 pandemic: The role of relapse, treatment access and nonprescribed buprenorphine/naloxone. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 149:209028. [PMID: 37003539 PMCID: PMC10063455 DOI: 10.1016/j.josat.2023.209028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 01/17/2023] [Accepted: 03/17/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Emerging data indicate a disproportionate increase in overdose deaths since the onset of COVID-19. Speculation about causes for the increase center on rising drug use, illicit drug supply changes, and reduced treatment access. Possible overdose mitigation factors include reduced federal MOUD prescribing restrictions, naloxone distribution programs, and increased use of telehealth. Similarly, nonprescribed buprenorphine (NPB) use, increasingly described as a harm reduction strategy in the absence of treatment, may have moderated overdose risk. This study explored factors associated with pandemic-related overdose in people who use opioids (PWUO) in New Jersey. METHODS We surveyed 342 PWUO from March to May 2021. Approximately 50 % of our sample was treated at some time since the COVID-19 emergency declaration in March 2020. The risk and protective factors associated with overdose were identified using Pearson's chi square test and ANOVA and tested in a series of multivariable logistic regression models for the full sample and the subsample of PWUO treated during the pandemic. RESULTS Forty-eight percent of respondents increased their drug use during the pandemic, including 32 % who relapsed after previous abstinence. Fifteen percent overdosed at least once since March 2020. In the full sample, overdose was associated with Hispanic ethnicity (AOR = 3.51; 95 % CI = 1.22-10.11), pre-pandemic overdose (AOR = 6.75; 95 % CI = 3.03-15.02), lack/loss of medical insurance (AOR = 3.02; 95 % CI = 1.01-9.02), relapse (AOR = 2.94; 95 % CI = 1.36-6.36), and nonprescribed use of buprenorphine/naloxone (AOR = 3.16; 95 % CI = 1.49-6.70). The study found similar trends in the treatment sample, with the exceptions that heroin/fentanyl use also predicted overdose (AOR = 3.43; 95 % CI = 1.20-9.78) and the association of overdose with nonprescribed buprenorphine/naloxone was stronger (AOR = 4.91; 95 % CI = 2.01-12.03). Potential mitigating factors, such as take-home methadone and telehealth, were not significant. CONCLUSIONS Relapse during the pandemic was widespread and a significant contributor to overdose. Lack/loss of medical insurance further exacerbated the risk. Despite the growing literature reporting "therapeutic" use of NPB, people using nonprescribed buprenorphine/naloxone in the current study experienced up to five times the risk of overdose as nonusers. This finding suggests that, despite therapeutic intent, PWUO may be using NPB in ways that are ineffectual for addiction management, especially in the context of changing buprenorphine induction protocols in the context of fentanyl.
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Affiliation(s)
- Anna Kline
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| | - Jill M Williams
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| | - Marc L Steinberg
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| | - Dina Mattern
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| | - Megan Chesin
- William Paterson University, 300 Pompton Road, Wayne, NJ 07470, United States
| | - Suzanne Borys
- New Jersey Department of Human Services, Division of Mental Health and Addiction Services, 222 S. Warren St., PO Box 700, Trenton, NJ 08625-0700, United States.
| | - Vamsee Chaguturu
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
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23
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Scott G, Turner S, Lowry N, Hodge A, Ashraf W, McClean K, Kelleher M, Mitcheson L, Marsden J. Patients' perceptions of self-administered dosing to opioid agonist treatment and other changes during the COVID-19 pandemic: a qualitative study. BMJ Open 2023; 13:e069857. [PMID: 36944465 PMCID: PMC10032386 DOI: 10.1136/bmjopen-2022-069857] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
OBJECTIVES During the COVID-19 pandemic, addiction treatment services received official guidance asking them to limit face-to-face contact with patients and to prescribe opioid agonist treatment (OAT) medication flexibly. With the aim for most patients to receive take-home supplies for self-administration rather than attendance for observed daily dosing. DESIGN This was a theory-driven, clinically applied qualitative study, with data for thematic analysis collected by semi-structured, audio-recorded, telephone interviews. PARTICIPANTS Twenty-seven adults (aged ≥18 years) enrolled in sublingual (tablet) buprenorphine and oral (liquid) methadone OAT. SETTING Community addictions centre in the London Borough of Lambeth operated by South London and Maudsley NHS Trust. RESULTS Three major themes were identified: (1) dissatisfaction and perceived stigma with OAT medication dispensing arrangements before the pandemic; (2) positive adaptations in response to COVID-19 by services; (3) participants recommended that, according to preference and evidence of adherence, OAT should be personalised to offer increasing medication supplies for self-administration from as early as 7 days after commencement of maintenance prescribing. CONCLUSIONS In an applied qualitative study of patients enrolled in OAT during the COVID-19 pandemic, participants endorsed their opportunity to take medication themselves at home and with virtual addiction support. Most patients described a preference for self-administration with increased dispensing supplies, from as early as 7 days into maintenance treatment, if they could demonstrate adherence to their prescription.
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Affiliation(s)
- Gemma Scott
- Lambeth Addiction, South London and Maudsley NHS Foundation Trust, London, UK
| | - Sophie Turner
- Lambeth Addiction, South London and Maudsley NHS Foundation Trust, London, UK
| | - Natalie Lowry
- Lambeth Addiction, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Addictions, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Annette Hodge
- Lambeth Addiction, South London and Maudsley NHS Foundation Trust, London, UK
| | - Waniya Ashraf
- Lambeth Addiction, South London and Maudsley NHS Foundation Trust, London, UK
| | - Katie McClean
- Lambeth Addiction, South London and Maudsley NHS Foundation Trust, London, UK
| | - Mike Kelleher
- Lambeth Addiction, South London and Maudsley NHS Foundation Trust, London, UK
| | - Luke Mitcheson
- Lambeth Addiction, South London and Maudsley NHS Foundation Trust, London, UK
| | - John Marsden
- Lambeth Addiction, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Addictions, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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24
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Furo H, Wiegand T, Rani M, Schwartz DG, Sullivan RW, Elkin PL. Association Between Buprenorphine Dose and the Urine "Norbuprenorphine" to "Creatinine" Ratio: Revised. Subst Abuse 2023; 17:11782218231153748. [PMID: 36937705 PMCID: PMC10014968 DOI: 10.1177/11782218231153748] [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: 07/08/2022] [Accepted: 01/12/2023] [Indexed: 03/16/2023]
Abstract
Background Utilizing a 1-year chart review as the data, Furo et al. conducted a research study on an association between buprenorphine dose and the urine "norbuprenorphine" to "creatinine" ratio and found significant differences in the ratio among 8-, 12-, and 16-mg/day groups with an analysis of variance (ANOVA) test. This study expands the data for a 2-year chart review and is intended to delineate an association between buprenorphine dose and the urine "norbuprenorphine" to "creatinine" ratio with a higher statistical power. Methods This study performed a 2-year chart review of data for the patients living in a halfway house setting, where their drug administration was closely monitored. The patients were on buprenorphine prescribed at an outpatient clinic for opioid use disorder (OUD), and their buprenorphine prescription and dispensing information were confirmed by the New York Prescription Drug Monitoring Program (PDMP). Urine test results in the electronic health record (EHR) were reviewed, focusing on the "buprenorphine," "norbuprenorphine," and "creatinine" levels. The Kruskal-Wallis H and Mann-Whitney U tests were performed to examine an association between buprenorphine dose and the "norbuprenorphine" to "creatinine" ratio. Results This study included 371 urine samples from 61 consecutive patients and analyzed the data in a manner similar to that described in the study by Furo et al. This study had similar findings with the following exceptions: (1) a mean buprenorphine dose of 11.0 ± 3.8 mg/day with a range of 2 to 20 mg/day; (2) exclusion of 6 urine samples with "creatinine" level <20 mg/dL; (3) minimum "norbuprenorphine" to "creatinine" ratios in the 8-, 12-, and 16-mg/day groups of 0.44 × 10-4 (n = 68), 0.1 × 10-4 (n = 133), and 1.37 × 10-4 (n = 82), respectively; however, after removing the 2 lowest outliers, the minimum "norbuprenorphine" to "creatinine" ratio in the 12-mg/day group was 1.6 × 10-4, similar to the findings in the previous study; and (4) a significant association between buprenorphine dose and the urine "norbuprenorphine" to "creatinine" ratios from the Kruskal-Wallis test (P < .01). In addition, the median "norbuprenorphine" to "creatinine" ratio had a strong association with buprenorphine dose, and this association could be formulated as: [y = 2.266 ln(x) + 0.8211]. In other words, the median ratios in 8-, 12-, and 16-mg/day groups were 5.53 × 10-4, 6.45 × 10-4, and 7.10 × 10-4, respectively. Therefore, any of the following features should alert providers to further investigate patient treatment compliance: (1) inappropriate substance(s) in urine sample; (2) "creatinine" level <20 mg/dL; (3) "buprenorphine" to "norbuprenorphine" ratio >50:1; (4) buprenorphine dose >24 mg/day; or (5) "norbuprenorphine" to "creatinine" ratios <0.5 × 10-4 in patients who are on 8 mg/day or <1.5 × 10-4 in patients who are on 12 mg/day or more. Conclusion The results of the present study confirmed those of the previous study regarding an association between buprenorphine dose and the "norbuprenorphine" to "creatinine" ratio, using an expanded data set. Additionally, this study delineated a clearer relationship, focusing on the median "norbuprenorphine" to "creatinine" ratios in different buprenorphine dose groups. These results could help providers interpret urine test results more accurately and apply them to outpatient opioid treatment programs for optimal treatment outcomes.
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Affiliation(s)
- Hiroko Furo
- Department of Psychiatry and Behavioral
Sciences, The University of Texas Health at San Antonio, San Antonio, TX, USA
- Department of Pathology, The University
of Texas Health at San Antonio, San Antonio, TX, USA
| | - Timothy Wiegand
- Department of Emergency Medicine, The
University of Rochester Medical Center and Strong Memorial Hospital, Rochester, NY,
USA
| | - Meenakshi Rani
- Department of Psychiatry and Behavioral
Sciences, The University of Texas Health at San Antonio, San Antonio, TX, USA
| | - Diane G Schwartz
- Department of Biomedical Informatics,
State University of New York at Buffalo, Buffalo, NY, USA
| | - Ross W Sullivan
- Department of Emergency Medicine, State
University of New York Upstate Medical University, Syracuse, NY, USA
| | - Peter L Elkin
- Department of Biomedical Informatics,
State University of New York at Buffalo, Buffalo, NY, USA
- Department of Veterans Affairs in
Western New York, Bioinformatics Laboratory, Buffalo, NY, USA
- Faculty of Engineering, University of
Southern Denmark, Odense, Denmark
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25
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Olson KM, Hillhouse TM, Burgess GE, West JL, Hallahan JE, Dripps IJ, Ladetto AG, Rice KC, Jutkiewicz EM, Traynor JR. Delta Opioid Receptor-Mediated Antidepressant-Like Effects of Diprenorphine in Mice. J Pharmacol Exp Ther 2023; 384:343-352. [PMID: 36456196 PMCID: PMC9976798 DOI: 10.1124/jpet.122.001182] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 11/11/2022] [Accepted: 11/22/2022] [Indexed: 12/03/2022] Open
Abstract
Major depressive disorder is a highly common disorder, with a lifetime prevalence in the United States of approximately 21%. Traditional antidepressant treatments are limited by a delayed onset of action and minimal efficacy in some patients. Ketamine is effective and fast-acting, but there are concerns over its abuse liability. Thus, there is a need for safe, fast-acting antidepressant drugs. The opioid buprenorphine shows promise but also has abuse liability due to its mu-agonist component. Preclinical evidence indicates that the delta-opioid system contributes to mood disorders, and delta-opioid agonists are effective in preclinical models of depression- and anxiety-like states. In this study, we test the hypothesis that the mu-opioid antagonist diprenorphine by virtue of its partial delta opioid agonist activity may offer a beneficial profile for an antidepressant medication without abuse liability. Diprenorphine was confirmed to bind with high affinity to all three opioid receptors, and functional experiments for G protein activation verified diprenorphine to be a partial agonist at delta- and kappa-opioid receptors and a mu-antagonist. Studies in C57BL/6 mice demonstrated that an acute dose of diprenorphine produced antidepressant-like effects in the tail suspension test and the novelty-induced hypophagia test that were inhibited in the presence of the delta-selective antagonist, naltrindole. Diprenorphine did not produce convulsions, a side effect of many delta agonists but rather inhibited convulsions caused by the full delta agonist SNC80; however, diprenorphine did potentiate pentylenetetrazole-induced convulsions. Diprenorphine, and compounds with a similar pharmacological profile, may provide efficient and safe rapidly acting antidepressants. SIGNIFICANCE STATEMENT: The management of major depressive disorder, particularly treatment-resistant depression, is a significant unmet medical need. Here we show that the opioid diprenorphine, a compound with mu-opioid receptor antagonist activity and delta- and kappa-opioid receptor partial agonist activities, has rapid onset antidepressant-like activity in animal models. Diprenorphine and compounds with a similar pharmacological profile to diprenorphine should be explored as novel antidepressant drugs.
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MESH Headings
- Animals
- Mice
- Analgesics, Opioid/pharmacology
- Antidepressive Agents/pharmacology
- Depressive Disorder, Major
- Diprenorphine/pharmacology
- Mice, Inbred C57BL
- Receptors, Opioid
- Receptors, Opioid, delta/metabolism
- Receptors, Opioid, kappa/metabolism
- Receptors, Opioid, mu/metabolism
- Seizures/chemically induced
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Affiliation(s)
- Keith M Olson
- Department of Pharmacology and Edward F Domino Research Center (K.M.O., T.M.H., G.E.B., J.L.W., J.E.H., I.J.D., A.G.L., E.M.J., J.R.T.) and Department of Medicinal Chemistry (J.R.T.), University of Michigan, Ann Arbor, Michigan; Department of Psychology, University of Wisconsin Green Bay, Green Bay, Wisconsin (T.M.H.); and Drug Design and Synthesis Section, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland (K.C.R.)
| | - Todd M Hillhouse
- Department of Pharmacology and Edward F Domino Research Center (K.M.O., T.M.H., G.E.B., J.L.W., J.E.H., I.J.D., A.G.L., E.M.J., J.R.T.) and Department of Medicinal Chemistry (J.R.T.), University of Michigan, Ann Arbor, Michigan; Department of Psychology, University of Wisconsin Green Bay, Green Bay, Wisconsin (T.M.H.); and Drug Design and Synthesis Section, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland (K.C.R.)
| | - Gwendolyn E Burgess
- Department of Pharmacology and Edward F Domino Research Center (K.M.O., T.M.H., G.E.B., J.L.W., J.E.H., I.J.D., A.G.L., E.M.J., J.R.T.) and Department of Medicinal Chemistry (J.R.T.), University of Michigan, Ann Arbor, Michigan; Department of Psychology, University of Wisconsin Green Bay, Green Bay, Wisconsin (T.M.H.); and Drug Design and Synthesis Section, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland (K.C.R.)
| | - Joshua L West
- Department of Pharmacology and Edward F Domino Research Center (K.M.O., T.M.H., G.E.B., J.L.W., J.E.H., I.J.D., A.G.L., E.M.J., J.R.T.) and Department of Medicinal Chemistry (J.R.T.), University of Michigan, Ann Arbor, Michigan; Department of Psychology, University of Wisconsin Green Bay, Green Bay, Wisconsin (T.M.H.); and Drug Design and Synthesis Section, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland (K.C.R.)
| | - James E Hallahan
- Department of Pharmacology and Edward F Domino Research Center (K.M.O., T.M.H., G.E.B., J.L.W., J.E.H., I.J.D., A.G.L., E.M.J., J.R.T.) and Department of Medicinal Chemistry (J.R.T.), University of Michigan, Ann Arbor, Michigan; Department of Psychology, University of Wisconsin Green Bay, Green Bay, Wisconsin (T.M.H.); and Drug Design and Synthesis Section, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland (K.C.R.)
| | - Isaac J Dripps
- Department of Pharmacology and Edward F Domino Research Center (K.M.O., T.M.H., G.E.B., J.L.W., J.E.H., I.J.D., A.G.L., E.M.J., J.R.T.) and Department of Medicinal Chemistry (J.R.T.), University of Michigan, Ann Arbor, Michigan; Department of Psychology, University of Wisconsin Green Bay, Green Bay, Wisconsin (T.M.H.); and Drug Design and Synthesis Section, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland (K.C.R.)
| | - Allison G Ladetto
- Department of Pharmacology and Edward F Domino Research Center (K.M.O., T.M.H., G.E.B., J.L.W., J.E.H., I.J.D., A.G.L., E.M.J., J.R.T.) and Department of Medicinal Chemistry (J.R.T.), University of Michigan, Ann Arbor, Michigan; Department of Psychology, University of Wisconsin Green Bay, Green Bay, Wisconsin (T.M.H.); and Drug Design and Synthesis Section, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland (K.C.R.)
| | - Kenner C Rice
- Department of Pharmacology and Edward F Domino Research Center (K.M.O., T.M.H., G.E.B., J.L.W., J.E.H., I.J.D., A.G.L., E.M.J., J.R.T.) and Department of Medicinal Chemistry (J.R.T.), University of Michigan, Ann Arbor, Michigan; Department of Psychology, University of Wisconsin Green Bay, Green Bay, Wisconsin (T.M.H.); and Drug Design and Synthesis Section, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland (K.C.R.)
| | - Emily M Jutkiewicz
- Department of Pharmacology and Edward F Domino Research Center (K.M.O., T.M.H., G.E.B., J.L.W., J.E.H., I.J.D., A.G.L., E.M.J., J.R.T.) and Department of Medicinal Chemistry (J.R.T.), University of Michigan, Ann Arbor, Michigan; Department of Psychology, University of Wisconsin Green Bay, Green Bay, Wisconsin (T.M.H.); and Drug Design and Synthesis Section, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland (K.C.R.)
| | - John R Traynor
- Department of Pharmacology and Edward F Domino Research Center (K.M.O., T.M.H., G.E.B., J.L.W., J.E.H., I.J.D., A.G.L., E.M.J., J.R.T.) and Department of Medicinal Chemistry (J.R.T.), University of Michigan, Ann Arbor, Michigan; Department of Psychology, University of Wisconsin Green Bay, Green Bay, Wisconsin (T.M.H.); and Drug Design and Synthesis Section, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland (K.C.R.)
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Farquharson S, Shende C, Newcomb J, Petrakis IL, Arias AJ. Analysis of Drugs in Saliva of US Military Veterans Treated for Substance Use Disorders Using Supported Liquid Extraction and Surface-Enhanced Raman Spectral Analysis. Molecules 2023; 28:molecules28052010. [PMID: 36903255 PMCID: PMC10004423 DOI: 10.3390/molecules28052010] [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: 01/29/2023] [Revised: 02/11/2023] [Accepted: 02/14/2023] [Indexed: 02/23/2023] Open
Abstract
According to the Center for Disease Control, there were more than 107,000 US drug overdose deaths in 2021, over 80,000 of which due to opioids. One of the more vulnerable populations is US military veterans. Nearly 250,000 military veterans suffer from substance-related disorders (SRD). For those seeking treatment, buprenorphine is prescribed to help treat opioid use disorder (OUD). Urinalysis is currently used to monitor buprenorphine adherence as well as to detect illicit drug use during treatment. Sometimes sample tampering occurs if patients seek to generate a false positive buprenorphine urine test or mask illicit drugs, both of which can compromise treatment. To address this problem, we have been developing a point-of-care (POC) analyzer that can rapidly measure both medications used for treatment and illicit drugs in patient saliva, ideally in the physi-cian's office. The two-step analyzer employs (1) supported liquid extraction (SLE) to isolate the drugs from the saliva and (2) surface-enhanced Raman spectroscopy (SERS) to detect the drugs. A prototype SLE-SERS-POC analyzer was used to quantify buprenorphine at ng/mL concentrations and identify illicit drugs in less than 1 mL of saliva collected from 20 SRD veterans in less than 20 min. It correctly detected buprenorphine in 19 of 20 samples (18 true positives, 1 true negative and 1 false negative). It also identified 10 other drugs in patient samples: acetaminophen, amphetamine, cannabidiol, cocaethylene, codeine, ibuprofen, methamphetamine, methadone, nicotine, and norbuprenorphine. The prototype analyzer shows evidence of accuracy in measuring treatment medications and relapse to drug use. Further study and development of the system is warranted.
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Affiliation(s)
- Stuart Farquharson
- Real-Time Analyzers, Inc., Middletown, CT 06457, USA
- Correspondence: ; Tel.: +1-860-635-9800
| | - Chetan Shende
- Real-Time Analyzers, Inc., Middletown, CT 06457, USA
| | - Jenelle Newcomb
- VA Connecticut Healthcare System, West Haven, CT 06516, USA
- Department of Psychiatry, School of Medicine, Yale University, New Haven, CT 06510, USA
| | - Ismene L. Petrakis
- VA Connecticut Healthcare System, West Haven, CT 06516, USA
- Department of Psychiatry, School of Medicine, Yale University, New Haven, CT 06510, USA
| | - Albert J. Arias
- VA Connecticut Healthcare System, West Haven, CT 06516, USA
- Department of Psychiatry, School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
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27
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Rubel SK, Eisenstat M, Wolff J, Calevski M, Mital S. Scope of, Motivations for, and Outcomes Associated with Buprenorphine Diversion in the United States: A Scoping Review. Subst Use Misuse 2023; 58:685-697. [PMID: 36803159 PMCID: PMC10961708 DOI: 10.1080/10826084.2023.2177972] [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] [Indexed: 02/22/2023]
Abstract
BACKGROUND Expanding access to medications to treat opioid use disorder (OUD), such as buprenorphine, is an evidence-based response to the mounting drug overdose crisis. However, concerns about buprenorphine diversion persist and contribute to limited access. METHODS To inform decisions about expanding access, a scoping review was conducted on publications describing the scope of, motivations for, and outcomes associated with diverted buprenorphine in the U.S. RESULTS In the 57 included studies, definitions for diversion were inconsistent. Most studied use of illicitly-obtained buprenorphine. Across studies, the scope of buprenorphine diversion ranged from 0% to 100%, varying by sample type and recall period. Among samples of people receiving buprenorphine for OUD treatment, diversion peaked at 4.8%. Motivations for using diverted buprenorphine were self-treatment, management of drug use, to get high, and when drug of choice was unavailable. Associated outcomes examined trended toward positive or neutral, including improved attitudes toward and retention in MOUD. CONCLUSIONS Despite inconsistent definitions of diversion, studies reported a low scope of diversion among people receiving MOUD, with inability to access treatment as a motivating factor for using diverted buprenorphine, and increased retention in MOUD as an outcome associated with use of diverted buprenorphine. Future research should explore reasons for diverted buprenorphine use in the context of expanded treatment availability to address persistent barriers to evidence-based treatment for OUD.
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Affiliation(s)
- Stephanie K Rubel
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Matthew Eisenstat
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jessica Wolff
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michael Calevski
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sasha Mital
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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28
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Bratberg JP, Falleni A. Preserving dignity through expanded and sustained access to buprenorphine. J Am Pharm Assoc (2003) 2023; 63:220-223. [PMID: 36599800 DOI: 10.1016/j.japh.2022.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Affiliation(s)
| | - Alyssa Falleni
- VA Health Professions Education, Evaluation and Research Fellow, West Haven, CT
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29
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Letter in Reply. J Addict Med 2023; 17:119-120. [PMID: 35916427 DOI: 10.1097/adm.0000000000001044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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30
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Laffont CM, Ngaimisi E, Gopalakrishnan M, Ivaturi V, Young M, Greenwald MK, Heidbreder C. Buprenorphine exposure levels to optimize treatment outcomes in opioid use disorder. Front Pharmacol 2022; 13:1052113. [PMID: 36467036 PMCID: PMC9715596 DOI: 10.3389/fphar.2022.1052113] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/28/2022] [Indexed: 12/04/2023] Open
Abstract
The severity of the ongoing opioid crisis, recently exacerbated by the COVID-19 pandemic, emphasizes the importance for individuals suffering from opioid use disorder (OUD) to have access to and receive efficacious, evidence-based treatments. Optimal treatment of OUD should aim at blocking the effects of illicit opioids while controlling opioid craving and withdrawal to facilitate abstinence from opioid use and promote recovery. The present work analyses the relationship between buprenorphine plasma exposure and clinical efficacy in participants with moderate to severe OUD using data from two clinical studies (39 and 504 participants). Leveraging data from placebo-controlled measures assessing opioid blockade, craving, withdrawal and abstinence, we found that buprenorphine plasma concentrations sustained at 2-3 ng/ml (corresponding to ≥70% brain mu-opioid receptor occupancy) optimized treatment outcomes in the majority of participants, while some individuals (e.g., injecting opioid users) needed higher concentrations. Our work also included non-linear mixed effects modeling and survival analysis, which identified a number of demographic, genetic and social factors modulating treatment response and retention. Altogether, these findings provide key information on buprenorphine plasma levels that optimize clinical outcomes and increase the likelihood of individual treatment success. NLM identifiers: NCT02044094, NCT02357901.
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Affiliation(s)
| | - Eliford Ngaimisi
- Center for Translational Medicine, University of Maryland, Baltimore, MD, United States
| | | | - Vijay Ivaturi
- Center for Translational Medicine, University of Maryland, Baltimore, MD, United States
| | - Malcolm Young
- Indivior Inc., North Chesterfield, VA, United States
| | - Mark K. Greenwald
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, United States
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Iyer V, Rangel-Barajas C, Woodward TJ, Kulkarni A, Cantwell L, Crystal JD, Mackie K, Rebec GV, Thakur GA, Hohmann AG. Negative allosteric modulation of CB 1 cannabinoid receptor signaling suppresses opioid-mediated reward. Pharmacol Res 2022; 185:106474. [PMID: 36179954 PMCID: PMC9948526 DOI: 10.1016/j.phrs.2022.106474] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/15/2022] [Accepted: 09/25/2022] [Indexed: 01/18/2023]
Abstract
Blockade of cannabinoid type 1 (CB1)-receptor signaling decreases the rewarding properties of many drugs of abuse and has been proposed as an anti-addiction strategy. However, psychiatric side-effects limit the clinical potential of orthosteric CB1 antagonists. Negative allosteric modulators (NAMs) represent a novel and indirect approach to attenuate CB1 signaling by decreasing affinity and/or efficacy of CB1 ligands. We hypothesized that a CB1-NAM would block opioid reward while avoiding the unwanted effects of orthosteric CB1 antagonists. GAT358, a CB1-NAM, failed to elicit cardinal signs of direct CB1 activation or inactivation when administered by itself. GAT358 decreased catalepsy and hypothermia but not antinociception produced by the orthosteric CB1 agonist CP55,940, suggesting that a CB1-NAM blocked cardinal signs of CB1 activation. Next, GAT358 was evaluated using in vivo assays of opioid-induced dopamine release and reward in male rodents. In the nucleus accumbens shell, a key component of the mesocorticolimbic reward pathway, morphine increased electrically-evoked dopamine efflux and this effect was blocked by a dose of GAT358 that lacked intrinsic effects on evoked dopamine efflux. Moreover, GAT358 blocked morphine-induced reward in a conditioned place preference (CPP) assay without producing reward or aversion alone. GAT358-induced blockade of morphine CPP was also occluded by GAT229, a CB1 positive allosteric modulator (CB1-PAM), and absent in CB1-knockout mice. Finally, GAT358 also reduced oral oxycodone (but not water) consumption in a two-bottle choice paradigm. Our results support the therapeutic potential of CB1-NAMs as novel drug candidates aimed at preventing opioid reward and treating opioid abuse while avoiding unwanted side-effects.
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Affiliation(s)
- Vishakh Iyer
- Program in Neuroscience, Indiana University, Bloomington, IN, USA,Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | | | - Taylor J. Woodward
- Program in Neuroscience, Indiana University, Bloomington, IN, USA,Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | - Abhijit Kulkarni
- Department of Pharmaceutical Sciences, Northeastern University, Boston, MA, USA
| | - Lucas Cantwell
- Department of Pharmaceutical Sciences, Northeastern University, Boston, MA, USA
| | - Jonathon D. Crystal
- Program in Neuroscience, Indiana University, Bloomington, IN, USA,Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | - Ken Mackie
- Program in Neuroscience, Indiana University, Bloomington, IN, USA,Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA,Gill Center for Biomolecular Science, Indiana University, Bloomington, IN, USA
| | - George V. Rebec
- Program in Neuroscience, Indiana University, Bloomington, IN, USA,Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | - Ganesh A. Thakur
- Department of Pharmaceutical Sciences, Northeastern University, Boston, MA, USA
| | - Andrea G. Hohmann
- Program in Neuroscience, Indiana University, Bloomington, IN, USA,Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA,Gill Center for Biomolecular Science, Indiana University, Bloomington, IN, USA,Corresponding Author: Andrea G. Hohmann, Psychological and Brain Sciences, Gill Center for Biomolecular Science, Indiana University, Bloomington, IN 47405-7007,
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32
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Pedersen MH, Danø A, Gibbons C, Jensen R. Administration and patient-incurred costs associated with opioid agonist treatment in Norway. Curr Med Res Opin 2022; 38:1959-1965. [PMID: 36172758 DOI: 10.1080/03007995.2022.2129230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Opioid use disorder is associated with high rates of mortality and has become an escalating global health issue. Opioid agonist treatment (OAT) with oral methadone or daily sublingual buprenorphine hydrochloride, either administered separately or in combination with naloxone hydrochloride (SL-BPN, SL-BPN/NX), is supervised by a healthcare professional experienced in treating opioid use disorder to ensure proper dosing and prevent misuse. For that reason, there may be substantial direct and indirect costs associated with OAT. Recently, weekly and monthly subcutaneous depot formulations of buprenorphine (SC-BPN) have been approved. This study aimed to estimate management and patient-incurred costs associated with the most commonly used OATs compared to the cost of weekly and monthly SC-BPN. METHODS We conducted a cost-minimisation analysis comparing the monthly costs of OAT treatment with oral formulations, i.e. oral methadone, SL-BPN, SL-BPN/NX and SC-BPN. The analysis assessed treatment acquisition costs and costs associated with management, supervision and administration of therapy, patients' transportation costs and the indirect costs associated with patients' time-use. The model was set up to reflect the Norwegian medically assisted rehabilitation system and considered the costs of a stable maintenance OAT regimen given continuously to patients already initiated and titrated on the therapy. RESULTS OAT management with monthly formulation of SC-BPN was associated with a reduction in monthly costs of €605, €586, and €411 per month compared to SL-BPN, SL-BPN/NX and oral methadone, respectively. Similar results were estimated when comparing to the weekly formulation of SC-BPN. CONCLUSION The analysis showed that the monthly formulation of SC-BPN was the cost-minimising alternative, followed by the weekly formulation, when considering all cost components.
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SCHERZ CHINA, BURRAWAY JOSHUA. Keeping it in the family. AMERICAN ETHNOLOGIST 2022. [DOI: 10.1111/amet.13105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- CHINA SCHERZ
- Department of Anthropology University of Virginia
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Bozinoff N, Tardelli V, Rubin-Kahana DS, Le Foll B. Patterns of use and adverse events reported among persons who regularly inject buprenorphine: a systematic review. Harm Reduct J 2022; 19:113. [PMID: 36229831 PMCID: PMC9559254 DOI: 10.1186/s12954-022-00695-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/30/2022] [Indexed: 11/29/2022] Open
Abstract
Background and Aims Given the ongoing opioid crisis, novel interventions to treat severe opioid use disorder (OUD) are urgently needed. Injectable opioid agonist therapy (iOAT) with diacetylmorphine or hydromorphone is effective for the treatment of severe, treatment-refractory OUD, however barriers to implementation persist. Intravenous buprenorphine for the treatment of OUD (BUP iOAT) has several possible advantages over traditional iOAT, including a safety profile that might enable take-home dosing. We aimed to characterize injecting practices among real-world populations of persons who regularly inject buprenorphine, as well as associated adverse events reported in order to inform a possible future BUP iOAT intervention. Methods We conducted a systematic review. We searched MEDLINE, EMBASE, and PsycINFO from inception through July 2020 and used backwards citation screening to search for publications reporting on dose, frequency among persons who regularly inject the drug, or adverse events associated with intravenous use of buprenorphine. The review was limited to English language publications and there was no limitation on study type. Study quality and risk of bias was assessed using the Mixed Methods Appraisal Tool. Narrative synthesis was used in reporting the results. Results Eighty-eight studies were included in our review. Regular injection of buprenorphine was identified across diverse settings world-wide. Daily dose of oral buprenorphine injected was < 1–12 mg. Frequency of injection was 0–10 times daily. Adverse events could be characterized as known side effects of opioids/buprenorphine or injection-related complications. Most studies were deemed to be of low quality. Conclusions Extramedical, intravenous use of buprenorphine, continues to be documented. BUP iOAT may be feasible and results may inform the development of a study to test the efficacy and safety of such an intervention. Future work should also examine acceptability among people with severe OUD in North America. Our review was limited by the quality of included studies. Supplementary Information The online version contains supplementary material available at 10.1186/s12954-022-00695-5.
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Affiliation(s)
- Nikki Bozinoff
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, ON, Toronto, Canada. .,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada. .,Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.
| | - Vitor Tardelli
- Departamento de Psiquiatria, Universidade Federal de Sao Paulo, São Paulo, Brazil.,Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Dafna Sara Rubin-Kahana
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Child, Youth, and Family Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Bernard Le Foll
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Division of Neurosciences and Clinical Translation, Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.,Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, ON, Canada
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35
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Mariottini C, Kriikku P, Ojanperä I. Investigation of buprenorphine-related deaths using urinary metabolite concentrations. Drug Test Anal 2022; 14:1696-1702. [PMID: 35834288 PMCID: PMC9796430 DOI: 10.1002/dta.3347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023]
Abstract
Quantitative analysis of postmortem urine, instead of blood, for buprenorphine and metabolites may provide additional evidence for the diagnosis of fatal buprenorphine poisoning. In this study, 247 autopsy urine samples, previously testing positive for buprenorphine or norbuprenorphine, were quantitatively reanalysed with a recently developed liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for unconjugated buprenorphine (BUP), norbuprenorphine (NBUP), naloxone (NAL), and their respective conjugated metabolites, buprenorphine glucuronide (BUPG), norbuprenorphine glucuronide (NBUPG), and naloxone glucuronide (NALG). The cases were divided, according to medical examiners' decision, to buprenorphine poisonings and other causes of death. The groups were compared for urinary concentrations and metabolite concentration ratios of the six analytes. All median concentrations were higher in the buprenorphine poisoning group. The median concentration of BUPG was significantly higher and the median metabolite ratios NBUP/BUP, NBUPG/BUPG, and NBUPtotal/BUPtotal were significantly lower in poisonings than in other causes of death. Naloxone-related concentrations and ratios were not significantly different between the groups.
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Affiliation(s)
- Claudia Mariottini
- Department of Forensic MedicineUniversity of HelsinkiHelsinkiFinland,Forensic Toxicology UnitFinnish Institute for Health and WelfareHelsinkiFinland
| | - Pirkko Kriikku
- Department of Forensic MedicineUniversity of HelsinkiHelsinkiFinland,Forensic Toxicology UnitFinnish Institute for Health and WelfareHelsinkiFinland
| | - Ilkka Ojanperä
- Department of Forensic MedicineUniversity of HelsinkiHelsinkiFinland,Forensic Toxicology UnitFinnish Institute for Health and WelfareHelsinkiFinland
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Winstanley EL, Thacker EP, Choo LY, Lander LR, Berry JH, Tofighi B. Patient-reported problems filling buprenorphine prescriptions and motivations for illicit use. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100091. [PMID: 36844166 PMCID: PMC9949336 DOI: 10.1016/j.dadr.2022.100091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/04/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
Background While barriers to accessing buprenorphine (BUP) therapy have been well described, little is known about pharmacy-related barriers. The objective of this study was to estimate the prevalence of patient-reported problems filling BUP prescriptions and determine whether these problems were associated with illicit use of BUP. The secondary objectives included identifying motivations for illicit BUP use and the prevalence of naloxone acquisition among patients prescribed BUP. Methods Between July 2019 and March 2020, 139 participants receiving treatment for an opioid use disorder (OUD) at two sites within a rurally-located health system, completed an anonymous 33-item survey. A multivariable model was used to assess the association between pharmacy-related problems filling BUP prescriptions and illicit substance use. Results More than a third of participants reported having problems filling their BUP prescription (34.1%, n = 47) with the most commonly reported problems being insufficient pharmacy stock of BUP (37.8%, n = 17), pharmacist refusal to dispense BUP (37.8%, n = 17), and insurance problems (34.0%, n = 16). Of those who reported illicit BUP use (41.5%, n = 56), the most common motivations were to avoid/ease withdrawal symptoms (n = 39), prevent/reduce cravings (n = 39), maintain abstinence (n = 30), and treat pain (n = 19). In the multivariable model, participants who reported a pharmacy-related problems were significantly more likely to use illicitly obtained BUP (OR=8.93, 95% CI: 3.12, 25.52, p < 0.0001). Conclusion Efforts to improve BUP access have primarily focused on increasing the number of clinicians waivered to prescribe; however, challenges persist with BUP dispensing and coordinated efforts may be needed to systematically reduce pharmacy-related barriers.
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Affiliation(s)
- Erin L. Winstanley
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States,Corresponding author at: Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States.
| | - Emily P. Thacker
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Lyn Yuen Choo
- West Virginia Clinical and Translational Science Institute, West Virginia University, Morgantown, WV, United States
| | - Laura R. Lander
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States
| | - James H. Berry
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States
| | - Babak Tofighi
- Department of Population Health, New York University School of Medicine, United States
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Poliwoda S, Noor N, Jenkins JS, Stark CW, Steib M, Hasoon J, Varrassi G, Urits I, Viswanath O, Kaye AM, Kaye AD. Buprenorphine and its formulations: a comprehensive review. Health Psychol Res 2022; 10:37517. [PMID: 35999975 PMCID: PMC9392838 DOI: 10.52965/001c.37517] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023] Open
Abstract
Buprenorphine, a novel long-acting analgesic, was developed with the intention of two purposes: analgesia and opioid use disorder. Regarding its pharmacodynamics, it is a partial agonist at mu receptors, an inverse agonist at kappa receptors, and an antagonist at delta receptors. For the purpose of analgesia, three formulations of buprenorphine were developed: IV/IM injectable formulation (Buprenex®), transdermal patch formulation (Butrans®), and buccal film formulation (Belbuca®). Related to opioid dependence, the formulations developed were subcutaneous extended release (Sublocade®), subdermal implant (Probuphine®), and sublingual tablets (Subutex®). Lastly, in order to avoid misuse of buprenorphine for opioid dependence, two combination formulations paired with naloxone were developed: film formulation (Suboxone®) and tablet formulation (Zubsolv®). In this review, we present details of each formulation along with their similarities and differences between each other and clinical considerations.
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Affiliation(s)
| | - Nazir Noor
- Department of Anesthesiology, Mount Sinai Medical Center
| | | | - Cain W Stark
- Medical College of Wisconsin, 8701 West Watertown Plank Road, Wauwatosa, WI 53226
| | - Mattie Steib
- Louisiana State University Health Shreveport School of Medicine
| | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, Beth Israel Deaconess Medical Center
| | | | - Ivan Urits
- Department of Anesthesiology, 1501 Kings Hwy, Shreveport, LA 71103, Louisiana State University Health Shreveport
| | - Omar Viswanath
- Clinical Professor of Anesthesiology, LSU Health Sciences Center School of Medicine, Creighton University School of Medicine, Innovative Pain and Wellness
| | - Adam M Kaye
- Department of Pharmacy Practice, Stockton, CA, 95211,, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific
| | - Alan D Kaye
- Department of Anesthesiology, Shreveport, LA, Louisiana State University Health Sciences Center - Shreveport
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Buprenorphine-naloxone versus Buprenorphine for Treatment of Opioid Use Disorder in Pregnancy. J Addict Med 2022; 16:e399-e404. [PMID: 35916423 DOI: 10.1097/adm.0000000000001004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Data regarding treatment outcomes with the use of buprenorphine-naloxone (BUP-NX) in pregnancy are scarce. The objective of this study is to examine the outcomes in a cohort of pregnancies treated with BUP-NX versus buprenorphine (BUP). METHODS This single-center, retrospective cohort study examined birthing person-infant dyads treated with BUP-NX versus BUP. The primary birthing person outcome was return to opioid use in pregnancy. The primary neonatal outcome was the need for pharmacologic treatment for neonatal opioid withdrawal syndrome (NOWS). RESULTS The BUP-NX and the BUP treatment groups included 33 and 73 dyads, respectively. Except for psychiatric medication use, all demographics were similar between groups. In the final regression models, neither the birthing person nor the neonatal outcomes differed. The adjusted odds ratio for return to use during pregnancy for the BUP-NX versus BUP groups was 1.93 (95% confidence interval, 0.78-4.76). The adjusted odds ratio for pharmacologic treatment of NOWS for the BUP-NX versus BUP groups was 0.65 (95% confidence interval, 0.27-1.54). Among a subgroup of persons who transitioned from BUP to BUP-NX mid-pregnancy, there was no proximate return to use or need for dose increase. CONCLUSIONS Compared with BUP, the use of BUP-NX in pregnancy is not associated with a higher risk of return to opioid use or a higher need for pharmacological treatment for NOWS.
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Permissive regulation: A critical review of the regulatory history of buprenorphine formulations in Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 105:103749. [DOI: 10.1016/j.drugpo.2022.103749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 11/20/2022]
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Smith CL, Keever A, Bowden T, Olson K, Rodin N, McDonell MG, Roll JM, Smoody G, LeBrun J, Miguel AQ, McPherson SM. Patient Feedback on a Mobile Medication Adherence Application for Buprenorphine/Naloxone: Feasibility and Acceptability Study (Preprint). JMIR Form Res 2022; 7:e40437. [PMID: 37074780 PMCID: PMC10157459 DOI: 10.2196/40437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 01/09/2023] [Accepted: 02/14/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Opioid use disorders impact the health and well-being of millions of Americans. Buprenorphine and naloxone (BUP and NAL) can reduce opioid overdose deaths, decrease misuse, and improve quality of life. Unfortunately, poor medication adherence is a primary barrier to the long-term efficacy of BUP and NAL. OBJECTIVE We aimed to examine patient feedback on current and potential features of a Bluetooth-enabled pill bottle cap and associated mobile app for patients prescribed BUP and NAL for an opioid use disorder, and to solicit recommendations for improvement to effectively and appropriately tailor the technology for people in treatment for opioid use disorder. METHODS A convenience sample of patients at an opioid use disorder outpatient clinic were asked about medication adherence, opioid cravings, experience with technology, motivation for treatment, and their existent support system through a brief e-survey. Patients also provided detailed feedback on current features and features being considered for inclusion in a technology designed to increase medication adherence (eg, inclusion of a personal motivational factor, craving and stress tracking, incentives, and web-based coaching). Participants were asked to provide suggestions for improvement and considerations specifically applicable to people in treatment for opioid use disorder with BUP and NAL. RESULTS Twenty people with an opioid use disorder who were prescribed BUP and NAL participated (mean age 34, SD 8.67 years; 65% female; 80% White). Participants selected the most useful, second-most useful, and least useful features presented; 42.1% of them indicated that motivational reminders would be most useful, followed by craving and stress tracking (26.3%) and web-based support forums (21.1%). Every participant indicated that they had at least 1 strong motivating factor for staying in treatment, and half (n=10) indicated children as that factor. All participants indicated that they had, at some point in their lives, the most extreme craving a person could have; however, 42.1% indicated that they had no cravings in the last month. Most respondents (73.7%) stated that tracking cravings would be helpful. Most respondents (84.2%) also indicated that they believed reinforcers or prizes would help them achieve their treatment goals. Additionally, 94.7% of respondents approved of adherence tracking to accommodate this feature using smart packaging, and 78.9% of them approved of selfie videos of them taking their medication. CONCLUSIONS Engaging patients taking treatment for opioid use disorder with BUP and NAL allowed us to identify preferences and considerations that are unique to this treatment area. As the technology developer of the pill cap and associated mobile app is able to take into consideration or integrate these preferences and suggestions, the smart cap and associated mobile app will become tailored to this population and more useful for them, which may encourage patient use of the smart cap and associated mobile app.
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Affiliation(s)
- Crystal L Smith
- Department of Community and Behavioral Health, Elson S Floyd College of Medicine, Washington State University, Spokane, WA, United States
- Analytics and PsychoPharmacology Laboratory, Washington State University, Spokane, WA, United States
- Program of Excellence in Addictions Research, Washington State University, Spokane, WA, United States
| | - Abigail Keever
- Department of Community and Behavioral Health, Elson S Floyd College of Medicine, Washington State University, Spokane, WA, United States
- Analytics and PsychoPharmacology Laboratory, Washington State University, Spokane, WA, United States
- Program of Excellence in Addictions Research, Washington State University, Spokane, WA, United States
| | - Theresa Bowden
- Analytics and PsychoPharmacology Laboratory, Washington State University, Spokane, WA, United States
- Program of Excellence in Addictions Research, Washington State University, Spokane, WA, United States
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, United States
| | | | - Nicole Rodin
- Analytics and PsychoPharmacology Laboratory, Washington State University, Spokane, WA, United States
- Program of Excellence in Addictions Research, Washington State University, Spokane, WA, United States
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, United States
| | - Michael G McDonell
- Department of Community and Behavioral Health, Elson S Floyd College of Medicine, Washington State University, Spokane, WA, United States
- Program of Excellence in Addictions Research, Washington State University, Spokane, WA, United States
| | - John M Roll
- Department of Community and Behavioral Health, Elson S Floyd College of Medicine, Washington State University, Spokane, WA, United States
- Program of Excellence in Addictions Research, Washington State University, Spokane, WA, United States
| | - Gillian Smoody
- Analytics and PsychoPharmacology Laboratory, Washington State University, Spokane, WA, United States
| | | | - Andre Qc Miguel
- Department of Community and Behavioral Health, Elson S Floyd College of Medicine, Washington State University, Spokane, WA, United States
- Analytics and PsychoPharmacology Laboratory, Washington State University, Spokane, WA, United States
- Program of Excellence in Addictions Research, Washington State University, Spokane, WA, United States
| | - Sterling M McPherson
- Department of Community and Behavioral Health, Elson S Floyd College of Medicine, Washington State University, Spokane, WA, United States
- Analytics and PsychoPharmacology Laboratory, Washington State University, Spokane, WA, United States
- Program of Excellence in Addictions Research, Washington State University, Spokane, WA, United States
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Janzow GE, Harding C, Flores M, Borodovsky J, Steinkamp J, Marsch LA, Schuman-Olivier Z. Assessing the feasibility, usability and acceptability of the MySafeRx platform among individuals in outpatient buprenorphine treatment: Lessons learned from a pilot randomized controlled trial. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 3:100045. [PMID: 36845988 PMCID: PMC9949338 DOI: 10.1016/j.dadr.2022.100045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 03/12/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
Background Increasing buprenorphine/naloxone (B/N) access for opioid use disorder (OUD) is essential yet ensuring adherence and preventing diversion remains challenging. This study examines the feasibility, usability, and acceptability of MySafeRx, a mobile platform integrating motivational coaching, adherence monitoring, and electronic dispensing during office-based B/N treatment. Methods In this multi-site randomized controlled trial, MySafeRx provided coaching and supervised self-administration of B/N by mobile recovery coaches (MRCs) via videoconference. Referred adults (ages 18-65) with OUD were randomized to 1) 42-days of adjunctive MySafeRx treatment (n = 13) or 2) a standard care control group (n = 14). Results The randomized sample was 63% female and 100% White. Twelve of 13 MySafeRx participants completed at least one MRC session. The mean system usability score reported by MySafeRx participants was 78.4 (n = 12). Participants indicated they would recommend MySafeRx to a friend (mean= 4.1 of 5), and that the dispenser (4.1 of 5) and videoconferencing (4.2 of 5) were easy to use. The MRC component had the highest acceptability (4.4 of 5). MRCs observed B/N self-administration for an average of 64.3% of the required study days (men: 68.9%; women: 57.9%). On average, men (n = 4) met with MRCs on 32±14 days versus 47±6 days for women (n = 8). Exploratory analyses did not show significant differences between intervention and control groups. Conclusions Despite the small sample, this study supports usability and acceptability of MySafeRx. Increased adherence monitoring, even with remote coaching had limited appeal, which impacted feasibility due to slow recruitment, especially as community prescribing with relaxed monitoring requirements became more widespread.
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Affiliation(s)
- Grace E. Janzow
- Cambridge Health Alliance, Harvard Medical School, Department of Psychiatry, 1035 Cambridge Street, Suite 21A – CMC, Cambridge, MA 02141, United States
| | - Cassandra Harding
- Cambridge Health Alliance, Harvard Medical School, Department of Psychiatry, 1035 Cambridge Street, Suite 21A – CMC, Cambridge, MA 02141, United States
| | - Michael Flores
- Cambridge Health Alliance, Harvard Medical School, Department of Psychiatry, 1035 Cambridge Street, Suite 21A – CMC, Cambridge, MA 02141, United States
| | - Jacob Borodovsky
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, EverGreen Center, Suite 315, NH 03766, Lebanon
| | - Jackson Steinkamp
- Cambridge Health Alliance, Harvard Medical School, Department of Psychiatry, 1035 Cambridge Street, Suite 21A – CMC, Cambridge, MA 02141, United States
| | - Lisa A. Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, EverGreen Center, Suite 315, NH 03766, Lebanon
| | - Zev Schuman-Olivier
- Cambridge Health Alliance, Harvard Medical School, Department of Psychiatry, 1035 Cambridge Street, Suite 21A – CMC, Cambridge, MA 02141, United States
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, EverGreen Center, Suite 315, NH 03766, Lebanon
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Guillou Landreat M, Dany A, Challet Bouju G, Laforgue EJ, Cholet J, Leboucher J, Hardouin JB, Bodenez P, Grall-Bronnec M, Guillou-Landreat M, Le Geay B, Martineau I, Levassor P, Bolo P, Guillet JY, Guillery X, Dano C, Victorri Vigneau C, Grall Bronnec M. How do people who use drugs receiving Opioid Medication Therapy perceive their treatment ? A multicentre study. Harm Reduct J 2022; 19:31. [PMID: 35346219 PMCID: PMC8961988 DOI: 10.1186/s12954-022-00608-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 03/04/2022] [Indexed: 01/04/2023] Open
Abstract
Abstract
Background
The resurgence of heroin use and the misuse of pharmaceutical opioids are some of the reasons for a worldwide increase in opioid dependence. Opioid Medication Therapies (OMT) have amply demonstrated their efficacy. From a medical point of view, the main objectives of OMT concern medical and social outcomes, centred on risk reduction and the cessation of opioid use. But patient points of view can differ and few studies have explored opioid-dependent patient viewpoints on their OMT. This variable seems important to consider in a patient-centred approach. The aim of our study was to explore points of view of people who use drugs (PWUD) treated with OMT, in a large multicentre sample.
Method
A cross-sectional multicentre study explored the points of view of PWUD with Opioid Use Disorder following OMT. Data regarding the patients’ points of view were collected using a self-administered questionnaire developed by the scientific committee of the study. A descriptive analysis and an exploratory factor analysis were performed to explore the structure of items exploring patient viewpoints.
Results
263 opioid dependent PWUD were included, a majority were men consuming heroin prior to being prescribed OMT. 68% were on methadone, 32% were on buprenorphine. Most PWUD identified a positive impact on their lives, with 92.8% agreeing or strongly agreeing that OMT had changed a lot of things in their lives. The exploratory factor analysis identified three factors: (F1) items related to points of views concerning the objectives and efficacy of OMT; (F2) items related to the legitimacy of OMT as a treatment compared to a drug, (F3) items related to experiences and relationships with OMT.
Conclusion
Patient viewpoints on efficacy were correlated with the pharmacological benefits of OMT and with the associated psychosocial measures. The implications of OMT in relationships, such as the feeling of being judged, concerned a majority. Points of view were ambivalent concerning the role of OMT as a treatment or as a drug. Involving patient points of view in therapeutic strategies decisions could help enhance positive views among PWUD on OMT and help PWUD towards their recovery.
Trial registration: OPAL study was registered: (NCT01847729).
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Bach P, Bawa M, Grant C, Milloy M, Hayashi K. Availability and use of non-prescribed buprenorphine-naloxone in a Canadian setting, 2014-2020. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 101:103545. [PMID: 34875527 PMCID: PMC8917069 DOI: 10.1016/j.drugpo.2021.103545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/14/2021] [Accepted: 11/16/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Buprenorphine-naloxone (BUP-NX) is a first-line treatment for opioid use disorder and has a superior safety profile compared to other forms of opioid agonist therapy. In Canada, restrictions on BUP-NX prescribing were relaxed in 2016, which may have had an effect on rates of diversion and non-prescribed use. We sought to longitudinally examine the reported availability and use of non-prescribed BUP-NX among people who use drugs (PWUD) in an urban Canadian setting. METHODS We collected data from two linked prospective cohorts of PWUD in Vancouver, Canada, and examined self-reported availability and use of non-prescribed BUP-NX over time. We used a multivariable generalized estimating equations model to identify trends and factors associated with the immediate availability (i.e., within 10 min) of non-prescribed BUP-NX. RESULTS Among 1617 participants between 2014 and 2020, the immediate availability of non-prescribed BUP-NX increased from 16% to 63% (p<0.001). In the multivariable analysis, factors independently associated with immediate BUP-NX availability included calendar year (adjusted odds ratio = 1.19, 95% confidence interval: 1.15-1.23), along with a number of other variables suggestive of more severe substance use disorders. Only 17 participants ever reported use of non-prescribed BUP-NX. CONCLUSIONS We observed that BUP-NX has become increasingly available in the unregulated drug supply in recent years but its use has remained infrequent in this setting. These results suggest that relaxed restrictions on BUP-NX prescribing have not been a major driver of increased non-prescribed use in this population.
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Affiliation(s)
- Paxton Bach
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver BC, V5Z 1M9, Canada; British Columbia Centre on Substance Use, Suite 400 - 1045 Howe Street, Vancouver BC, V6Z 2A9, Canada.
| | - Misha Bawa
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver BC, V5Z 1M9, Canada,British Columbia Centre on Substance Use, Suite 400 – 1045 Howe Street, Vancouver BC, V6Z 2A9, Canada
| | - Cameron Grant
- British Columbia Centre on Substance Use, Suite 400 – 1045 Howe Street, Vancouver BC, V6Z 2A9, Canada
| | - M.J. Milloy
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver BC, V5Z 1M9, Canada,British Columbia Centre on Substance Use, Suite 400 – 1045 Howe Street, Vancouver BC, V6Z 2A9, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, Suite 400 – 1045 Howe Street, Vancouver BC, V6Z 2A9, Canada,Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby BC, V5A 1S6, Canada
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Westenberg JN, Tai AMY, Elsner J, Kamel MM, Wong JSH, Azar P, Vo DX, Moore E, Mathew N, Seethapathy V, Choi F, Vogel M, Krausz RM. Treatment approaches and outcome trajectories for youth with high-risk opioid use: A narrative review. Early Interv Psychiatry 2022; 16:207-220. [PMID: 33913589 DOI: 10.1111/eip.13155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/22/2021] [Indexed: 12/26/2022]
Abstract
AIM First use of opioids often happens in adolescence and an increasing number of opioid overdoses are being reported among youth. The purpose of this narrative review was to present the treatment approaches for youth with high-risk opioid use, determine whether the literature supports the use of opioid agonist treatment among youth and identify evidence for better treatment outcomes in the younger population. METHODS A search of the literature on PubMed using MeSH terms specific to youth, opioid use and treatment approaches generated 1436 references. Following a screening process, 137 papers were found to be relevant to the treatment of high-risk opioid use among youth. After full-text review, 19 eligible studies were included: four randomized controlled trials, nine observational studies and six reviews. RESULTS Research for the different treatment options among youth is limited. The available evidence shows better outcomes in terms of retention in care and cost-effectiveness for opioid agonist treatment than abstinence-based comparisons. Integrating psychosocial interventions into the continuum of care for youth can be an effective way of addressing comorbid psychiatric conditions and emotional drivers of substance use, leading to improved treatment trajectories. CONCLUSIONS From the limited findings, there is no evidence to deny youth with high-risk opioid use the same treatment options available to adults. A combination of pharmacological and youth-specific psychosocial interventions is required to maximize retention and survival. There is an urgent need for more research to inform clinical strategies toward appropriate treatment goals for such vulnerable individuals.
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Affiliation(s)
- Jean Nicolas Westenberg
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andy M Y Tai
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julie Elsner
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mostafa M Kamel
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Neuropsychiatry, Tanta University, Tanta, Egypt
| | - James S H Wong
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pouya Azar
- Complex Pain and Addiction Services, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Department of Psychiatry, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Dzung X Vo
- Division of Adolescent Health and Medicine, Department of Pediatrics, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Eva Moore
- Division of Adolescent Health and Medicine, Department of Pediatrics, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Nickie Mathew
- Department of Psychiatry, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada.,BC Mental Health & Substance Use Services, Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Vijay Seethapathy
- Department of Psychiatry, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada.,BC Mental Health & Substance Use Services, Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Fiona Choi
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marc Vogel
- Psychiatric University Clinic Basel, Basel, Switzerland
| | - Reinhard M Krausz
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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45
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Wood CA, Duello A, Miles J, Lohmann B, Gochez-Kerr T, Richardson K, Anderson-Harper R, Winograd RP. Acceptance of medications for opioid use disorder in recovery housing programs in Missouri. J Subst Abuse Treat 2022; 138:108747. [DOI: 10.1016/j.jsat.2022.108747] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 01/05/2022] [Accepted: 02/14/2022] [Indexed: 01/20/2023]
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46
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Bapat S, Washburn M, Tata V, Fleming M, Abughosh SM, Essien EJ, Thornton D. Barriers and Facilitators to DATA Waivered Providers Prescribing Buprenorphine: A Qualitative Analysis Applying the Theory of Planned Behavior. Subst Use Misuse 2022; 57:1761-1771. [PMID: 35993387 DOI: 10.1080/10826084.2022.2112226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Background: Provider beliefs about the treatment of people with addiction may influence their prescribing behavior. Objective: This study applied the Theory of Planned Behavior (TPB), to identify the salient beliefs of Drug Addiction Treatment Act of 2000 (DATA 2000) waivered providers, concerning prescribing buprenorphine to patients with Opioid Use Disorder (OUD). Methods: Texas buprenorphine providers participated in one of four online focus group discussions conducted in fall 2019. The focus group discussion were audio recorded and the total length was between 60-90 minutes. Thematic analysis was conducted to identify emerging themes and to categorize the behavioral, normative, and control beliefs related to buprenorphine prescribing. Results: Of the 14 total participants, 57% of the participants were male and annually treated between zero to sixty patients with buprenorphine. The codes generated were represented in thematic maps, specifying the positive or negative aspects of buprenorphine prescribing. Results indicate that providers' primary motivation to prescribe buprenorphine was, implementation of a whole-patient approach through collaboration with behavioral health providers, in the provision of medications for opioid use disorder (MOUD). Providers primary normative belief was the recognition of key members of the medical community and patients' families and friends as influential groups. Providers' control beliefs focused on their ability to use buprenorphine in different practice settings. Conclusion: These results indicate that buprenorphine access may be expanded by increasing support for DATA waivered providers from other parts of the healthcare system such as behavioral health providers and pharmacists. Implications for clinical practice and future research will be discussed.
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Affiliation(s)
- Shweta Bapat
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, Houston, Texas, USA
| | - Micki Washburn
- Arlington School of Social Work, University of Texas at Arlington, Arlington, Texas, USA
| | - Vaishnavi Tata
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, Houston, Texas, USA
| | - Marc Fleming
- Department of Pharmaceutical Economics and Policy, Chapman University School of Pharmacy, Irvine, California, USA
| | - Susan M Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, Houston, Texas, USA
| | - E James Essien
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, Houston, Texas, USA
| | - Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, Houston, Texas, USA
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47
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McLean K, Kavanaugh PR. "I'm Not a Good Drug Dealer": Styles of Buprenorphine Diversion in a Multisite Qualitative Study. Subst Use Misuse 2022; 57:452-460. [PMID: 35067160 DOI: 10.1080/10826084.2021.2019775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Against the backdrop of the U.S. opioid epidemic, there has been a concerted movement to improve access to buprenorphine maintenance therapy (BMT). In Pennsylvania, where overdose mortality increased 65% between 2015 and 2017, over $75 million has been appropriated toward BMT since 2016. Concurrently, efforts to increase BMT availability while lowering barriers to entry have given way to fears of increased diversion and illegitimate patients. Little is known about the circumstances and motivations that surround buprenorphine diversion, particularly within the context of treatment expansion. METHOD Drawing on 27 in-depth interviews with individuals who reported sharing or selling buprenorphine in the past year, in this study we consider the relationship between treatment access, treatment experiences, and individuals' decision to divert buprenorphine, while further comparing motivations for buprenorphine diversion across two Pennsylvania counties with disparate levels of BMT availability. RESULTS We identify four styles of buprenorphine diversion ("ad hoc sellers," "concerned suppliers," "social sharers," "professional dealers"), with different levels of representation by county. Overall, our analysis found the explicit economic exploitation of BMT was rare, while a plurality of participants reported selling unwanted or unneeded buprenorphine only when presented with an opportunity. CONCLUSIONS Across our typology, market demand in the form of unmet need for buprenorphine was the major driver of diversion, suggesting that "supply-side interventions" intended to again limit access to BMT may be counterproductive.
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Affiliation(s)
- Katherine McLean
- Administration of Justice, Penn State Greater Allegheny, McKeesport, Pennsylvania, USA
| | - Philip R Kavanaugh
- School of Public Affairs, Penn State Harrisburg, Middletown, Pennsylvania, USA
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Treatment of opioid overdose: current approaches and recent advances. Psychopharmacology (Berl) 2022; 239:2063-2081. [PMID: 35385972 PMCID: PMC8986509 DOI: 10.1007/s00213-022-06125-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 03/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The USA has recently entered the third decade of the opioid epidemic. Opioid overdose deaths reached a new record of over 74,000 in a 12-month period ending April 2021. Naloxone is the primary opioid overdose reversal agent, but concern has been raised that naloxone is not efficacious against the pervasive illicit high potency opioids (i.e., fentanyl and fentanyl analogs). METHODS This narrative review provides a brief overview of naloxone, including its history and pharmacology, and the evidence regarding naloxone efficacy against fentanyl and fentanyl analogs. We also highlight current advances in overdose treatments and technologies that have been tested in humans. RESULTS AND CONCLUSIONS The argument that naloxone is not efficacious against fentanyl and fentanyl analogs rests on case studies, retrospective analyses of community outbreaks, pharmacokinetics, and pharmacodynamics. No well-controlled studies have been conducted to test this argument, and the current literature provides limited evidence to suggest that naloxone is ineffective against fentanyl or fentanyl analog overdose. Rather a central concern for treating fentanyl/fentanyl analog overdose is the rapidity of overdose onset and the narrow window for treatment. It is also difficult to determine if other non-opioid substances are contributing to a drug overdose, for which naloxone is not an effective treatment. Alternative pharmacological approaches that are currently being studied in humans include other opioid receptor antagonists (e.g., nalmefene), respiratory stimulants, and buprenorphine. None of these approaches target polysubstance overdose and only one novel approach (a wearable naloxone delivery device) would address the narrow treatment window.
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Furo H, Schwartz DG, Sullivan RW, Elkin PL. Buprenorphine Dosage and Urine Quantitative Buprenorphine, Norbuprenorphine, and Creatinine Levels in an Office-Based Opioid Treatment Program. Subst Abuse 2021; 15:11782218211061749. [PMID: 34898987 PMCID: PMC8655441 DOI: 10.1177/11782218211061749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/05/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Treatment progress is routinely monitored by urine testing in patients with opioid use disorder (OUD) undergoing buprenorphine medication-assisted treatment (MAT). However, interpretation of urine test results could be challenging. This retrospective study aims to examine the results of quantitative buprenorphine, norbuprenorphine, and creatinine levels in urine testing in relation to sublingual buprenorphine dosage to facilitate an accurate interpretation of urine testing results. METHODS We reviewed the medical charts of 41 consecutive patients, who were residing in halfway houses where their medication intake was closely monitored and who had enrolled in an office-based MAT program at an urban clinic between July 2018 and June 2019. The patients' urine testing results were reviewed, and demographic variables were recorded. We focused on the patients treated with 8-, 12-, or 16-mg/day of buprenorphine, examining their urine buprenorphine, norbuprenorphine, and creatinine levels. Analysis of variance tested the statistical association between the dosage and urine testing results on the norbuprenorphine-to-creatinine ratio. RESULTS A total of 240 urine samples from 41 patients were included for this study. The 41 patients received a mean buprenorphine dose of 10.5 ± 3.7 mg/day (range, 4-20 mg/day). Then, this study examined the distribution of the 240 urine samples and then focused on 184 urine samples that came from the 33 patients who were treated with 8-, 12-, and 16-mg/day of buprenorphine, the 3 most common dosages. All of the 184 urine samples had a creatinine level of >20 mg/dL and buprenorphine-to-norbuprenorphine ratio <50:1. The average norbuprenorphine-to-creatinine ratio in the 8 mg/day dosage group was 3.85 ± 2.24 × 10-4 (n = 66; range, 0.44-11.12). The respective ratios in the 12- and 16-mg dosage groups were 5.64 ± 3.40 × 10-4 (n = 83; range, 1.55-22.72) and 6.23 ± 4.92 × 10-4 (n = 35; range, 1.37-27.12). The 3 dosage groups differed significantly in the mean ratios (P < .01), except when the 12- and 16-mg dosage groups were compared (P = .58). The results of this study thus suggest that prescribers should pay attention to the following features: (1) unexpected substance(s) in urine testing, (2) creatinine level under 20 mg/dL, (3) buprenorphine-to-creatinine ratio over 50:1, (4) buprenorphine dosage over 24 mg/day, and (5) norbuprenorphine-to-creatinine ratio consistently under 0.5 × 10-4 in patients treated with 8 mg/day or 1.5 × 10-4 in patients treated with 12 mg/day or more. CONCLUSION This study suggested parameters for interpreting quantitative urine test results in relation to buprenorphine intake dose in office-based opioid treatment programs.
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Affiliation(s)
- Hiroko Furo
- Department of Biomedical Informatics, State University of New York (SUNY) at Buffalo, Buffalo, NY, USA
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health at San Antonio, San Antonio, TX, USA
| | - Diane G Schwartz
- Department of Biomedical Informatics, State University of New York (SUNY) at Buffalo, Buffalo, NY, USA
| | - Ross W Sullivan
- Department of Emergency Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, NY, USA
| | - Peter L Elkin
- Department of Biomedical Informatics, State University of New York (SUNY) at Buffalo, Buffalo, NY, USA
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50
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Cotton AJ, Lo K, Kurtz FB, Waldbauer L. Extended-release buprenorphine outcomes among treatment resistant veterans. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2021; 48:334-337. [PMID: 34780319 DOI: 10.1080/00952990.2021.1992773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Buprenorphine Extended-Release (BUP-XR) is an FDA approved, monthly subcutaneous injection for opioid use disorder. This formulation provides an alternative for patients who have difficulty adhering to daily sublingual buprenorphine; however, its cost may be prohibitive compared to other medication alternatives. OBJECTIVES The objective of this project was to evaluate the effectiveness of BUP-XR and provide a rationale for its utilization in health care facilitates. METHODS Across two VA outpatient clinics, twenty-six (22 male, 4 female) clinically complex patients received at least one BUP-XR injection between December 1, 2018 and April 1, 2020. The sample was high risk for hospital admission and mortality. Data was collected retrospectively from the medical records. Outcomes examined included: medication adherence, urine drug and alcohol screenings, emergency department visits, hospital admissions, and housing status. Within-subject comparisons were made between the six month period prior to and following the first injection. RESULTS Treatment retention was robust, as 81% of the sample received six or more monthly BUP-XR injections. Most patients (77%) maintained 300 mg dosage and a majority (70%) missed or were late for at least one injection. BUP-XR was associated with reduction in: emergency department visits, days of hospitalization, non-prescribed opioid use, and homelessness. Mortality rate was 23%. CONCLUSIONS BUP-XR with a flexible dosing schedule and a nonstandard default dose of 300 mgs resulted in robust retention, provided effective treatment of OUD, and reduced health care utilization for these complex patients with high mortality risk. However, due to the lack of statistical significance generalization of these findings is limited.
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Affiliation(s)
- Ann J Cotton
- Addiction Treatment Center, U.S. Department of Veterans Affairs Puget Sound Health Care System, Seattle, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA
| | - Katelyn Lo
- Addiction Treatment Center, U.S. Department of Veterans Affairs Puget Sound Health Care System, Seattle, USA
| | - Fiona B Kurtz
- Addiction Treatment Center, U.S. Department of Veterans Affairs Puget Sound Health Care System, Seattle, USA.,Center of Excellence in Substance Addiction Treatment and Education, Veterans Affairs Puget Sound Health Care System, Seattle, USA
| | - LeAnna Waldbauer
- Addiction Treatment Center, U.S. Department of Veterans Affairs Puget Sound Health Care System, Seattle, USA
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