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Shikalgar S, Weiner SG, Young GJ, Noor-E-Alam M. Self-help groups and opioid use disorder treatment: An investigation using a machine learning-assisted robust causal inference framework. Int J Med Inform 2024; 190:105530. [PMID: 38964004 DOI: 10.1016/j.ijmedinf.2024.105530] [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: 11/01/2023] [Revised: 05/04/2024] [Accepted: 06/23/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVES This study investigates the impact of participation in self-help groups on treatment completion among individuals undergoing medication for opioid use disorder (MOUD) treatment. Given the suboptimal adherence and retention rates for MOUD, this research seeks to examine the association between treatment completion and patient-level factors. Specifically, we evaluated the causal relationship between self-help group participation and treatment completion for patients undergoing MOUD. METHODS We used the Substance Abuse and Mental Health Services Administration's (SAMHSA) Treatment Episode Data Set: Discharges (TEDS-D) from 2015 to 2019. The data are filtered by the patient's opioid use history, demographics, treatment modality, and other relevant information. In this observational study, machine learning models (Lasso Regression, Decision Trees, Random Forest, and XGBoost) were developed to predict treatment completion. Outcome Adaptive Elastic Net (OAENet) was used to select confounders and outcome predictors, and the robust McNemars test was used to evaluate the causal relationship between self-help group participation and MOUD treatment completion. RESULTS The machine-learning models showed a strong association between participation in self-help groups and treatment completion. Our causal analysis demonstrated an average treatment effect on treated (ATT) of 0.260 and a p-value < 0.0001 for the robust McNemars test. CONCLUSIONS Our study demonstrates the importance of participation in self-help groups for MOUD treatment recipients. We found that participation in MOUD along with self-help groups caused higher chances of treatment completion than MOUD alone. This suggests that policymakers should consider further integrating self-help groups into the treatment for OUD to improve the adherence and completion rate.
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Affiliation(s)
- Sahil Shikalgar
- Dept. of Mechanical and Industrial Engineering, College of Engineering, Northeastern University, 360 Huntington Avenue, Boston, MA 02135, USA
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, NH-226, Boston, MA 02115, USA
| | - Gary J Young
- D'Amore-McKim School of Business, Bouve College of Health Sciences, Center for Health Policy and Healthcare Research, Northeastern University, 360 Huntington Avenue, Boston, MA 02135, USA
| | - Md Noor-E-Alam
- Dept. of Mechanical and Industrial Engineering, College of Engineering, Northeastern University, 360 Huntington Avenue, Boston, MA 02135, USA.
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Ross RK, Rudolph KE, Shover CL. Prescribing of extended release buprenorphine injection for Medicaid beneficiaries, 2018-2022. Addiction 2024. [PMID: 39149781 DOI: 10.1111/add.16652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 07/19/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND AND AIMS Extended release buprenorphine injection (INJ-BUP) has been available in the United States since 2018. INJ-BUP has the potential to positively impact opioid use disorder (OUD) treatment outcomes by providing additional treatment options . As one of the largest payers of OUD treatment in the US, Medicaid coverage is important for access and uptake of INJ-BUP. Uptake of INJ-BUP among Medicaid beneficiaries has not been described since 2019 and variation in uptake by state has not previously been explored. We aimed to measure prescribing of INJ-BUP for Medicaid beneficiaries since 2018, nationwide and by state. METHODS We analyzed State Drug Utilization Data from 2017 to 2022 and calculated the number of prescription fills for INJ-BUP and oral buprenorphine paid by Medicaid. To compare across states, we calculated the number of prescription fills per 100 Medicaid beneficiaries treated for OUD using data from Transformed Medicaid Statistical Information System Substance Use Disorder (T-MSIS SUD) Data Books. Data sources are publicly available. RESULTS The number of prescription fills for INJ-BUP paid by Medicaid increased from 4322 (0.1% of all buprenorphine prescription fills) in 2018 to 186 861 (2.0%) in 2022. Each year the increase in fills exceeded the prior year change, indicating accelerating uptake. There was notable variability across states. CONCLUSIONS The number of extended release buprenorphine injection prescriptions among US Medicaid beneficiaries treated for opioid use disorder increased from over 4000 prescriptions in 2018 to over 185 000 in 2022 but uptake is much less than observed in other countries over shorter time periods.
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Affiliation(s)
- Rachael K Ross
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Chelsea L Shover
- Division of General Internal Medicine and Health Services Research, School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Ross RK, Nunes EV, Olfson M, Shulman M, Krawczyk N, Stuart EA, Rudolph KE. Comparative effectiveness of extended-release naltrexone and sublingual buprenorphine for treatment of opioid use disorder among Medicaid patients. Addiction 2024. [PMID: 39099417 DOI: 10.1111/add.16630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/27/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND AND AIMS Extended-release naltrexone (XR-NTX) and sublingual buprenorphine (SL-BUP) are both approved for opioid use disorder (OUD) treatment in any medical setting. We aimed to compare the real-world effectiveness of XR-NTX and SL-BUP. DESIGN AND SETTING This was an observational active comparator, new user cohort study of Medicaid claims records for patients in New Jersey and California, USA, 2016-19. PARTICIPANTS/CASES The participants were adult Medicaid patients aged 18-64 years who initiated XR-NTX or SL-BUP for maintenance treatment of OUD and did not use medications for OUD in the 90 days before initiation. Our cohort included 1755 XR-NTX and 9886 SL-BUP patients. MEASUREMENTS We examined two outcomes up to 180 days after medication initiation: (1) composite of medication discontinuation and death and (2) composite of overdose and death. FINDINGS In adjusted analyses, treatment with XR-NTX was more likely to result in discontinuation or death by the end of follow-up than treatment with SL-BUP: cumulative risk 75.9% [95% confidence interval (CI) = 73.9%, 77.9%] versus 62.2% (95% CI = 61.2%, 63.2%), respectively (risk difference = 13.7 percentage points, 95% CI = 11.4, 16.0). There was minimal difference in the cumulative risk of overdose or death by the end of follow-up: XR-NTX 3.9% (95% CI = 3.0%, 4.8%) versus SL-BUP 3.3% (95% CI = 2.9%, 3.7%); risk difference = 0.5 percentage points, 95% CI = -0.4, 1.5. Results were consistent across sensitivity analyses. CONCLUSIONS Medicaid patients in California and New Jersey, USA, receiving treatment for opioid use disorder stayed in treatment longer on sublingual buprenorphine than on extended-release naltrexone, but the risk of overdose was similar. Most patients in this study discontinued medication within 6 months, regardless of which medication was initiated.
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Affiliation(s)
- Rachael K Ross
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Edward V Nunes
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Mark Olfson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Matisyahu Shulman
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Noa Krawczyk
- Department of Population Health, New York University, New York, NY, USA
| | - Elizabeth A Stuart
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Guerra-Alejos BC, Yan Y, Kurz M, Mudalige N, Min JE, Homayra F, Nosyk B. Prescribing practices in opioid agonist treatment and changes in compliance to clinical dosing guidelines in British Columbia, Canada. Addiction 2024; 119:1453-1459. [PMID: 38584294 DOI: 10.1111/add.16491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/01/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND AND AIM In British Columbia, Canada, clinical guidelines for the treatment of opioid use disorders (OUD) were updated in 2017, during a period in which the potency and composition of the illicit drug supply changed rapidly. We aimed to describe changes in opioid agonist treatment (OAT) prescribing practices at the population level in a setting in which fentanyl and its analogs have become the primary illicit opioid of use. DESIGN, SETTING AND PARTICIPANTS This was a population-based retrospective cohort study using three linked health administrative databases in British Columbia (BC), Canada. All individuals with at least one OAT dispensation in BC between 1 January 2014 and 31 August 2021 took part. MEASUREMENTS To assess changes in OAT prescribing practices over time, we calculated initiation doses, dose titration intervals, maintenance doses and take-home dosing intervals stratified by medication [methadone, buprenorphine-naloxone and slow-release oral morphine (SROM)] according to recommended guidelines. FINDINGS A total of 265 410 OAT episodes (57.5% on methadone, 34.5% on buprenorphine-naloxone and 8.0% on SROM) were initiated during the study period. Compared with the guideline recommendation, observed initiation doses were higher among all medications from 2014 (2017 for SROM) to 2021 (buprenorphine-naloxone: 14-29%; methadone: 53-66%; SROM: 26-55%). Titration intervals were shorter for all medications, consistent with guidelines for buprenorphine-naloxone (26-49%), but shorter than recommended for methadone or SROM (28-51% and 12-41%, respectively). Higher maintenance dosing was observed for methadone (68-78%) and SROM (3-21%). Take-home allowances extending beyond the recommended guideline length increased across medications (buprenorphine-naloxone: 18-35%; methadone: 50-64%; SROM: 34-39%). Changes in prescribing patterns were similar for first-time OAT initiators. CONCLUSION In British Columbia, Canada, from 2014 to 2021, prescribers of opioid agonist treatment (OAT) appeared to initiate both new and experienced OAT clients at higher doses than guideline recommendations, titrate them more rapidly and maintain clients at higher doses. Take-home dose allowances also gradually increased.
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Affiliation(s)
| | - Youwei Yan
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | - Megan Kurz
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Nishan Mudalige
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | - Fahmida Homayra
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
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Shafer PO, Dean P, Brooks L, Gidal B, Misra SN, Carrazana E. Intranasal Delivery of Medications for the Treatment of Neurologic Conditions: A Pharmacology Update. J Neurosci Nurs 2024; 56:136-142. [PMID: 38976832 DOI: 10.1097/jnn.0000000000000769] [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: 07/10/2024]
Abstract
ABSTRACT INTRODUCTION: Nurses have a central role in educating patients and families about treatment options and how to integrate them into action plans for neurologic conditions. In recent years, a growing number of intranasal formulations have become available as rescue therapy for neurologic conditions or symptoms including migraine, opioid overdose, and seizures. Rescue therapies do not replace maintenance medications or emergency care but are designed to enable rapid treatment of urgent or disabling conditions in community settings. Yet, discussion of rescue therapies for neurologic conditions remains limited in nursing literature. CONTENT: Intranasal formulations are specifically formulated for delivery and absorption in the nose and have several characteristics that are well suited as rescue therapies for neurologic conditions. Intranasal formulations include triptans for migraine, naloxone and nalmefene for opioid overdose, and benzodiazepines for seizure clusters in patients with epilepsy. Therapeutic attributes discussed here include ease of use in community settings by nonmedical professionals, relatively rapid onset of action, and favorable safety profile and patient experience. This information is critical for nurses to make informed decisions about rescue therapy options, incorporate these into plans of care, and educate patients, care partners, and other healthcare providers. CONCLUSION: Rescue therapies are increasingly important in the care of people with neurologic conditions. Various formulations are available and continue to evolve, offering easy and quick ways for nurses, patients, and nonmedical care partners to administer critical rescue medications. For nurses overseeing medication management, the attributes of intranasal rescue therapies should be considered in the context of providing patients with the right care at the right time.
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Archambault L, Bertrand K, Martel MO, Bérubé M, Belhouari S, Perreault M. The current state of knowledge on care for co-occurring chronic pain and opioid use disorder: A scoping review. J Clin Nurs 2024; 33:3056-3076. [PMID: 38532646 DOI: 10.1111/jocn.17139] [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: 10/04/2023] [Revised: 03/11/2024] [Accepted: 03/18/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND AND AIMS Opioid use disorder often co-occurs with chronic pain but assessment and treatment of these co-occurring disorders is complex. This review aims to identify current treatments and delivery models for co-occurring chronic pain and opioid use disorder (OUD) documented in the scientific literature. DESIGN Scoping review. METHODS The review was conducted in six databases in June 2022 (no time limit): CINAHL, PsycINFO, Web of Science, Cochrane, PubMed and Embase. The PRISMA-ScR checklist was used to guide reporting. RESULTS Forty-seven publications addressing the issue of co-occurring chronic pain and OUD management were included. Randomized controlled trials provide evidence for the effectiveness of opioid agonist treatments (OAT) such as methadone or buprenorphine/naloxone, as well as for combining OAT with Mindfulness-Oriented Recovery Enhancement or cognitive behavioural therapy. A number of other pharmacological treatments (opioid and nonopioid), nonpharmacological treatments (e.g. physiotherapy) and service delivery models (e.g. simultaneous treatment of comorbidities, interdisciplinary and interprofessional collaboration) are also underlined. In most cases, authors recommend a combination of strategies to meet patient needs. CONCLUSIONS The scoping review reveals gaps in evidence-based knowledge to effectively care for co-occurring chronic pain and OUD, but several experts recommend the uptake of known 'best' practices such as integrated treatment of the multiple biopsychosocial dimensions of the co-occurring disorders as well as collaborative interdisciplinary work. CLINICAL RELEVANCE Improving services is dependent on alleviating barriers such as working in silos, the costs associated with nonpharmacological treatments, and the double stigma associated with pain in people with a substance use disorder.
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Affiliation(s)
- Léonie Archambault
- Université de Sherbrooke and Douglas Research Center, Montréal, Quebec, Canada
- Institut universitaire sur les dépendances, Direction de l'enseignement universitaire et de la recherche, CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montréal, Quebec, Canada
| | - Karine Bertrand
- Institut Universitaire Sur les dépendances and Community Health Science Dept., Université de Sherbrooke, Longueuil, Quebec, Canada
| | - Marc O Martel
- Faculty of Dentistry & Department of Anesthesiology, McGill University, Montréal, Quebec, Canada
| | - Mélanie Bérubé
- Faculté Des Sciences infimières, Université Laval, Quebec City, Quebec, Canada
| | | | - Michel Perreault
- Douglas Research Center and Dept. of Psychiatry, McGill University, Montréal, Quebec, Canada
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Madden K. Cochrane in CORR®: Opioid Agonist Treatment for People Who are Dependent on Pharmaceutical Opioids. Clin Orthop Relat Res 2024; 482:00003086-990000000-01691. [PMID: 39051901 PMCID: PMC11343545 DOI: 10.1097/corr.0000000000003202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/05/2024] [Indexed: 07/27/2024]
Affiliation(s)
- Kim Madden
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St. Joseph's Hamilton, Hamilton, Ontario, Canada
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Schachman KA, Macomber CA, Mitchell ML, Brown JM, Scott JL, Darr RL, Fabbro MA, Morrone WR, Peckham KA, Charbonneau-Ivey TK. Gaining Recovery in Addiction for Community Elders (GRACE) Project: The Impact of Age-Specific Care on Clinical Outcomes and Health Care Resource Utilization in Older Adults With Substance Use Disorder in an Interprofessional Addiction Clinic. J Am Psychiatr Nurses Assoc 2024:10783903241261694. [PMID: 39049443 DOI: 10.1177/10783903241261694] [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: 07/27/2024]
Abstract
BACKGROUND The prevalence of substance use disorders (SUDs) in older adults has been increasing, necessitating tailored and effective addiction care for this aging demographic. AIMS The purpose of this study was to assess the impact of age-specific, interprofessional addiction care on clinical outcomes and health care resource utilization in older adults with SUD. METHODS This quasi-experimental study directly compares patients enrolled in the Gaining Recovery in Addiction for Community Elders (GRACE) Project, an interprofessional age-specific addictions treatment program, with age-matched older adults who received conventional "treatment as usual" (TAU). Through retrospective comparative analysis, substance use outcomes, mental and physical health improvements, and inappropriate use of emergency services were examined among 78 older adults with SUD. RESULTS Clinical outcomes and health care resource utilization were superior for older adults who received age-specific addictions care through the GRACE Project, as compared to mixed-age conventional "TAU." GRACE patients had improved treatment adherence, fewer relapses, and longer treatment engagement. While both groups exhibited significant reductions in depression and anxiety scores, GRACE patients showed greater improvements. This group demonstrated superior control of both hypertension and diabetes. Importantly, they had fewer inappropriate emergency department visits and avoidable hospitalizations than conventional "TAU." CONCLUSIONS Addiction treatment delivered by an interprofessional team to meet the unique strengths and needs of older adults has the potential to improve treatment adherence and more favorable long-term outcomes in substance use, mental health, and chronic medical conditions. Nurses are poised to lead interprofessional teams to meet the growing demand for specialized addiction treatment and integrated care for older adults.
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Affiliation(s)
- Kathleen A Schachman
- Kathleen A. Schachman, PhD, FNP-BC, PMHNP-BC, FIAAN, FAANP, Saginaw Valley State University, University Center, MI, USA
| | - Catherine A Macomber
- Catherine A. Macomber, PhD, LMSW, Saginaw Valley State University, University Center, MI, USA
| | - Matthew L Mitchell
- Matthew L. Mitchell, DHA, LMSW, MBA, CAADC, CCS, Saginaw Valley State University, University Center, MI, USA
| | - Jill M Brown
- Jill M. Brown, PhD, MOST, OTRL, Saginaw Valley State University, University Center, MI, USA
| | - Jennifer L Scott
- Jennifer L. Scott, DNP, FNP-BC, PMHNP-BC, Saginaw Valley State University, University Center, MI, USA
| | - Rachel L Darr
- Rachel L. Darr, PhD, RD, CSSD, Saginaw Valley State University, University Center, MI, USA
| | - Mindy A Fabbro
- Mindy A. Fabbro, DNP, FNP-BC, PMHNP-BC, Saginaw Valley State University, University Center, MI, USA
| | - William R Morrone
- William R. Morrone, DO, MPH, MS, FACOFP, Recovery Pathways, LLC, Bay City, MI, USA
| | - Kari A Peckham
- Kari A. Peckham, EMT-B, CADC, Saginaw Valley State University, University Center, MI, 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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Weimer MB, Devoto A, Kansagara D, Safarian T, Brunner E, Stock A, Rastegar DA, Nelson LS, Tirado CF, Korthuis PT, Boyle MP. The American Society of Addiction Medicine Clinical Practice Guideline Development Methodology. J Addict Med 2024; 18:366-372. [PMID: 38752709 DOI: 10.1097/adm.0000000000001312] [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: 05/22/2024]
Abstract
ABSTRACT The American Society of Addiction Medicine (ASAM) has published clinical practice guidelines (CPGs) since 2015. As ASAM's CPG work continues to develop, it maintains an organizational priority to establish rigorous standards for the trustworthy production of these important documents. In keeping with ASAM's mission to define and promote evidence-based best practices in addiction prevention, treatment, and recovery, ASAM has rigorously updated its CPG methodology to be in line with evolving international standards. The CPG Methodology and Oversight Subcommittee was formed to establish and publish a methodology for the development of ASAM CPGs and to develop an ASAM CPG strategic plan. This article provides a focused overview of the ASAM CPG methodology.
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Affiliation(s)
- Melissa B Weimer
- From the Program in Addiction Medicine, Yale School of Medicine, New Haven, CT (MBW); American Society of Addiction Medicine, Rockville, MD (AD, TS, MPB); VA Portland Health Care System, Portland, OR (DK); Department of Medicine, Oregon Health and Science University, Portland, OR (DK, PTK); Gateway Recovery Center, Lake Elmo, MN (EB); USA Landstuhl Regional Medical Center, APO, AE (AS); Johns Hopkins University School of Medicine, Baltimore, MD (DAR); Rutgers New Jersey Medical School, Newark, NJ (LSN); and CARMA Health, Austin, TX (CFT)
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Feeney ME, Law AC, Walkey AJ, Bosch NA. Variation in Use of Medications for Opioid Use Disorder in Critically Ill Patients Across the United States. Crit Care Med 2024; 52:e365-e375. [PMID: 38501933 PMCID: PMC11176030 DOI: 10.1097/ccm.0000000000006257] [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] [Indexed: 03/20/2024]
Abstract
OBJECTIVES To describe practice patterns surrounding the use of medications to treat opioid use disorder (MOUD) in critically ill patients. DESIGN Retrospective, multicenter, observational study using the Premier AI Healthcare Database. SETTING The study was conducted in U.S. ICUs. PATIENTS Adult (≥ 18 yr old) patients with a history of opioid use disorder (OUD) admitted to an ICU between 2016 and 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 108,189 ICU patients (658 hospitals) with a history of OUD, 20,508 patients (19.0%) received MOUD. Of patients receiving MOUD, 13,745 (67.0%) received methadone, 2,950 (14.4%) received buprenorphine, and 4,227 (20.6%) received buprenorphine/naloxone. MOUD use occurred in 37.9% of patients who received invasive mechanical ventilation. The median day of MOUD initiation was hospital day 2 (interquartile range [IQR] 1-3) and the median duration of MOUD use was 4 days (IQR 2-8). MOUD use per hospital was highly variable (median 16.0%; IQR 10-24; range, 0-70.0%); admitting hospital explained 8.9% of variation in MOUD use. A primary admitting diagnosis of unintentional poisoning (aOR 0.41; 95% CI, 0.38-0.45), presence of an additional substance use disorder (aOR 0.66; 95% CI, 0.64-0.68), and factors indicating greater severity of illness were associated with reduced odds of receiving MOUD in the ICU. CONCLUSIONS In a large multicenter, retrospective study, there was large variation in the use of MOUD among ICU patients with a history of OUD. These results inform future studies seeking to optimize the approach to MOUD use during critical illness.
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Affiliation(s)
| | - Anica C. Law
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine School of Medicine, Boston, MA
| | - Allan J. Walkey
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine School of Medicine, Boston, MA
| | - Nicholas A. Bosch
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine School of Medicine, Boston, MA
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Sanni A, Goble S, Gilbertson DT, Johnson D, Linzer M. The Associations Between Opioid Use Disorder and Healthcare-Related Outcomes in Vaso-occlusive Crisis. J Gen Intern Med 2024; 39:1666-1672. [PMID: 38499723 PMCID: PMC11254892 DOI: 10.1007/s11606-024-08717-7] [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] [Received: 06/23/2023] [Accepted: 02/23/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND In patients who experience frequent vaso-occlusive crises (VOC), opioid dependence may be due to a need for pain control as opposed to addiction; the implications of opioid use disorder (OUD) in this population are unclear. OBJECTIVE To compare outcomes in hospitalizations for VOC in those with a history of OUD to those without a history of OUD. DESIGN A retrospective assessment of hospitalizations for adults in the USA with a primary discharge diagnosis of VOC using the National Inpatient Sample database from 2016 to 2019. We also compared VOC hospitalizations to hospitalizations for all other reasons to assess differences in OUD-associated clinical factors. PARTICIPANTS In total, 273,460 hospitalizations for VOC; 23,120 (8.5%) of these hospital stays involved a secondary diagnosis of OUD. MAIN MEASURES Primary outcomes were length of hospital stay and cost. Mortality was a secondary outcome. KEY RESULTS Hospital length of stay was increased (mean 6.2 vs 4.9 days) in patients with OUD (adjusted rate ratio = 1.24, 95% CI 1.20-1.29, p < 0.001). Mean cost was also higher in those with OUD ($9076) than those without OUD ($8020, p < 0.001). Mortality was decreased in VOC hospitalizations in those with OUD, but the difference was not statistically significant (adjusted OR = 0.64, 95% CI 0.028-1.48, p = 0.30). CONCLUSIONS OUD is associated with increased length of stay and costs in patients with VOC. While there are many possible explanations, providers should consider undertreatment of pain due to addiction concerns as a potential factor; individualized pain plans to mitigate this challenge could be explored.
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Affiliation(s)
- Abdulsabur Sanni
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Spencer Goble
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA.
| | - David T Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | | | - Mark Linzer
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
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13
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Lepley J. President's message. J Addict Dis 2024; 42:167-169. [PMID: 38783526 DOI: 10.1080/10550887.2024.2358265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Affiliation(s)
- Jon Lepley
- Addiction Medicine, Penn Medicine Lancaster General Health, Lancaster, PA, USA
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Dowell D, Brown S, Gyawali S, Hoenig J, Ko J, Mikosz C, Ussery E, Baldwin G, Jones CM, Olsen Y, Tomoyasu N, Han B, Compton WM, Volkow ND. Treatment for Opioid Use Disorder: Population Estimates - United States, 2022. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2024; 73:567-574. [PMID: 38935567 PMCID: PMC11254342 DOI: 10.15585/mmwr.mm7325a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
In 2022, 81,806 opioid-involved overdose deaths were reported in the United States, more than in any previous year. Medications for opioid use disorder (OUD), particularly buprenorphine and methadone, substantially reduce overdose-related and overall mortality. However, only a small proportion of persons with OUD receive these medications. Data from the 2022 National Survey on Drug Use and Health were applied to a cascade of care framework to estimate and characterize U.S. adult populations who need OUD treatment, receive any OUD treatment, and receive medications for OUD. In 2022, 3.7% of U.S. adults aged ≥18 years needed OUD treatment. Among these, only 25.1% received medications for OUD. Most adults who needed OUD treatment either did not perceive that they needed it (42.7%) or received OUD treatment without medications for OUD (30.0%). Compared with non-Hispanic Black or African American and Hispanic or Latino adults, higher percentages of non-Hispanic White adults received any OUD treatment. Higher percentages of men and adults aged 35-49 years received medications for OUD than did women and younger or older adults. Expanded communication about the effectiveness of medications for OUD is needed. Increased efforts to engage persons with OUD in treatment that includes medications are essential. Clinicians and other treatment providers should offer or arrange evidence-based treatment, including medications, for patients with OUD. Pharmacists and payors can work to make these medications available without delays.
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Jeminiwa R, Park S, Popielaski C, Gannon M, Myers R, Abatemarco DJ. Development of an Educational Brochure about Treatment Options for Pregnant Women with Opioid Use Disorders. PHARMACY 2024; 12:97. [PMID: 39051381 PMCID: PMC11270208 DOI: 10.3390/pharmacy12040097] [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: 05/06/2024] [Revised: 06/17/2024] [Accepted: 06/19/2024] [Indexed: 07/27/2024] Open
Abstract
The goal of this study was to describe the development of an educational brochure for pregnant women with opioid use disorders (OUDs) about treatment options. Based on findings from a preliminary review of the literature, we drafted a brochure that addressed the following questions: (1) What are your options (Medication-Assisted Treatment (MAT) versus no treatment)? (2) What are the benefits of MAT? (3) What are the risks of MAT? (4) Can I take buprenorphine or methadone while breastfeeding? (5) Which medication should I choose? Clinicians and doulas (n = 19) who provide care to pregnant women with OUDs were recruited. Semi-structured interviews elicited participants' feedback on brochure content and their perceptions about brochure use for patient education. Thematic data analyses were performed. Three emergent themes were identified (suggested uses and settings of use, content revisions, and perceptions about the brochure) and used to refine the final brochure. This study provides valuable insights into the desired content of an educational brochure describing treatment options for pregnant women with OUDs from the provider's standpoint. Research is needed to assess the use of the brochure in shared decision-making conversations with providers about treatment.
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Affiliation(s)
- Ruth Jeminiwa
- Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA 19107, USA; (S.P.); (C.P.)
| | - Sohyeon Park
- Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA 19107, USA; (S.P.); (C.P.)
| | - Caroline Popielaski
- Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA 19107, USA; (S.P.); (C.P.)
| | - Meghan Gannon
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA 19107, USA; (M.G.); (D.J.A.)
| | - Ronald Myers
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA 19107, USA;
| | - Diane J. Abatemarco
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA 19107, USA; (M.G.); (D.J.A.)
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Boanca K, Borris J, Noufi P. Alpha(α)-2 Receptor Agonists in Palliative Care #482. J Palliat Med 2024; 27:816-818. [PMID: 38686515 DOI: 10.1089/jpm.2024.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
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Liu O, Leon D, Gough E, Hanna M, Jaremko K. A retrospective analysis of perioperative medications for opioid-use disorder and tapering additional postsurgical opioids via a transitional pain service. Br J Clin Pharmacol 2024. [PMID: 38817150 DOI: 10.1111/bcp.16118] [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: 01/10/2024] [Revised: 04/19/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024] Open
Abstract
AIMS To investigate perioperative opioid requirements in patients on methadone or buprenorphine as medication for opioid-use disorder (MOUD) who attended a transitional pain clinic (Personalized Pain Program, PPP). METHODS This retrospective cohort study assessed adults on MOUD with surgery and attendance at the Johns Hopkins PPP between 2017 and 2022. Daily non-MOUD opioid use over 6 time-points was evaluated with regression models controlling for days since surgery. The time to complete non-MOUD opioid taper was analysed by accelerated failure time and Kaplan-Meier models. RESULTS Fifty patients (28 on methadone, 22 on buprenorphine) were included with a median age of 44.3 years, 54% male, 62% Caucasian and 54% unemployed. MOUD inpatient administration occurred in 92.8% of patients on preoperative methadone but only in 36.3% of patients on preoperative buprenorphine. Non-MOUD opioid use decreased over time postoperatively (β = -0.54, P < .001) with a median decrease of 90 mg morphine equivalents (MME) between the first and last PPP visit, resulting in 46% tapered off by PPP completion. Older age and duration in PPP were associated with lower MME, while mental health conditions, longer hospital stays and higher discharge opioid prescriptions were associated with higher MME. The average time to non-MOUD opioid taper was 1.79× longer in patients on buprenorphine (P = .026), 2.75× in males (P = .023), 4.66× with mental health conditions (P < .001), 2.37× with chronic pain (P = .031) and 3.51× if on preoperative non-MOUD opioids; however, higher initial MOUD level decreased time to taper (P = .001). CONCLUSIONS Postoperative opioid tapering utilizing a transitional pain service is possible in patients on MOUD.
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Affiliation(s)
- Olivia Liu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Leon
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ethan Gough
- Department of Biostatistics, Epidemiology and Data Management Core, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kellie Jaremko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Pasman E, Lee G, Singer S, Burson N, Agius E, Resko SM. Attitudes toward medications for opioid use disorder among peer recovery specialists. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2024; 50:391-400. [PMID: 38640497 DOI: 10.1080/00952990.2024.2332597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/30/2024] [Accepted: 03/06/2024] [Indexed: 04/21/2024]
Abstract
Background: Peer recovery specialists (PRSs) are substance use service providers with lived experience in recovery. Although a large body of research demonstrates the efficacy of medications for opioid use disorder (MOUD), emerging research suggests PRSs' attitudes toward MOUD are ambivalent or mixed. Few studies have quantitatively assessed factors influencing PRSs' attitudes.Objectives: This study identifies personal and professional characteristics associated with attitudes toward MOUD among PRSs.Methods: PRSs working at publicly funded agencies in Michigan completed a self-administered web-based survey (N = 266, 60.5% women). Surveys assessed socio-demographics, treatment and recovery history, attitudes toward clients, and attitudes toward MOUD. Multiple linear regression was used to identify factors associated with attitudes toward MOUD.Results: A minority of PRSs (21.4%) reported a history of treatment with MOUD, while nearly two-thirds reported current 12-step involvement (62.5%). Compared to PRSs without a history of MOUD treatment, PRSs who had positive (b = 4.71, p < .001) and mixed (b = 3.36, p = .010) experiences with MOUD had more positive attitudes; PRSs with negative experiences with MOUD had less positive attitudes (b = -3.16, p = .003). Current 12-step involvement (b = -1.63, p = .007) and more stigmatizing attitudes toward clients (b = -.294, p < .001) were associated with less positive attitudes toward MOUD. Black PRSs had less positive attitudes than White PRSs (b = -2.50, p = .001), and women had more positive attitudes than men (b = 1.19, p = .038).Conclusion: PRSs' attitudes toward MOUD varied based on the nature of their lived experience. Findings highlight considerations for training and supervising PRSs who serve individuals with opioid use disorder.
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Affiliation(s)
- Emily Pasman
- Center for the Study of Drugs, Alcohol, Smoking and Health, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Guijin Lee
- Department of Counseling and Human Development Services, University of Georgia, Athens, GA, USA
| | - Samantha Singer
- School of Social Work, Wayne State University, Detroit, MI, USA
| | - Nick Burson
- School of Social Work, Wayne State University, Detroit, MI, USA
| | - Elizabeth Agius
- School of Social Work, Wayne State University, Detroit, MI, USA
| | - Stella M Resko
- School of Social Work, Wayne State University, Detroit, MI, USA
- Merrill Palmer Skillman Institute, Wayne State University, Detroit, MI, USA
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Choi SA, Yan CH, Gastala NM, Touchette DR, Stranges PM. Cost-effectiveness of full and partial opioid agonists for opioid use disorder in outpatient settings: United States healthcare sector perspective. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 160:209237. [PMID: 38061629 DOI: 10.1016/j.josat.2023.209237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/30/2023] [Accepted: 11/30/2023] [Indexed: 01/07/2024]
Abstract
INTRODUCTION Studies show that medications for opioid use disorder (MOUD) reduce illicit opioid use, emergency healthcare services, opioid-related overdose, and death. However, few studies have investigated the long-term cost-effectiveness of MOUD in office-based opioid treatment (OBOT) and opioid treatment program (OTP) settings. We aimed to estimate the cost, utility, quality-adjusted life years gained (QALYs), and incremental cost-effectiveness ratios (ICERs) of three MOUD compared to each other and counseling without medication from a US healthcare sector perspective. METHODS Our study developed a Markov model to conduct a cost-effectiveness analysis of counseling and three MOUD in the OBOT and OTP settings: sublingual buprenorphine/naloxone (BUPNX), buprenorphine extended-release (XR-BUP) injection, and oral methadone. The model included five health states representing combinations of receiving or off treatment while either using or not actively using illicit opioids, and death. The cycle length was one month; the time-horizon was ten years. The study obtained model inputs from systematic reviews of published literature and public data. A 3 % annual discount rate was applied to cost and utility calculation. The primary outcomes included total costs, life-years (LYs), QALYs, and ICERs. We also conducted a scenario analysis using a hypothetical OBOT outpatient setting with methadone. RESULTS In the base-case OBOT setting, the total costs and QALYs, respectively, were counseling $22,848, 5.60; BUPNX $29,875, 5.82; and XR-BUP $63,936, 5.87. ICERs were $32,345/QALY (BUPNX vs. counseling) and $625,858/QALY (XR-BUP vs BUPNX). In the OTP setting, the total costs of counseling, methadone, BUPNX, and XR-BUP were $20,124, $27,000, $33,500, and $75,272, respectively. QALYs of methadone were 5.86. QALYs of counseling, BUPNX, and XR-BUP remained the same as in the OBOT setting. Incremental ICERs were $26,714/QALY (methadone vs counseling) and $3,337,623/QALY (XR-BUP vs methadone). BUPNX was dominated by methadone. In the scenario analysis, BUPNX was also dominated by methadone. CONCLUSIONS Outpatient MOUD resulted in important gains in quality of life and life expectancy. In both OBOT and OTP settings, XR-BUP was not cost-effective. BUPNX was cost-effective in the OBOT setting, while it was dominated by methadone in the OTP setting. The cost-effectiveness of BUPNX and XR-BUP could be enhanced if the costs of these medications were reduced.
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Affiliation(s)
- Sun A Choi
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood Street MC 871, Chicago, IL 60612, USA.
| | - Connie H Yan
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood Street MC 871, Chicago, IL 60612, USA.
| | - Nicole M Gastala
- Department of Family Medicine, Mile Square Health Centers, University of Illinois Hospital and Health Science Systems, 1220 S. Wood St., 60608 Chicago, IL, USA.
| | - Daniel R Touchette
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood Street MC 871, Chicago, IL 60612, USA.
| | - Paul M Stranges
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, 833 South Wood Street Rm C-300, Chicago, IL 60612, USA.
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Sandhu S, Calcaterra SL. How Do I Manage Acute Pain for Patients Prescribed Buprenorphine for Opioid Use Disorder? NEJM EVIDENCE 2024; 3:EVIDccon2300275. [PMID: 38815158 PMCID: PMC11282871 DOI: 10.1056/evidccon2300275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
AbstractA growing number of patients are prescribed buprenorphine for opioid use disorder (OUD). Consequently, clinicians are likely to encounter hospitalized patients with acute surgical or nonsurgical pain who are also prescribed buprenorphine for OUD. This scenario evokes the clinical question of how to adequately manage acute pain among hospitalized patients receiving buprenorphine for OUD. This article reviews buprenorphine's pharmacology, describes various buprenorphine products used to treat pain and OUD, and provides pain management recommendations for patients prescribed buprenorphine in the setting of acute surgical and nonsurgical pain.
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Affiliation(s)
- Sukhmeet Sandhu
- Department of Family Medicine, University of Colorado, Aurora
| | - Susan L Calcaterra
- Department of Medicine, Divisions of General Internal Medicine and Hospital Medicine, University of Colorado, Aurora
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Spinella S, McCarthy R. Buprenorphine for Pain: A Narrative Review and Practical Applications. Am J Med 2024; 137:406-413. [PMID: 38340973 DOI: 10.1016/j.amjmed.2024.01.022] [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] [Received: 01/22/2024] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
Chronic noncancer pain affects about 20% of US adults and can significantly affect function and quality of life. Current guidelines recommend multimodal pain control. Despite risks associated with long-term opioid therapy, opioids are commonly prescribed. Buprenorphine is a partial opioid agonist with an improved safety profile compared to full agonists. Some formulations are approved for chronic pain and others for opioid use disorder. Buprenorphine is an option for patients who use chronic daily opioids for pain. This review summarizes the literature on buprenorphine's efficacy and safety for chronic pain and provides recommendations to generalists on initiation, titration, and monitoring of buprenorphine-based pain treatment. We also discuss a communication approach when considering buprenorphine for pain.
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Affiliation(s)
- Sara Spinella
- Department of Medicine, University of Pittsburgh School of Medicine and VA Pittsburgh Healthcare System, Pittsburgh, Pa.
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Eleftheriou G, Zandonella Callegher R, Butera R, De Santis M, Cavaliere AF, Vecchio S, Lanzi C, Davanzo R, Mangili G, Bondi E, Somaini L, Gallo M, Balestrieri M, Mannaioni G, Salvatori G, Albert U. Consensus Panel Recommendations for the Pharmacological Management of Breastfeeding Women with Postpartum Depression. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:551. [PMID: 38791766 PMCID: PMC11121006 DOI: 10.3390/ijerph21050551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION Our consensus statement aims to clarify the use of antidepressants and anxiolytics during breastfeeding amidst clinical uncertainty. Despite recent studies, potential harm to breastfed newborns from these medications remains a concern, leading to abrupt discontinuation of necessary treatments or exclusive formula feeding, depriving newborns of benefits from mother's milk. METHODS A panel of 16 experts, representing eight scientific societies with a keen interest in postpartum depression, was convened. Utilizing the Nominal Group Technique and following a comprehensive literature review, a consensus statement on the pharmacological treatment of breastfeeding women with depressive disorders was achieved. RESULTS Four key research areas were delineated: (1) The imperative to address depressive and anxiety disorders during lactation, pinpointing the risks linked to untreated maternal depression during this period. (2) The evaluation of the cumulative risk of unfavorable infant outcomes associated with exposure to antidepressants or anxiolytics. (3) The long-term impact on infants' cognitive development or behavior due to exposure to these medications during breastfeeding. (4) The assessment of pharmacological interventions for opioid abuse in lactating women diagnosed with depressive disorders. CONCLUSIONS The ensuing recommendations were as follows: Recommendation 1: Depressive and anxiety disorders, as well as their pharmacological treatment, are not contraindications for breastfeeding. Recommendation 2: The Panel advocates for the continuation of medication that has demonstrated efficacy during pregnancy. If initiating an antidepressant during breastfeeding is necessary, drugs with a superior safety profile and substantial epidemiological data, such as SSRIs, should be favored and prescribed at the lowest effective dose. Recommendation 3: For the short-term alleviation of anxiety symptoms and sleep disturbances, the Panel determined that benzodiazepines can be administered during breastfeeding. Recommendation 4: The Panel advises against discontinuing opioid abuse treatment during breastfeeding. Recommendation 5: The Panel endorses collaboration among specialists (e.g., psychiatrists, pediatricians, toxicologists), promoting multidisciplinary care whenever feasible. Coordination with the general practitioner is also recommended.
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Affiliation(s)
- Georgios Eleftheriou
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Riccardo Zandonella Callegher
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy;
- UCO Clinica Psichiatrica, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
| | - Raffaella Butera
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Marco De Santis
- Italian Society of Obstetrics and Gynecology (SIGO), Via di Porta Pinciana 6, 00187 Rome, Italy; (M.D.S.); (A.F.C.)
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Anna Franca Cavaliere
- Italian Society of Obstetrics and Gynecology (SIGO), Via di Porta Pinciana 6, 00187 Rome, Italy; (M.D.S.); (A.F.C.)
- Department of Gynecology and Obstetrics, Fatebenefratelli Gemelli, Isola Tiberina, 00186 Rome, Italy
| | - Sarah Vecchio
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Addiction Centre, Ser.D, Local Health Unit, 28100 Novara, Italy
| | - Cecilia Lanzi
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
| | - Riccardo Davanzo
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy; (R.D.); (G.M.)
- Maternal and Child Health Institute IRCCS “Burlo Garofolo”, 34137 Trieste, Italy
- Task Force on Breastfeeding, Ministry of Health, 00144 Rome, Italy
| | - Giovanna Mangili
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy; (R.D.); (G.M.)
- Department of Neonatology, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Emi Bondi
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- Department of Psychiatry, ASST Papa Giovanni XXIII, 24100 Bergamo, Italy
| | - Lorenzo Somaini
- Ser.D Biella, Drug Addiction Service, 13875 Biella, Italy;
- Italian Society of Addiction Diseases (S.I.Pa.D), Via Tagliamento 31, 00198 Rome, Italy
| | - Mariapina Gallo
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
- Italian Society for Drug Addiction (SITD), Via Roma 22, 12100 Cuneo, Italy
| | - Matteo Balestrieri
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy;
- Italian Society of Neuropsychopharmacology (SINPF), Via Cernaia 35, 00158 Rome, Italy
| | - Guido Mannaioni
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
- Italian Society of Pharmacology, Via Giovanni Pascoli, 3, 20129 Milan, Italy
| | - Guglielmo Salvatori
- Italian Society of Pediatrics, Via Gioberti 60, 00185 Rome, Italy;
- Department of Medical and Surgical Neonatology Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Umberto Albert
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- UCO Clinica Psichiatrica, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
- Italian Society of Neuropsychopharmacology (SINPF), Via Cernaia 35, 00158 Rome, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34128 Trieste, Italy
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Bali B, Tuan WJ, Scott A, Bollampally P, Groff D, Leong SL, King VL, Bone C. Assessing men with opioid use disorder for testosterone deficiency after the development of symptoms. J Addict Dis 2024:1-7. [PMID: 38619057 DOI: 10.1080/10550887.2024.2327751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
OBJECTIVE Individuals with opioid use disorder (OUD) have reduced life expectancy and inferior outcomes when treated for depression, diabetes, and fractures. Their elevated risk of testosterone deficiency may contribute to all of these relationships, however few individuals prescribed opioids are evaluated with testosterone assays. The purpose of this study is to determine whether patients with opioid use disorder are evaluated for testosterone deficiency after development of a symptom that may merit investigation, such as erectile dysfunction (ED). METHOD We conducted a retrospective longitudinal cohort study that utilized data from a national database called TriNetX. Patients were eligible for inclusion if they were 20 to 90 years of age, male, and diagnosed with erectile dysfunction. We utilized descriptive statistics and logistic regression to address study aims. RESULTS Testosterone testing was uncommon for all patients with ED. Among 20,658 patients, it was assessed in 11.2% with OUD and 15.1% without OUD. Among those screened, 40% individuals with OUD and ED had testosterone deficiency. Odds of screening those with OUD were lower than matched controls (RR 0.74). CONCLUSIONS Individuals with OUD are at increased risk of testosterone deficiency than the general population, but nearly 90% are not evaluated for this condition even after development symptoms. That 40% of individuals assessed were classified as testosterone deficient suggests endocrine disorders may be contributing to increased fracture risk, chronic pain, and severe depression commonly encountered in patients with OUD. Addressing this care gap may reduce morbidity and mortality associated with opioid use disorder.
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Affiliation(s)
- Bhavna Bali
- Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Wen Jan Tuan
- Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Alyssa Scott
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | | | - Destin Groff
- Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Shou Ling Leong
- Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Van L King
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Curtis Bone
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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Terasaki D, Abts D, Ferraro K. Questioning methadone split-dosing for analgesia among hospitalized patients with opioid use disorder. Addiction 2024. [PMID: 38615677 DOI: 10.1111/add.16502] [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: 11/12/2023] [Accepted: 03/21/2024] [Indexed: 04/16/2024]
Abstract
Methadone is hypothesized to provide greater analgesic coverage when split into two or more divided doses. However, empirical data are lacking, and our anecdotal experience at a safety-net hospital among patients with opioid use disorder suggests that it may not be straightforward. Guidelines and clinicians should exercise appropriate caution when recommending this strategy.
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Affiliation(s)
- Dale Terasaki
- Denver Health & Hospital Authority, Department of Behavioral Health, Denver, CO, USA
| | - David Abts
- Denver Health & Hospital Authority, Department of Anesthesiology, Denver, CO, USA
| | - Kelly Ferraro
- Denver Health & Hospital Authority, Department of Palliative Care, Denver, CO, USA
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Ross RK, Nunes EV, Olfson M, Shulman M, Krawczyk N, Stuart EA, Rudolph KE. Comparative effectiveness of extended release naltrexone and sublingual buprenorphine for treatment of opioid use disorder among Medicaid patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.24.24301555. [PMID: 38343815 PMCID: PMC10854342 DOI: 10.1101/2024.01.24.24301555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Aims To compare the real-world effectiveness of extended release naltrexone (XR-NTX) and sublingual buprenorphine (SL-BUP) for the treatment of opioid use disorder (OUD). Design An observational active comparator, new user cohort study. Setting Medicaid claims records for patients in New Jersey and California, 2016-2019. Participants/Cases Adult Medicaid patients aged 18-64 years who initiated XR-NTX or SL-BUP for maintenance treatment of OUD and did not use medications for OUD in the 90-days before initiation. Comparators New initiation with XR-NTX versus SL-BUP for the treatment of OUD. Measurements We examined two outcomes up to 180 days after medication initiation, 1) composite of medication discontinuation and death, and 2) composite of overdose and death. Findings Our cohort included 1,755 XR-NTX and 9,886 SL-BUP patients. In adjusted analyses, treatment with XR-NTX was more likely to result in discontinuation or death by the end of follow-up than treatment with SL-BUP: cumulative risk 76% (95% confidence interval [CI] 75%, 78%) versus 62% (95% CI 61%, 63%), respectively (risk difference 14 percentage points, 95% CI 13, 16). There was minimal difference in the cumulative risk of overdose or death by the end of follow-up: XR-NTX 3.8% (95% CI 2.9%, 4.7%) versus SL-BUP 3.3% (95% 2.9%, 3.7%); risk difference 0.5 percentage points, 95%CI -0.5, 1.5. Results were consistent across sensitivity analyses. Conclusions Longer medication retention is important because risks of negative outcomes are elevated after discontinuation. Our results support selection of SL-BUP over XR-NTX. However, most patients discontinued medication by 6 months indicating that more effective tools are needed to improve medication retention, particularly after initiation with XR-NTX, and to identify which patients do best on which medication.
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Affiliation(s)
- Rachael K Ross
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Edward V Nunes
- Department of Psychiatry, Columbia University Irving Medical Center
- New York State Psychiatric Institute, New York, NY
| | - Mark Olfson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
- Department of Psychiatry, Columbia University Irving Medical Center
- New York State Psychiatric Institute, New York, NY
| | - Matisyahu Shulman
- Department of Psychiatry, Columbia University Irving Medical Center
- New York State Psychiatric Institute, New York, NY
| | - Noa Krawczyk
- Department of Population Health, New York University, New York, NY
| | - Elizabeth A Stuart
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Wells DA, Parnacott T, Volberding K, Brandl E. Methadone-Induced Hypoglycemia in a Hospitalized Patient. Hosp Pharm 2024; 59:149-151. [PMID: 38450362 PMCID: PMC10913876 DOI: 10.1177/00185787231207750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Methadone is used as an agent for chronic pain and management of opioid use disorder. While similar pharmacologically to other opioids, methadone does have unique characteristics, including long half-life, low cost, and high oral bioavailability. While advantageous in some ways, methadone is associated with unique adverse effects not seen with other opioids (ie, hypoglycemia). In this case, we describe a patient in his late-60s with opioid use disorder on chronic methadone who presents with symptoms of generalized weakness, fatigue, and decreased appetite for 2 days. The hospital course was complicated by hypoglycemia, without obvious cause other than methadone-induced hypoglycemia. The patient was managed with supportive care to maintain normoglycemia. He was continued on methadone and instructed to follow-up with his opioid treatment program to assess for dose de-escalation to minimize future hypoglycemia risk. While other case reports of methadone-induced hypoglycemia highlight the risk of this adverse effect, our case highlights the importance of assessing methadone as a cause of hypoglycemia and provides discussion around the legality of dose de-escalation at discharge from an acute care setting.
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Affiliation(s)
- Drew A. Wells
- Methodist Le Bonheur Healthcare - University Hospital, Memphis, TN, USA
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tara Parnacott
- Methodist Le Bonheur Healthcare - University Hospital, Memphis, TN, USA
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Krista Volberding
- Methodist Le Bonheur Healthcare - University Hospital, Memphis, TN, USA
| | - Emily Brandl
- Jr. Veterans Affairs Medical Center, Memphis, TN, USA
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Kast KA, Le TDV, Stewart LS, Wiese AD, Reddy IA, Smith J, Marcovitz DE, Reese TJ. Impact of inpatient addiction psychiatry consultation on opioid use disorder outcomes. Am J Addict 2024. [PMID: 38546154 DOI: 10.1111/ajad.13540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 02/01/2024] [Accepted: 03/13/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Addiction consultation services provide access to specialty addiction care during general hospital admission. This study assessed opioid use disorder (OUD) outcomes associated with addiction consultation. METHODS Retrospective cohort study of individuals with OUD admitted to an academic medical center between 2018 and 2023. The exposure was addiction consultation. Outcomes included initiating medication for OUD (MOUD), hospital length of stay, before-medically-advised (BMA) discharge, and 30- and 90-day postdischarge acute care utilization. RESULTS Of 26,766 admissions (10,501 patients) with OUD, 2826 addiction consultations were completed. Consultation cohort was more likely to be young, male, and White than controls. Consultation was associated with greater MOUD initiation (adjusted odds ratio [aOR], 5.07; 95% confidence interval [CI], 4.41-5.82), fewer emergency department visits at 30 (aOR, 0.78; 95% CI, 0.67-0.92) and 90 (aOR, 0.79; 95% CI, 0.69-0.89) days, and fewer hospitalizations at 30 (aOR, 0.65; 95% CI, 0.56 to 0.76) and 90 (aOR, 0.67; 95% CI, 0.59-0.76) days. Additionally, consultation patients were more likely to have a longer hospital stay and leave BMA. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Addiction consultation was associated with increased MOUD initiation and reduced postdischarge acute care utilization. This is the largest study to date showing a significant association between addiction psychiatry consultation and improved OUD outcomes when compared to controls. The observed reduction in postdischarge acute care utilization remains even after adjusting for MOUD initiation. Disparities in access to addiction consultation warrant further study.
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Affiliation(s)
- Kristopher A Kast
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thao D V Le
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Lisa S Stewart
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew D Wiese
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - India A Reddy
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan Smith
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David E Marcovitz
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thomas J Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Adler J, Mallick-Searle T, Garofoli M, Zimmerman A. Frontline Perspectives on Buprenorphine for the Management of Chronic Pain. J Multidiscip Healthc 2024; 17:1375-1383. [PMID: 38563040 PMCID: PMC10982663 DOI: 10.2147/jmdh.s449748] [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: 12/08/2023] [Accepted: 03/08/2024] [Indexed: 04/04/2024] Open
Abstract
Due to the prevalence of chronic pain and high-impact chronic pain in the US, a significant percentage of the population is prescribed opioids for pain management. However, opioid use disorder is associated with reduced quality of life, along with fatal opioid overdoses, and is a significant burden on the US economy. Considering the clinical needs of patients with intractable chronic pain and the potential harms associated with prescribed and illicit opioids in our communities, having a deep understanding of current treatment options, supporting evidence, and clinical practice guidelines is essential for optimizing treatment selections. Buprenorphine is a Schedule III opioid with a unique mechanism of action, allowing effective and long-lasting analgesia at microgram doses with fewer negative side effects and adverse events, including respiratory depression, when compared with other immediate-release, long-acting, and extended-release prescription opioids. Due to its relatively lower risk for overdose and misuse, buprenorphine was recently added to the Clinical Practice Guideline for the Use of Opioids in the Management of Chronic Pain as a first-line treatment for chronic pain managed by opioids by the US Departments of Defense and Veterans Affairs, and the Department of Health and Human Services recommends that buprenorphine be made available for the treatment of chronic pain. In this narrative review, we discuss the different buprenorphine formulations, clinical efficacy, advantages for older adults and other special populations, clinical practice guideline recommendations, and payer considerations of buprenorphine and suggest that buprenorphine products approved for chronic pain should be considered as a first-line treatment for this indication.
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Affiliation(s)
- Jeremy Adler
- Pacific Pain Medicine Consultants, Encinitas, CA, USA
| | | | - Mark Garofoli
- West Virginia University School of Pharmacy, Morgantown, WV, USA
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Shelton T, Nama S, Hall O, Williams M. Case report: Successful induction of buprenorphine in medically complex patients concurrently on opioids: a case series at a tertiary care center. Front Pharmacol 2024; 15:1335345. [PMID: 38523636 PMCID: PMC10960361 DOI: 10.3389/fphar.2024.1335345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/08/2024] [Indexed: 03/26/2024] Open
Abstract
Effective pain management is essential for optimal surgical outcomes; however, it can be challenging in patients with a history of opioid use disorder (OUD). Buprenorphine, a partial opioid agonist, is a valuable treatment option for patients with OUD. Initiating buprenorphine treatment in patients concurrently taking opioids can be complex due to potential adverse outcomes like precipitated withdrawal. Evolving guidelines suggest there are benefits to continuing buprenorphine for surgical patients throughout the perioperative period, however situations do arise when buprenorphine has been discontinued. Typically, in this scenario patients would be restarted on buprenorphine after they have fully recovered from post-surgical pain and no longer require opioids for pain control. Unfortunately, holding MOUD may expose the patient to risks such as opioid induced respiratory depression or addiction relapse. In this case series, we discuss a novel method to restart buprenorphine in small incremental doses, known as micro-dosing, while the patient is still taking opioids for pain. We will present two complex clinical cases when this method was used successfully at a tertiary care hospital system.
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Affiliation(s)
- Thomas Shelton
- The Ohio State University College of Medicine, Columbus, OH, United States
| | - Sharanya Nama
- Department of Anesthesiology and Pain Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Orman Hall
- Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Margaret Williams
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Bowman LA, Berger O, Nesbit S, Stoller KB, Buresh M, Stewart R. Operationalizing the new DEA exception: A novel process for dispensing of methadone for opioid use disorder at discharge from acute care settings. Am J Health Syst Pharm 2024; 81:204-218. [PMID: 38091380 DOI: 10.1093/ajhp/zxad288] [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: 03/08/2024] Open
Abstract
PURPOSE To describe one strategy for dispensing of methadone at emergency department (ED) and hospital discharge implemented within 2 urban academic medical centers. SUMMARY Expanding access to medications for opioid use disorder (OUD) is a national priority. ED visits and hospitalizations offer an opportunity to initiate or continue these lifesaving medications, including methadone and buprenorphine. However, federal regulations governing methadone treatment and significant gaps in treatment availability have made continuing methadone upon ED or hospital discharge challenging. To address this issue, the Drug Enforcement Administration (DEA) granted an exception allowing hospitals, clinics, and EDs to dispense a 72-hour supply of methadone while continued treatment is arranged. Though this exception addresses a critical unmet need, guidance for operationalizing this service is limited. To facilitate expanded patient access to methadone on ED or hospital discharge at 2 Baltimore hospitals, key stakeholders within the parent health system were identified, and a workgroup was formed. Processes were established for requesting, approving, preparing, and dispensing the methadone supply using an electronic health record order set. Multidisciplinary educational materials were created to support end users of the workflow. In the first 3 months of implementation, 42 requests were entered, of which 36 were approved, resulting in 79 dispensed methadone doses. CONCLUSION This project demonstrates feasibility of methadone dispensing at hospital and ED discharge. Further work is needed to evaluate impact on patient outcomes, such as hospital and ED utilization, length of stay, linkage to treatment, and retention in treatment.
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Affiliation(s)
- Lindsay A Bowman
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Olivia Berger
- Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Suzanne Nesbit
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kenneth B Stoller
- Johns Hopkins Broadway Center for Addiction, Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Megan Buresh
- Bayview Medical Center Addiction Consult Service, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rosalyn Stewart
- Johns Hopkins Hospital Addiction Consult Service, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
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31
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Treitler P, Crystal S, Cantor J, Chakravarty S, Kline A, Morton C, Powell KG, Borys S, Cooperman NA. Emergency Department Peer Support Program and Patient Outcomes After Opioid Overdose. JAMA Netw Open 2024; 7:e243614. [PMID: 38526490 PMCID: PMC10964115 DOI: 10.1001/jamanetworkopen.2024.3614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/30/2024] [Indexed: 03/26/2024] Open
Abstract
Importance Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking. Objective To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization. Design, Setting, and Participants This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023. Exposure Hospital OORP implementation. Main Outcomes and Measures The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access. Results A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities. Conclusions and Relevance In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.
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Affiliation(s)
- Peter Treitler
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- Boston University School of Social Work, Boston, Massachusetts
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- School of Social Work, Rutgers University, New Brunswick, New Jersey
- School of Public Health, Rutgers University, Piscataway, New Jersey
| | - Joel Cantor
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
| | - Sujoy Chakravarty
- Department of Health Sciences, Rutgers University, Camden, New Jersey
| | - Anna Kline
- Department of Psychiatry, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
| | - Cory Morton
- School of Social Work, Rutgers University, New Brunswick, New Jersey
- Center for Prevention Science, Rutgers University, New Brunswick, New Jersey
- Northeast and Caribbean Prevention Technology Transfer Center, Rutgers University, New Brunswick, New Jersey
| | - Kristen Gilmore Powell
- School of Social Work, Rutgers University, New Brunswick, New Jersey
- Center for Prevention Science, Rutgers University, New Brunswick, New Jersey
- Northeast and Caribbean Prevention Technology Transfer Center, Rutgers University, New Brunswick, New Jersey
| | - Suzanne Borys
- Division of Mental Health and Addiction Services, New Jersey Department of Human Services, Trenton
| | - Nina A. Cooperman
- Department of Psychiatry, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
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Barrett J, Schapiro R, Casey E, Chertok J. Evaluation and Management of Buprenorphine Extended-Release Injection Thrombophlebitis: A Case Report. J Addict Med 2024; 18:209-211. [PMID: 38227854 DOI: 10.1097/adm.0000000000001261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
INTRODUCTION Buprenorphine extended-release subcutaneous injection (BUP-XR) is a medication used to treat opioid use disorder. It is a long-acting formulation of buprenorphine, which is a partial opioid agonist. Buprenorphine extended-release subcutaneous injection is injected into the subcutaneous space forming a depot that can last up to a month. The most common adverse effects of BUP-XR are injection site pain, erythema, and induration. CASE REPORT A man in his late 30s presented to the emergency department 48 hours after BUP-XR injection with abdominal pain. He was found to have superficial venous thrombosis of an abdominal wall vessel extending near the deep venous system. He was subsequently started on apixaban for 30 days and cefadroxil for 7 days to reduce the risk of extension and infection. He fully recovered and has since restarted BUP-XR without further complications. CONCLUSIONS Venous thrombosis is a rare but potentially life-threatening complication of BUP-XR. It is important for emergency and outpatient clinicians to be aware of adverse reactions associated with this medication. The patient was successfully treated with a 30-day course of apixaban and able to resume taking BUP-XR without further complications. Clinicians may want to consider supplementing BUP-XR with sublingual film after injection-related complications due to possible lower serum levels.
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Affiliation(s)
- John Barrett
- From the Penn Medicine, University of Pennsylvania, Philadelphia, PA (JB, EC); University of Pennsylvania School of Nursing, Philadelphia, PA (JB); Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (RS, JC)
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Hughes T, Nasser N, Mitra A. Overview of best practices for buprenorphine initiation in the emergency department. Int J Emerg Med 2024; 17:23. [PMID: 38373992 PMCID: PMC10877824 DOI: 10.1186/s12245-024-00593-6] [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: 09/28/2023] [Accepted: 01/26/2024] [Indexed: 02/21/2024] Open
Abstract
In recent decades, opioid overdoses have increased dramatically in the United States and peer countries. Given this, emergency medicine physicians have become adept in reversing and managing complications of acute overdose. However, many remain unfamiliar with initiating medication for opioid use disorder such as buprenorphine, a high-affinity partial opioid agonist. Emergency department-based buprenorphine initiation is supported by a significant body of literature demonstrating a marked reduction in mortality in addition to increased engagement in care. Buprenorphine initiation is also safe, given both the pharmacologic properties of buprenorphine that reduce the risk of diversion or recreational use, and previously published literature demonstrating low rates of respiratory depression, sedation, and precipitated withdrawal. Further, barriers to emergency department-based initiation have been reduced in recent years, with publicly available dosing and up-titration schedules, numerous publications overviewing best practices for managing precipitated withdrawal, and removal of USA policies previously restricting patient access and provider prescribing, with the removal of the X-waiver via the Medication Access and Training Expansion Act. Despite reductions in barriers, buprenorphine initiation in the emergency room remains underutilized. Poor uptake has been attributed to numerous individual and systemic barriers, including inadequate education, provider stigma, and insufficient access to outpatient follow-up care. The following practice innovation aims to summarize previously published evidence-based best practices and provide an accessible, user-friendly initiation guide to increase emergency physician comfortability with buprenorphine initiation going forward.
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Affiliation(s)
- Terence Hughes
- The Mount Sinai Hospital, 1 Gustav Levy Place, New York, NY, 10029-6574, USA
| | - Nicholas Nasser
- The Mount Sinai Hospital, 1 Gustav Levy Place, New York, NY, 10029-6574, USA.
| | - Avir Mitra
- Mount Sinai Beth Israel, 281 1st Ave, New York, NY, 10003, USA
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Tsang VWL, Wong JS, Westenberg JN, Ramadhan NH, Fadakar H, Nikoo M, Li VW, Mathew N, Azar P, Jang KL, Krausz RM. Systematic review on intentional non-medical fentanyl use among people who use drugs. Front Psychiatry 2024; 15:1347678. [PMID: 38414500 PMCID: PMC10896833 DOI: 10.3389/fpsyt.2024.1347678] [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: 12/01/2023] [Accepted: 01/18/2024] [Indexed: 02/29/2024] Open
Abstract
Objectives Fentanyl is a highly potent opioid and has, until recently, been considered an unwanted contaminant in the street drug supply among people who use drugs (PWUD). However, it has become a drug of choice for an increasing number of individuals. This systematic review evaluated intentional non-medical fentanyl use among PWUD, specifically by summarizing demographic variance, reasons for use, and resulting patterns of use. Methods The search strategy was developed with a combination of free text keywords and MeSH and non-MeSH keywords, and adapted with database-specific filters to Ovid MEDLINE, Embase, Web of Science, and PsychINFO. Studies included were human studies with intentional use of non-medical fentanyl or analogues in individuals older than 13. Only peer-reviewed original articles available in English were included. Results The search resulted in 4437 studies after de-duplication, of which 132 were selected for full-text review. Out of 41 papers included, it was found that individuals who use fentanyl intentionally were more likely to be young, male, and White. They were also more likely to have experienced overdoses, and report injection drug use. There is evidence that fentanyl seeking behaviours are motivated by greater potency, delay of withdrawal, lower cost, and greater availability. Conclusions Among PWUD, individuals who intentionally use fentanyl have severe substance use patterns, precarious living situations, and extensive overdose history. In response to the increasing number of individuals who use fentanyl, alternative treatment approaches need to be developed for more effective management of withdrawal and opioid use disorder. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42021272111.
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Affiliation(s)
- Vivian W. L. Tsang
- Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - James S.H. Wong
- Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Complex Pain and Addiction Service, Vancouver General Hospital, Vancouver, BC, Canada
| | - Jean N. Westenberg
- Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Noor H. Ramadhan
- Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Hasti Fadakar
- Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Mohammadali Nikoo
- Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Complex Pain and Addiction Service, Vancouver General Hospital, Vancouver, BC, Canada
| | - Victor W. Li
- Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Complex Pain and Addiction Service, Vancouver General Hospital, Vancouver, BC, Canada
| | - Nick Mathew
- Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- BC Mental Health & Substance Use Services, Provincial Health Services Authority, Burnaby, BC, Canada
| | - Pouya Azar
- Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Complex Pain and Addiction Service, Vancouver General Hospital, Vancouver, BC, Canada
| | - Kerry L. Jang
- Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Reinhard M. Krausz
- Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
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Burke H, Sarmiento BA, Gunther M, Czuma R, Klippel C, Jiang S. Herba Epimedii and Increased Opioid Cravings While on Buprenorphine: A Case Report. Cureus 2024; 16:e51886. [PMID: 38327958 PMCID: PMC10849866 DOI: 10.7759/cureus.51886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 02/09/2024] Open
Abstract
Herba Epimedii, commonly known as yin yang huo, inyokaku, and horny goat weed, is a traditional Chinese herbal medicine utilized for treating osteoporosis and enhancing libido. Studies conducted in vitro have demonstrated that Herba Epimedii interacts with the enzyme cytochrome P450 3A4 (CYP3A4). This interaction poses a potential risk for drug-drug interactions, particularly with medications metabolized by CYP3A4, such as buprenorphine. This paper presents a case of a patient experiencing exacerbated opioid cravings following the initiation of Herba Epimedii. This is the first reported case supporting this interaction, emphasizing the necessity of screening for alternative medicines in patients undergoing medication-assisted treatments for opioid use disorder.
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Affiliation(s)
- Heather Burke
- Department of Psychiatry and Human Behavior, Brown University, Providence, USA
| | | | - Matthew Gunther
- Department of Psychiatry, Stanford University School of Medicine, Palo Alto, USA
| | - Richard Czuma
- Department of Psychiatry, Edward Hines, Jr. Veterans Administration Hospital, Hines, USA
| | - Cory Klippel
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Hospital, Tampa, USA
| | - Shixie Jiang
- Department of Psychiatry, University of Florida College of Medicine, Gainesville, USA
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Tormohlen KN, Eisenberg MD, Fingerhood MI, Yu J, McCourt AD, Stuart EA, Rutkow L, Quintero L, White SA, McGinty EE. Trends in Opioid Use Disorder Outpatient Treatment and Telehealth Utilization Before and During the COVID-19 Pandemic. Psychiatr Serv 2024; 75:72-75. [PMID: 37461819 PMCID: PMC11034749 DOI: 10.1176/appi.ps.20230102] [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: 01/02/2024]
Abstract
OBJECTIVE The authors examined trends in opioid use disorder treatment and in-person and telehealth modalities before and after COVID-19 pandemic onset among patients who had received treatment prepandemic. METHODS The sample included 13,113 adults with commercial insurance or Medicare Advantage and receiving opioid use disorder treatment between March 2018 and February 2019. Trends in opioid use disorder outpatient treatment, treatment with medications for opioid use disorder (MOUD), and in-person and telehealth modalities were examined 1 year before pandemic onset and 2 years after (March 2019-February 2022). RESULTS From March 2019 to February 2022, the proportion of patients with opioid use disorder outpatient and MOUD visits declined by 2.8 and 0.3 percentage points, respectively. Prepandemic, 98.6% of outpatient visits were in person; after pandemic onset, at least 34.9% of patients received outpatient care via telehealth. CONCLUSIONS Disruptions in opioid use disorder outpatient and MOUD treatments were marginal during the pandemic, possibly because of increased telehealth utilization.
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Affiliation(s)
- Kayla N Tormohlen
- Departments of Health Policy and Management (Tormohlen, Eisenberg, McCourt, Stuart, Rutkow, White) and Mental Health (Fingerhood, Stuart), Johns Hopkins Bloomberg School of Public Health, Baltimore; Department of Population Health Sciences, Division of Health Policy and Economics, Weill Cornell Medicine, New York City (Yu, McGinty); Johns Hopkins Carey Business School, Washington, D.C. (Quintero)
| | - Matthew D Eisenberg
- Departments of Health Policy and Management (Tormohlen, Eisenberg, McCourt, Stuart, Rutkow, White) and Mental Health (Fingerhood, Stuart), Johns Hopkins Bloomberg School of Public Health, Baltimore; Department of Population Health Sciences, Division of Health Policy and Economics, Weill Cornell Medicine, New York City (Yu, McGinty); Johns Hopkins Carey Business School, Washington, D.C. (Quintero)
| | - Michael I Fingerhood
- Departments of Health Policy and Management (Tormohlen, Eisenberg, McCourt, Stuart, Rutkow, White) and Mental Health (Fingerhood, Stuart), Johns Hopkins Bloomberg School of Public Health, Baltimore; Department of Population Health Sciences, Division of Health Policy and Economics, Weill Cornell Medicine, New York City (Yu, McGinty); Johns Hopkins Carey Business School, Washington, D.C. (Quintero)
| | - Jiani Yu
- Departments of Health Policy and Management (Tormohlen, Eisenberg, McCourt, Stuart, Rutkow, White) and Mental Health (Fingerhood, Stuart), Johns Hopkins Bloomberg School of Public Health, Baltimore; Department of Population Health Sciences, Division of Health Policy and Economics, Weill Cornell Medicine, New York City (Yu, McGinty); Johns Hopkins Carey Business School, Washington, D.C. (Quintero)
| | - Alexander D McCourt
- Departments of Health Policy and Management (Tormohlen, Eisenberg, McCourt, Stuart, Rutkow, White) and Mental Health (Fingerhood, Stuart), Johns Hopkins Bloomberg School of Public Health, Baltimore; Department of Population Health Sciences, Division of Health Policy and Economics, Weill Cornell Medicine, New York City (Yu, McGinty); Johns Hopkins Carey Business School, Washington, D.C. (Quintero)
| | - Elizabeth A Stuart
- Departments of Health Policy and Management (Tormohlen, Eisenberg, McCourt, Stuart, Rutkow, White) and Mental Health (Fingerhood, Stuart), Johns Hopkins Bloomberg School of Public Health, Baltimore; Department of Population Health Sciences, Division of Health Policy and Economics, Weill Cornell Medicine, New York City (Yu, McGinty); Johns Hopkins Carey Business School, Washington, D.C. (Quintero)
| | - Lainie Rutkow
- Departments of Health Policy and Management (Tormohlen, Eisenberg, McCourt, Stuart, Rutkow, White) and Mental Health (Fingerhood, Stuart), Johns Hopkins Bloomberg School of Public Health, Baltimore; Department of Population Health Sciences, Division of Health Policy and Economics, Weill Cornell Medicine, New York City (Yu, McGinty); Johns Hopkins Carey Business School, Washington, D.C. (Quintero)
| | - Luis Quintero
- Departments of Health Policy and Management (Tormohlen, Eisenberg, McCourt, Stuart, Rutkow, White) and Mental Health (Fingerhood, Stuart), Johns Hopkins Bloomberg School of Public Health, Baltimore; Department of Population Health Sciences, Division of Health Policy and Economics, Weill Cornell Medicine, New York City (Yu, McGinty); Johns Hopkins Carey Business School, Washington, D.C. (Quintero)
| | - Sarah A White
- Departments of Health Policy and Management (Tormohlen, Eisenberg, McCourt, Stuart, Rutkow, White) and Mental Health (Fingerhood, Stuart), Johns Hopkins Bloomberg School of Public Health, Baltimore; Department of Population Health Sciences, Division of Health Policy and Economics, Weill Cornell Medicine, New York City (Yu, McGinty); Johns Hopkins Carey Business School, Washington, D.C. (Quintero)
| | - Emma E McGinty
- Departments of Health Policy and Management (Tormohlen, Eisenberg, McCourt, Stuart, Rutkow, White) and Mental Health (Fingerhood, Stuart), Johns Hopkins Bloomberg School of Public Health, Baltimore; Department of Population Health Sciences, Division of Health Policy and Economics, Weill Cornell Medicine, New York City (Yu, McGinty); Johns Hopkins Carey Business School, Washington, D.C. (Quintero)
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Hamilton R, Mulvihill A, Butler L, Chow A, Irving E, McCulloch DL, McNeil A, Michael K, Spowart KM, Waterson-Wilson J, Mactier H. Impaired vision in children prenatally exposed to methadone: an observational cohort study. Eye (Lond) 2024; 38:118-126. [PMID: 37402864 PMCID: PMC10764882 DOI: 10.1038/s41433-023-02644-3] [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: 04/03/2023] [Revised: 06/05/2023] [Accepted: 06/15/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND/OBJECTIVES To examine prevalence of failed visual assessment at 8-10 years in children born to methadone-maintained opioid dependent (MMOD) mothers and relate this to known in utero substance exposure. SUBJECTS/METHODS Follow up of observational cohort study of methadone-exposed and comparison children matched for birthweight, gestation and postcode of residence at birth. Participants were 144 children (98 exposed, 46 comparison). Prenatal drug exposure was previously established via comprehensive maternal and neonatal toxicology. Children were invited to attend for visual assessment and casenotes were reviewed. Presence of acuity poorer than 0.2 logMAR, strabismus, nystagmus and/or impaired stereovision constituted a 'fail'. Fail rates were compared between methadone-exposed and comparison children after adjusting for known confounding variables. RESULTS 33 children attended in person: data were also derived from casenote review for all children. After controlling for maternal reported tobacco use, methadone-exposed children were more likely to have a visual 'fail' outcome, adjusted odds ratio 2.6, 95% CI 1.1-6.2; adjusted relative risk 1.8 (95% CI 1.1-3.4). Visual 'fail' outcome rates did not differ between methadone-exposed children who had (n = 47) or had not (n = 51) received pharmacological treatment for neonatal abstinence/opioid withdrawal syndrome (NAS/NOWS); fail rate 62% vs 53% (95% CI of difference-11-27%). CONCLUSIONS Children born to MMOD mothers are almost twice as likely as unexposed peers to have significant visual abnormalities at primary school age. Prenatal methadone exposure should be considered in the differential diagnosis of nystagmus. Findings support visual assessment prior to school entry for children with any history of prenatal opioid exposure. TRIAL REGISTRATION The study was prospectively registered on ClinicalTrials.gov (NCT03603301), https://clinicaltrials.gov/ct2/show/NCT03603301 .
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Affiliation(s)
- R Hamilton
- Royal Hospital for Children, NHS Greater Glasgow & Clyde and the University of Glasgow, Glasgow, G51 4TF, UK.
| | - A Mulvihill
- Princess Alexandra Eye Pavilion, NHS Lothian, Edinburgh, EH3 9HA, UK
| | - L Butler
- Tennant Institute of Ophthalmology, NHS Greater Glasgow & Clyde, Glasgow, G12 0YN, UK
| | - A Chow
- School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, N2L 3G1, Canada
| | - E Irving
- School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, N2L 3G1, Canada
| | - D L McCulloch
- School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, N2L 3G1, Canada
| | - A McNeil
- Royal Hospital for Children, NHS Greater Glasgow & Clyde, Glasgow, G51 4TF, UK
| | - K Michael
- Crosshouse Hospital, NHS Ayrshire & Arran, Kilmarnock, KA2 0BE, UK
| | - K M Spowart
- Specialist Children's Services, NHS Greater Glasgow & Clyde, Glasgow, G40 1DA, UK
| | - J Waterson-Wilson
- Royal Hospital for Children, NHS Greater Glasgow & Clyde, Glasgow, G51 4TF, UK
| | - H Mactier
- NHS Greater Glasgow & Clyde and the University of Glasgow, Glasgow, UK
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Woods RH. Dental Disorders Reported to the FDA Adverse Event Reporting System in Association with Buprenorphine: An Analysis by Ingredient Composition and Route of Administration. Curr Drug Saf 2024; 19:261-267. [PMID: 37526182 DOI: 10.2174/1574886318666230731151447] [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: 03/24/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Prior research has suggested buprenorphine-containing medications may be associated with an increased risk of dental disorders. However, published data describing adverse dental reactions in buprenorphine users by active ingredient composition and route of administration are limited. OBJECTIVE The purpose of this study was to evaluate the influence of formulation on spontaneous reporting of dental disorders among patients treated with buprenorphine. METHODS Adverse event reports submitted to the United States Food and Drug Administration Adverse Event Reporting System (FAERS) between 2015 and 2022 were analyzed. Reporting odds ratios (ROR) and 95% confidence intervals (CI) were calculated to measure disproportionality of dental disorder reporting as classified by 39 Medical Dictionary for Regulatory Activities preferred terms. RESULTS Compared to pooled reports for all other drugs across FAERS, both buprenorphine monotherapy (ROR 3.09; 95% CI 2.61-3.66) and combination buprenorphine/naloxone (ROR 14.61; 95% CI 13.34-16.01) were associated with positive disproportionality signals. Signals of disproportionate dental disorder reporting were also detected for buprenorphine medicines administered by sublingual (ROR 20.03; 95% CI 18.04-22.24), buccal (ROR 4.46; 95% CI 3.00-6.61) and oral (ROR 7.17; 95% CI 5.03-10.22) routes, but not for other modalities. In considering active ingredient and route together, sublingual buprenorphine monotherapies (ROR 23.55; 95% CI 17.84-31.11) and sublingual buprenorphine/naloxone (ROR 19.47; 95% CI 17.39-21.80) were each associated with disproportionate reporting of dental disorders. CONCLUSION Subject to the limitations of spontaneous adverse event data, this study identified significantly disproportionate reporting of dental disorders to FAERS among patients treated with buprenorphine- containing medications, including formulations administered by sublingual, buccal and oral routes. These findings are consistent with prior data and suggest that regular oral care and proper dental hygiene be emphasized for patients undergoing therapy with orally dissolving buprenorphine.
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Affiliation(s)
- Richard H Woods
- Levin, Papantonio, Rafferty, Proctor, Buchanan, O'Brien, Barr & Mougey, P.A., Pensacola, FL 32502, United States
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Bodnar A, Diffenderffer C, Jablonski LA, Bai E, Stewart RW. Use of intravenous buprenorphine microdosing to initiate medication for opioid use disorder in a patient with co-occurring pain: case report. J Addict Dis 2023:1-5. [PMID: 38044861 DOI: 10.1080/10550887.2023.2285201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
INTRODUCTION Buprenorphine is used to treat opioid use disorder (OUD). However, therapy is often disrupted during acute pain episodes, and re-initiation is often deferred due to intolerable interruption in opioid analgesics. This case report describes a unique strategy for inducing buprenorphine without stopping opioid analgesics. CASE One patient with OUD and acute pain was initiated on buprenorphine using intravenous microdosing without precipitated withdrawal or pain exacerbation. Full agonist opioids were successfully weaned after discharge and the patient was linked with a community-based treatment program. CONCLUSION This case describes use of intravenous buprenorphine to treat OUD and acute pain without adverse consequences.
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Affiliation(s)
- Alia Bodnar
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Eric Bai
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Rosalyn W Stewart
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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DiPaula BA, Cooke CE. Assessing suboxone access in community pharmacies: Secret shopper model. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 12:100356. [PMID: 38023634 PMCID: PMC10663689 DOI: 10.1016/j.rcsop.2023.100356] [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: 07/06/2023] [Revised: 09/01/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To assess whether Maryland community pharmacies had Suboxone available for dispensing. Methods This cross-sectional study used a secret shopper model to contact public-facing community pharmacies in Maryland. The secret shopper, guided by a script, asked whether a prescription for Suboxone was available for the same or next day pick-up. A small convenience sample of pharmacies who did not have Suboxone available received an in-person visit to inquire about medication availability and dispensing barriers. Results After contacting 99% (n = 1046) of Maryland public-facing pharmacies, Suboxone was confirmed available for immediate pick-up in 31% (n = 326). The remaining did not have, would not disclose, or had limited access (existing patients or specific providers only). Significant differences in Suboxone availability were found for National Capital vs. Baltimore metro region and when pharmacist asked questions vs. no questions. Of the 11 pharmacy visits completed, 10 said they had Suboxone currently in stock, with one clarifying medication was for existing patients only. Conclusion About 69% of patients may face challenges when calling to find out whether they can obtain Suboxone in Maryland pharmacies. Better patient education and more thorough pharmacy-level investigation of system and workflow barriers could offer solutions.
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Miller JC, Brooks MA, Wurzel KE, Cox EJ, Wurzel JF. A Guide to Expanding the Use of Buprenorphine Beyond Standard Initiations for Opioid Use Disorder. Drugs R D 2023; 23:339-362. [PMID: 37938531 PMCID: PMC10676346 DOI: 10.1007/s40268-023-00443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 11/09/2023] Open
Abstract
Buprenorphine has become an important medication in the context of the ongoing opioid epidemic. However, complex pharmacologic properties and varying government regulations create barriers to its use. This narrative review is intended to facilitate buprenorphine use-including non-traditional initiation methods-by providers ranging from primary care providers to addiction specialists. This article briefly discusses the opioid epidemic and the diagnosis and treatment of opioid use disorder (OUD). We then describe the basic and complex pharmacologic properties of buprenorphine, linking these properties to their clinical implications. We guide readers through the process of initiating buprenorphine in patients using full agonist opioids. As there is no single recommended approach for buprenorphine initiation, we discuss the details, advantages, and disadvantages of the standard, low-dose, bridging-strategy, and naloxone-facilitated initiation techniques. We consider the pharmacology of, and evidence base for, buprenorphine in the treatment of pain, in both OUD and non-OUD patients. Throughout, we address the use of buprenorphine in children and adolescent patients, and we finish with considerations related to the settings of pregnancy and breastfeeding.
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Affiliation(s)
- James C Miller
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Michael A Brooks
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Kelly E Wurzel
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Emily J Cox
- Providence Research Network, Renton, WA, USA
| | - John F Wurzel
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA.
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Pasman E, O'Shay S, Brown S, Madden EF, Agius E, Resko SM. Ambivalence and contingencies: A qualitative examination of peer recovery coaches' attitudes toward medications for opioid use disorder. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 155:209121. [PMID: 37474006 DOI: 10.1016/j.josat.2023.209121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 02/18/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Peer recovery coaches (PRCs) are an important provider group affecting medications for opioid use disorder (MOUD) uptake and retention. However, some PRCs may have experiences and beliefs that do not align with the use of MOUD. This study examines PRCs' perceptions of MOUD and how PRCs' attitudes affect their interactions with clients. The article also explores factors influencing PRCs' attitudes. METHODS The study team conducted semi-structured interviews by phone with PRCs in Michigan (N = 34, July through September 2021). The study asked participants about their opinion of MOUD, how they help clients to make decisions about MOUD, and whether they have encountered negative attitudes toward MOUD in their work. Data analysis was guided by Tracy's (2020) iterative phronetic approach. RESULTS Nearly all PRCs acknowledged the social stigma surrounding MOUD. PRCs described the stigma toward MOUD as affecting treatment access, utilization, and recovery support. While most PRCs expressed support for many recovery pathways, support for MOUD was contingent on the type of medication and the conditions under which it is used. PRCs often described MOUD as acceptable only in the short-term when paired with psychosocial interventions, after nonpharmacological treatment attempts had failed. PRCs with concerns about MOUD reported sometimes avoiding discussions about MOUD with clients, spreading misinformation about MOUD, and encouraging clients to discontinue treatment. However, many PRCs expressed a desire to support clients' self-determination despite their own biases. CONCLUSIONS Findings highlight a need for education and stigma reduction among PRCs and point to specific areas for intervention. PRCs described deeply engrained beliefs about MOUD rooted in their own treatment histories and recovery practices. Provision of high-quality training and supervision to shift attitudes among PRCs will be key to increasing the use of MOUD.
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Affiliation(s)
- Emily Pasman
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, United States of America.
| | - Sydney O'Shay
- Department of Communication Studies & Philosophy, Utah State University, 0720 Old Main Hill, Logan, UT 84322, United States of America
| | - Suzanne Brown
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, United States of America
| | - Erin Fanning Madden
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, 3939 Woodward Ave, Detroit, MI 48201, United States of America
| | - Elizabeth Agius
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, United States of America
| | - Stella M Resko
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, United States of America; Merrill Palmer Skillman Institute, Wayne State University, 71 E Ferry St, Detroit, MI 48202, United States of America
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Peacock BB, Shull CN, Hildebrandt CA, Bodner GB, Lindaman KJ, Gillette C. Opioid use disorder and motivational interviewing: Training physician assistants for the epidemic. J Opioid Manag 2023; 19:507-513. [PMID: 38189192 DOI: 10.5055/jom.0835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
OBJECTIVES (1) To evaluate the effectiveness of a curriculum on physician assistant (PA) students' knowledge about opioid use disorder (OUD) treatment and management and (2) present student satisfaction with the curriculum. METHODS Three cohorts of PA students completed pre- and post-intervention questionnaires about their knowledge of motivational interviewing (MI) for OUD. One cohort of students completed the 11-item questionnaire without exposure to the intervention (control group). Students' satisfaction with the curriculum was assessed as was their pre- and post-intervention knowledge about using MI for OUD. Bivariate statistical tests were used to analyze the quantitative data. RESULTS Three hundred complete and usable responses were obtained from the four cohorts of PA students (n = 300, 87.7 percent response rate). The intervention groups answered a higher number of items correctly (median = 7) than the control group (median = 6, Wilcoxon sign test M = 31, p < 0.0001). Among the intervention group, there was not a statistically significant between cohort difference on: (1) the number of identical pre- and post-intervention questionnaire items answered correctly (Chi-square = 3.77, DF = 2, p = 0.15), and (2) the total number of items answered correctly on the post-intervention questionnaire (Chi-square = 0.32, DF = 2, p = 0.85). Student comments suggest students were supportive of the curriculum, with improvements noted on how to deliver the material. CONCLUSIONS An educational intervention using MI for PA students was found to be valuable, and students who completed the intervention had greater knowledge about using MI with OUD patients than those who did not complete the training. The size of the effect was small, and more research on the curriculum is necessary prior to widespread adoption.
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Affiliation(s)
- Brian B Peacock
- Department of PA Studies, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Catherine N Shull
- Department of PA Studies, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Carol A Hildebrandt
- Department of PA Studies, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Gayle B Bodner
- Department of PA Studies, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kristin J Lindaman
- Department of PA Studies, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Chris Gillette
- Department of PA Studies, Wake Forest School of Medicine, Winston-Salem, North Carolina. ORCID: https://orcid.org/0000-0002-8623-1285
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Jarrett JB, Bratberg J, Burns AL, Cochran G, DiPaula BA, Dopp AL, Elmes A, Green TC, Hill LG, Homsted F, Hsia SL, Matthews ML, Ghitza UE, Wu LT, Bart G. Research Priorities for Expansion of Opioid Use Disorder Treatment in the Community Pharmacy. Subst Abus 2023; 44:264-276. [PMID: 37902032 PMCID: PMC10870734 DOI: 10.1177/08897077231203849] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
In the last decade, the U.S. opioid overdose crisis has magnified, particularly since the introduction of synthetic opioids, including fentanyl. Despite the benefits of medications for opioid use disorder (MOUD), only about a fifth of people with opioid use disorder (OUD) in the U.S. receive MOUD. The ubiquity of pharmacists, along with their extensive education and training, represents great potential for expansion of MOUD services, particularly in community pharmacies. The National Institute on Drug Abuse's National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) convened a working group to develop a research agenda to expand OUD treatment in the community pharmacy sector to support improved access to MOUD and patient outcomes. Identified settings for research include independent and chain pharmacies and co-located pharmacies within primary care settings. Specific topics for research included adaptation of pharmacy infrastructure for clinical service provision, strategies for interprofessional collaboration including health service models, drug policy and regulation, pharmacist education about OUD and OUD treatment, including didactic, experiential, and interprofessional curricula, and educational interventions to reduce stigma towards this patient population. Together, expanding these research areas can bring effective MOUD to where it is most needed.
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Affiliation(s)
- Jennie B. Jarrett
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, USA
| | - Jeffrey Bratberg
- Department of Pharmacy Practice and Clinical Research, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Anne L. Burns
- American Pharmacists Association, Washington, DC, USA (retired)
| | - Gerald Cochran
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Bethany A. DiPaula
- Department of Practice, Sciences, and Health Outcomes Research, School of Pharmacy, University of Maryland Baltimore, Baltimore, MD, USA
| | | | - Abigail Elmes
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, USA
| | - Traci C. Green
- COBER on Opioids and Overdose at Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI, USA
- Opioid Policy Research Collaborative, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Lucas G. Hill
- The University of Texas at Austin, College of Pharmacy, Austin, TX, USA
| | | | - Stephanie L. Hsia
- Department of Clinical Pharmacy, San Francisco School of Pharmacy, University of California, San Francisco, CA, USA
| | - Michele L. Matthews
- Department of Pharmacy Practice, School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
| | - Udi E. Ghitza
- National Institute on Drug Abuse (NIDA), Center for the Clinical Trials Network (CCTN), Bethesda, MD, USA
| | - Li-Tzy Wu
- Duke University School of Medicine, Durham, NC, USA
| | - Gavin Bart
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
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Ruggiero E, Pambuku A, Caccese M, Lombardi G, Gallio I, Brunello A, Ceccato F, Formaglio F. Case report: The lesson from opioid withdrawal symptoms mimicking paraganglioma recurrence during opioid deprescribing in cancer pain. FRONTIERS IN PAIN RESEARCH 2023; 4:1256809. [PMID: 37810433 PMCID: PMC10556467 DOI: 10.3389/fpain.2023.1256809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023] Open
Abstract
Pain is one of the predominant and troublesome symptoms that burden cancer patients during their whole disease trajectory: adequate pain management is a fundamental component of cancer care. Opioid are the cornerstone of cancer pain relief therapy and their skillful management must be owned by physicians approaching cancer pain patients. In light of the increased survival of cancer patients due to advances in therapy, deprescription should be considered as a part of the opioid prescribing regime, from therapy initiation, dose titration, and changing or adding drugs, to switching or ceasing. In clinical practice, opioid tapering after pain remission could be challenging due to withdrawal symptoms' onset. Animal models and observations in patients with opioid addiction suggested that somatic and motivational symptoms accompanying opioid withdrawal are secondary to the activation of stress-related process (mainly cortisol and catecholamines mediated). In this narrative review, we highlight how the lack of validated guidelines and tools for cancer patients can lead to a lower diagnostic awareness of opioid-related disorders, increasing the risk of developing withdrawal symptoms. We also described an experience-based approach to opioid withdrawal, starting from a case-report of a symptomatic patient with a history of metastatic pheochromocytoma-paraganglioma.
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Affiliation(s)
- Elena Ruggiero
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
| | - Ardi Pambuku
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
| | - Mario Caccese
- Department of Oncology, Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Ivan Gallio
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
| | - Antonella Brunello
- Department of Oncology, Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Fabio Formaglio
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
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Pytell JD, Fojo AT, Keruly JC, Snow LN, Falade-Nwulia O, Moore RD, Chander G, Lesko CR. Measuring time in buprenorphine treatment stages among people with HIV and opioid use disorder by retention definition and its association with cocaine and hazardous alcohol use. Addict Sci Clin Pract 2023; 18:51. [PMID: 37660116 PMCID: PMC10474763 DOI: 10.1186/s13722-023-00408-8] [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: 05/05/2023] [Accepted: 08/23/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND We use a novel, longitudinal approach to describe average time spent in opioid use disorder (OUD) cascade of care stages for people with HIV (PWH) and with OUD, incorporating four definitions of treatment retention. Using this approach, we describe the impact of cocaine or hazardous alcohol use on time spent retained on buprenorphine. METHODS We followed PWH with OUD enrolled in the Johns Hopkins HIV Clinical Cohort from their first buprenorphine treatment episode between 2013 and 2020. We estimated 4-year restricted mean time spent on buprenorphine below buprenorphine retention threshold, on buprenorphine above retention threshold, off buprenorphine and in HIV care, loss to follow-up, and death. Retention definitions were based on retention threshold (180 vs 90 days) and allowable treatment gap (7 vs 30 days). Differences in 2-year restricted mean time spent retained on buprenorphine were estimated for patients with and without cocaine or hazardous alcohol use. RESULTS The study sample (N = 179) was 63% male, 82% non-Hispanic Black, and mean age was 53 (SD 8) years. Patients spent on average 13.9 months (95% CI 11.4, 16.4) on buprenorphine over 4 years. There were differences in time spent retained on buprenorphine based on the retention definition, ranging from 6.5 months (95% CI 4.6, 8.5) to 9.6 months (95% CI 7.4, 11.8). Patients with cocaine use spent fewer months retained on buprenorphine. There were no differences for patients with hazardous alcohol use. CONCLUSIONS PWH with OUD spend relatively little time receiving buprenorphine in their HIV primary care clinic. Concurrent cocaine use at buprenorphine initiation negatively impact time on buprenorphine.
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Affiliation(s)
- Jarratt D Pytell
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Mail Stop B180, 12631 E. 17Th Ave, Aurora, CO, 80045, USA.
| | - Anthony T Fojo
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jeanne C Keruly
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - LaQuita N Snow
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Oluwaseun Falade-Nwulia
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard D Moore
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Geetanjali Chander
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Tsui JI, Whitney BM, Korthuis PT, Chan B, Pho MT, Jenkins WD, Young AM, Cooper HLF, Friedmann PD, Stopka TJ, de Gijsel D, Miller WC, Go VF, Westergaard R, Brown R, Seal DW, Zule WA, Feinberg J, Smith GS, Mixson LS, Fredericksen R, Crane HM, Delaney JA. Methamphetamine use and utilization of medications for opioid use disorder among rural people who use drugs. Drug Alcohol Depend 2023; 250:110911. [PMID: 37549545 PMCID: PMC10599300 DOI: 10.1016/j.drugalcdep.2023.110911] [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: 04/07/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Methamphetamine use is common among persons with opioid use disorder. This study evaluated associations between methamphetamine use and treatment with agonist medications for opioid use disorder (MOUD, specifically buprenorphine, and/or methadone) in U.S. rural communities. METHODS The Rural Opioid Initiative (ROI) is a consortium spanning 10 states and 65 rural counties that included persons who reported past 30-day use of opioids and/or injection drug use between 1/2018 and 3/2020. Analyses were restricted to participants who had ever used opioids and had data on past 30-day methamphetamine use. Multivariable models examined the relationship between methamphetamine use and utilization of agonist MOUD. RESULTS Among 2899 participants, 2179 (75.2%) also reported recent methamphetamine use. Persons with methamphetamine use compared to those without were younger, more likely to have injected drugs, be unhoused, criminal justice involved, and less likely to have health insurance. Adjusted for age, sex, race, and study site, recent methamphetamine use was associated with lower relative odds of past 30-day methadone treatment (aOR=0.66; 95% CI: 0.45-0.99) and fewer methadone treatment days (aIRR=0.76; 0.57-0.99), but not past 30-day buprenorphine receipt (aOR=0.90; 0.67-1.20), buprenorphine treatment days in past 6 months: aIRR=0.88; 0.69-1.12) or perceived inability to access buprenorphine (aOR=1.12; 0.87-1.44) or methadone (aOR=1.06; 0.76-1.48). CONCLUSION Methamphetamine use is common among persons who use opioids in rural U.S. areas and negatively associated with current treatment and retention on methadone but not buprenorphine. Future studies should examine reasons for this disparity and reduce barriers to methadone for persons who use opioids and methamphetamine.
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Affiliation(s)
- Judith I Tsui
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195-6420, USA.
| | - Bridget M Whitney
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195-6420, USA
| | - P Todd Korthuis
- Department of Medicine, Oregon Health & Science University, 3270 Southwest Pavilion Loop OHSU Physicians Pavilion, Suite 350, Portland, OR 97239, USA
| | - Brian Chan
- Department of Medicine, Oregon Health & Science University, 3270 Southwest Pavilion Loop OHSU Physicians Pavilion, Suite 350, Portland, OR 97239, USA
| | - Mai T Pho
- University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Wiley D Jenkins
- Southern Illinois University School of Medicine, Springfield, IL 62794, USA
| | - April M Young
- University of Kentucky, 760 Press Avenue Suite 280, Lexington, KY 40536, USA
| | - Hannah L F Cooper
- Rollins School of Public Health, Emory University, Grace Crum Rollins Building 1518 Clifton Road, Atlanta, GA 30322, USA
| | - Peter D Friedmann
- Office of Research, UMass Chan Medical School - Baystate and Baystate Health, 3601 Main Street, 3rd Floor, Springfield, MA 01199, USA
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - David de Gijsel
- Dartmouth-Hitchcock Medical Center, Section of Infectious Disease and International Health, Lebanon, NH, USA
| | - William C Miller
- The Ohio State University, 346 Cunz Hall 1841 Neil Ave, Columbus, OH 43210, USA
| | - Vivian F Go
- University of North Carolina-Chapel Hill, 363 Rosenau Hall CB# 7440, Chapel Hill, NC 27599, USA
| | - Ryan Westergaard
- University of Wisconsin-Madison, 1685 Highland Avenue, 5th Floor, Madison, WI 53705-2281, USA
| | - Randall Brown
- University of Wisconsin-Madison, 1685 Highland Avenue, 5th Floor, Madison, WI 53705-2281, USA
| | - David W Seal
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2210, New Orleans, LA 70112, USA
| | - William A Zule
- RTI International, 3040 E. Cornwallis Road, PO Box 12194, Research Triangle Park, NC 2709-2194, USA
| | - Judith Feinberg
- West Virginia University, 930 Chestnut Ridge Road, PO Box 9156, Morgantown, WV 26505, USA
| | - Gordon S Smith
- West Virginia University, 930 Chestnut Ridge Road, PO Box 9156, Morgantown, WV 26505, USA
| | - L Sarah Mixson
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195-6420, USA
| | - Rob Fredericksen
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195-6420, USA
| | - Heidi M Crane
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195-6420, USA
| | - Joseph A Delaney
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195-6420, USA
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Hammerslag L, Talbert J, Donohue JM, Sharbaugh M, Ahrens K, Allen L, Austin AE, Gordon AJ, Jarlenski M, Kim JY, Mohamoud S, Tang L, Burns M. Urine drug testing among Medicaid enrollees initiating buprenorphine treatment for opioid use disorder within 9 MODRN states. Drug Alcohol Depend 2023; 250:110875. [PMID: 37413960 PMCID: PMC10529442 DOI: 10.1016/j.drugalcdep.2023.110875] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Treatment guidelines recommend regular urine drug testing (UDT) for persons initiating buprenorphine for opioid use disorder (OUD). However, little is known about UDT utilization. We describe state variation in UDT utilization and examine demographic, health, and health care utilization factors associated with UDT in Medicaid. METHODS We used Medicaid claims and enrollment data from persons initiating buprenorphine treatment for OUD during 2016-2019 in 9 states (DE, KY, MD, ME, MI, NC, PA, WI, WV). The main outcome was at least 1 UDT within 180 days of buprenorphine initiation, the secondary outcome was at least 3. Logistic regression models included demographics, pre-initiation comorbidities, and health service use. State estimates were pooled using meta-analysis. RESULTS The study cohort included 162,437 Medicaid enrollees initiating buprenorphine. The percent receiving ≥1 UDT varied from 62.1% to 89.8% by state. In the pooled analysis, enrollees with pre-initiation UDT had much higher odds of ≥1 UDT after initiation (aOR=3.83, 3.09-4.73); odds were also higher for enrollees with HIV, HCV, and/or HBV infection (aOR=1.25, 1.05-1.48) or who initiated in later years (2018 v 2016: aOR=1.39, 1.03-1.89; 2019 v 2016: aOR=1.67, 1.24-2.25). The odds of having ≥3 UDT were lower with pre-initiation opioid overdose (aOR=0.79, 0.64-0.96) and higher with pre-initiation UDT (aOR=2.63, 2.13-3.25) or OUD care (aOR=1.35, 1.04-1.74). The direction of associations with demographics varied by state. CONCLUSIONS Rates of UDT increased over time and there was variability among states in UDT rates and demographic predictors of UDT. Pre-initiation conditions, UDT, and OUD care were associated with UDT.
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Affiliation(s)
- Lindsey Hammerslag
- Division of Biomedical Informatics, College of Medicine, University of Kentucky, United States.
| | - Jeffery Talbert
- Institute for Biomedical Informatics, College of Medicine, University of Kentucky, United States
| | - Julie M Donohue
- Health Policy and Management, University of Pittsburgh School of Public Health, United States
| | - Michael Sharbaugh
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, United States
| | - Katherine Ahrens
- University of Southern Maine, Muskie School of Public Service, United States
| | - Lindsay Allen
- Feinberg School of Medicine, Northwestern University, United States
| | - Anna E Austin
- Gillings School of Global Public Health and Injury Prevention Research Center, University of North Carolina at Chapel Hill, United States
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy, Department of Internal Medicine, University of Utah School of Medicine and VA Salt Lake City Health Care System, United States
| | - Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, United States
| | - Joo Yeon Kim
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, United States
| | - Shamis Mohamoud
- The Hilltop Institute, University of Maryland Baltimore County, United States
| | - Lu Tang
- Department of Biostatistics, University of Pittsburgh School of Public Health, United States
| | - Marguerite Burns
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, United States
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DeMaria PA. Managing Benzodiazepine Withdrawal-The Emperor's New Clothes. J Addict Med 2023; 17:626-627. [PMID: 37788627 DOI: 10.1097/adm.0000000000001181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Affiliation(s)
- Peter A DeMaria
- Department of Psychiatry and Behavioral Sciences, Lewis Katz School of Medicine, Tuttleman Counseling Services, Temple University, Philadelphia, PA
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50
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Mazel S, Alexander K, Cioffi C, Terplan M. Interventions to Support Engagement in Addiction Care Postpartum: Principles and Pitfalls. Subst Abuse Rehabil 2023; 14:49-59. [PMID: 37424702 PMCID: PMC10327918 DOI: 10.2147/sar.s375652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/27/2023] [Indexed: 07/11/2023] Open
Abstract
There is a fundamental disconnect between the optimal management of addiction in general and care delivery in pregnancy and postpartum. Addiction is a chronic condition requiring some degree of management across the life course. Yet, in the US, reproductive care is episodic and centers more on pregnancy than at other stages of the reproductive life course. Pregnancy is prioritized in access to insurance as almost all pregnant people are Medicaid eligible but access ends at varying points postpartum. This results in a structural mismatch: the episodic management of the chronic condition of addiction only within gestational periods. Though people with substance use disorder (SUD) may access care in pregnancy, treatment attrition is common postpartum. Postpartum is a time of increased vulnerabilities where insurance churn and newborn caretaking responsibilities collide in a context of care withdrawal from the health system and health providers. In part in consequence, return to use, SUD recurrence, overdose, and overdose death are more common postpartum than in pregnancy, and drug deaths have become a leading cause of maternal deaths in the US. This review addresses interventions to support engagement in addiction care postpartum. We begin with a scoping review of model programs and evidence-informed interventions that have been shown to increase continuation of care postpartum. We then explore the realities of contemporary care through a review of clinical and ethical principles, with particular attention to harm reduction. We conclude with suggestions of strategies (clinical, research, and policy) to improve care postpartum and highlight potential pitfalls in the uptake of evidence-based and person-centered services.
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Affiliation(s)
- Shayna Mazel
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | | | - Camille Cioffi
- Center on Parenting and Opioids, Prevention Science Institute, University of Oregon, Eugene, OR, USA
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