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Green M, Veltri CA, Grundmann O. Nalmefene Hydrochloride: Potential Implications for Treating Alcohol and Opioid Use Disorder. Subst Abuse Rehabil 2024; 15:43-57. [PMID: 38585160 PMCID: PMC10999209 DOI: 10.2147/sar.s431270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/16/2024] [Indexed: 04/09/2024] Open
Abstract
Nalmefene hydrochloride was first discovered as an opioid antagonist derivative of naltrexone in 1975. It is among the most potent opioid antagonists currently on the market and is differentiated from naloxone and naltrexone by its partial agonist activity at the kappa-opioid receptor which may benefit in the treatment of alcohol use disorder. Oral nalmefene has been approved in the European Union for treatment of alcohol use disorder since 2013. As of 2023, nalmefene is available in the United States as an intranasal spray for reversal of opioid overdose but is not approved for alcohol or opioid use disorder as a maintenance treatment. The substantially longer half-life of nalmefene and 5-fold higher binding affinity to opioid receptors makes it a superior agent over naloxone in the reversal of high potency synthetic opioids like fentanyl and the emerging nitazenes. Nalmefene presents with a comparable side effect profile to other opioid antagonists and should be considered for further development as a maintenance treatment for opioid and other substance use disorders.
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Affiliation(s)
- MeShell Green
- College of Pharmacy, Department of Pharmaceutical Sciences, Midwestern University, Glendale, AZ, USA
| | - Charles A Veltri
- College of Pharmacy, Department of Pharmaceutical Sciences, Midwestern University, Glendale, AZ, USA
| | - Oliver Grundmann
- College of Pharmacy, Department of Pharmaceutical Sciences, Midwestern University, Glendale, AZ, USA
- College of Pharmacy, Department of Medicinal Chemistry, University of Florida, Gainesville, FL, USA
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2
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Winiker AK, Schneider KE, Hamilton White R, O'Rourke A, Grieb SM, Allen ST. A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia. Harm Reduct J 2023; 20:69. [PMID: 37264367 PMCID: PMC10233537 DOI: 10.1186/s12954-023-00795-w] [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: 03/15/2022] [Accepted: 05/11/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia. METHODS From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data. RESULTS Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff. CONCLUSIONS Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.
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Affiliation(s)
- Abigail K Winiker
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway St., Baltimore, MD, 21205, USA.
| | - Kristin E Schneider
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway St., Baltimore, MD, 21205, USA
| | - Rebecca Hamilton White
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway St., Baltimore, MD, 21205, USA
| | - Allison O'Rourke
- DC Center for AIDS Research, Department of Psychological and Brain Sciences, George Washington University, 2125 G St. NW, Washington, DC, 20052, USA
| | - Suzanne M Grieb
- Center for Child and Community Health Research, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, 21224, USA
| | - Sean T Allen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway St., Baltimore, MD, 21205, USA
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3
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Enns B, Krebs E, Whitehurst DGT, Jutras-Aswad D, Le Foll B, Socias ME, Nosyk B. Cost-effectiveness of flexible take-home buprenorphine-naloxone versus methadone for treatment of prescription-type opioid use disorder. Drug Alcohol Depend 2023; 247:109893. [PMID: 37120920 DOI: 10.1016/j.drugalcdep.2023.109893] [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: 11/08/2022] [Revised: 03/21/2023] [Accepted: 04/19/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Our objective was to examine the cost-effectiveness of flexible take-home buprenorphine-naloxone (BNX) versus methadone alongside the OPTIMA trial in Canada. METHODS The OPTIMA study was a pragmatic, open-label, noninferiority, two-arm randomized controlled trial, to assess the comparative effectiveness of flexible take-home BNX vs. methadone in routine clinical care for individuals with prescription-type opioid use disorder. We evaluated cost-effectiveness using a semi-Markov cohort model. Probabilities of overdose were calibrated, accounting for fentanyl prevalence and other overdose risk factors such as naloxone availability. We considered health sector and societal cost perspectives, including costs (2020 CAD) for treatment, health resource use, criminal activity, and health state-specific preference weights as outcomes to calculate incremental cost-effectiveness ratios. Six-month and lifetime (3% annual discount rate) time-horizons were explored. RESULTS Over a lifetime time horizon, individuals accumulated -0.144 [CI: -0.302, -0.025] incremental quality-adjusted life years (QALYs) in BNX compared with methadone. Incremental costs were -$2047 [CI: -$39,197, $24,250] from a societal perspective, and -$4549 [CI: -$6332, -$3001] from a health sector perspective. Over a six-month time-horizon, individuals accumulated 0.002 [credible interval (CI): -0.011, 0.016] incremental QALYs in BNX compared with methadone. Incremental costs were -$307 [CI: -$10,385, $8466] from a societal perspective and -$1111 [CI: -$1517, -$631] from a health sector perspective. BNX was dominated (costlier, less effective) in 49.7% of simulations when adopting a societal perspective over a lifetime time horizon. CONCLUSIONS Flexible take-home BNX was not cost-effective versus methadone over a lifetime time horizon, resulting from better treatment retention in methadone compared to BNX.
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Affiliation(s)
- Benjamin Enns
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Emanuel Krebs
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - David G T Whitehurst
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Didier Jutras-Aswad
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 Saint-Denis Street, Montréal, QuébecH2X 0A9, Canada; Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, 2900 boul. Edouard-Montpetit, Montréal, QuébecH3T1J4, Canada
| | - Bernard Le Foll
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, OntarioM5S 1A8, Canada; Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 250 College Street, 8th floor, Toronto, OntarioM5T 1R8, Canada; Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, OntarioM5T 3M7, Canada; Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Center for Addiction and Mental Health (CAMH), 33 Ursula Franklin Street, Toronto, OntarioM5S 2S1, Canada; Acute Care Program, CAMH, 33 Ursula Franklin Street, Toronto, OntarioM5S 2S1, Canada
| | - M Eugenia Socias
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, British ColumbiaV6Z 2A9, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, 1045 Howe Street, Vancouver, British ColumbiaV6Z 2A9, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
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Paul LA, Bayoumi AM, Chen C, Kocovska E, Smith BT, Raboud JM, Gomes T, Kendall C, Rosella LC, Bitonti-Bengert L, Rush B, Yu M, Spithoff S, Crichlow F, Wright A, Watford J, Besharah J, Munro C, Taha S, Nosyk B, Strike C, Manson H, Kahan M, Leece P. Evaluation of the gap in delivery of opioid agonist therapy among individuals with opioid-related health problems: a population-based retrospective cohort study. Addiction 2023; 118:686-697. [PMID: 36401610 DOI: 10.1111/add.16096] [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: 12/09/2021] [Accepted: 10/17/2022] [Indexed: 11/21/2022]
Abstract
AIMS Although opioid-related harms have reached new heights across North America, the size of the gap in opioid agonist therapy (OAT) delivery for opioid-related health problems is unknown in most jurisdictions. This study sought to characterize the gap in OAT treatment using a cascade of care framework, and determine factors associated with engagement and retention in treatment. DESIGN A population-based retrospective cohort study. SETTING Ontario, Canada. PARTICIPANTS Individuals who sought medical care for opioid-related health problems or died from an opioid-related cause between 2005 and 2019. MEASUREMENTS Monthly treatment status for buprenorphine/naloxone or methadone OAT between 2013 and 2019 (i.e. 'off OAT', 'retained on OAT < 6 months', 'retained on OAT ≥ 6 months'). FINDINGS Of 122 811 individuals in the cohort, 97 516 (79.4%) received OAT at least once during the study period. There was decreasing 6-month treatment retention over time. Model results indicated that males had higher odds of being on OAT each month [odds ratio (OR) = 1.26, 95% confidence interval (CI) = 1.23-1.28] but lower odds of OAT retention (OR = 0.90, 95% CI = 0.88-0.92), while the reverse was observed for older individuals (monthly: OR = 0.76 per 10-year increase, 95% CI = 0.76-0.77; retention: OR = 1.36 per 10-year increase, 95% CI = 1.34-1.38) and individuals with higher neighbourhood income (e.g. highest income quintile, monthly: OR = 0.79, 95% CI = 0.77-0.82; highest income quintile, retention: OR = 1.15, 95% CI = 1.11-1.20). Individuals residing in rural areas and with a history of mental health diagnoses had poorer outcomes overall, including lower odds of being on OAT each month (rural: OR = 0.75, 95% CI = 0.73-0.78; mental health: OR = 0.89, 95% CI = 0.87-0.92) and OAT retention (rural: OR = 0.79, 95% CI = 0.77-0.82; mental health: OR = 0.81, 95% CI = 0.78-0.83), as well as higher risk of starting/stopping OAT [rural, starting OAT: hazard ratio (HR) = 1.07, 95% CI = 1.05-1.10; mental health, starting OAT: HR = 1.20, 95% CI: 1.18-1.23; rural, stopping OAT: HR = 1.24, 95% CI: = 1.22-1.26; mental health, stopping OAT: HR = 1.11, 95% CI = 1.09-1.13]. Individuals with a history of mental health diagnoses also had a higher risk of death, regardless of OAT status (off OAT death: HR = 1.49, 95% CI = 1.33-1.66; on OAT death: HR = 1.20, 95% CI = 1.09-1.31). CONCLUSIONS Factors influencing engagement and declining retention in treatment with opioid agonist therapy in Ontario's health system include age, sex and neighbourhood income, as well as mental health diagnoses or residing in rural regions.
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Affiliation(s)
- Lauren A Paul
- Health Protection, Public Health Ontario, Toronto, ON, Canada
| | - Ahmed M Bayoumi
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,MAP Centre for Urban Health Solutions, St Michael's Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Cynthia Chen
- ICES, Toronto, ON, Canada.,Knowledge Services, Public Health Ontario, Toronto, ON, Canada
| | - Elena Kocovska
- Health Promotion, Chronic Disease and Injury Prevention, Public Health Ontario, Toronto, ON, Canada
| | - Brendan T Smith
- Health Promotion, Chronic Disease and Injury Prevention, Public Health Ontario, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Janet M Raboud
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | | | - Laura C Rosella
- ICES, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.,Vector Institute, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, ON, Canada
| | | | - Brian Rush
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Homewood Research Institute, Guelph, ON, Canada
| | - Melissa Yu
- St Joseph's Health Centre, Toronto, ON, Canada.,St Michael's Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Sheryl Spithoff
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada
| | | | - Amy Wright
- Ryerson University (renaming in process), Toronto, ON, Canada
| | | | - Jes Besharah
- Leeds, Grenville and Lanark District Health Unit, ON, Canada.,Lanark, Leeds and Grenville Addictions and Mental Health, Brockville, ON, Canada
| | - Charlotte Munro
- Ontario Drug Policy Research Network Lived Experience Advisory Group, St Michael's Hospital, ON, Canada
| | - Sheena Taha
- Canadian Centre on Substance Use and Addiction, Ottawa, ON, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Carol Strike
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Heather Manson
- Health Promotion, Chronic Disease and Injury Prevention, Public Health Ontario, Toronto, ON, Canada
| | - Meldon Kahan
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Substance Use Service, Women's College Hospital, Toronto, ON, Canada
| | - Pamela Leece
- Health Promotion, Chronic Disease and Injury Prevention, Public Health Ontario, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Substance Use Service, Women's College Hospital, Toronto, ON, Canada
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5
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Zhang J, Song C, Dai J, Li L, Yang X, Chen Z. Mechanism of opioid addiction and its intervention therapy: Focusing on the reward circuitry and mu‐opioid receptor. MedComm (Beijing) 2022; 3:e148. [PMID: 35774845 PMCID: PMC9218544 DOI: 10.1002/mco2.148] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 05/03/2022] [Accepted: 05/07/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Jia‐Jia Zhang
- National Translational Science Center for Molecular Medicine & Department of Cell Biology The Fourth Military Medical University Xi'an China
| | - Chang‐Geng Song
- Department of Neurology Xijing Hospital The Fourth Military Medical University Xi'an China
| | - Ji‐Min Dai
- Department of Hepatobiliary Surgery Xijing Hospital The Fourth Military Medical University Xi'an China
| | - Ling Li
- National Translational Science Center for Molecular Medicine & Department of Cell Biology The Fourth Military Medical University Xi'an China
| | - Xiang‐Min Yang
- National Translational Science Center for Molecular Medicine & Department of Cell Biology The Fourth Military Medical University Xi'an China
| | - Zhi‐Nan Chen
- National Translational Science Center for Molecular Medicine & Department of Cell Biology The Fourth Military Medical University Xi'an China
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Sadek J, Saunders J. Treatment retention in opioid agonist therapy: comparison of methadone versus buprenorphine/naloxone by analysis of daily-witnessed dispensed medication in a Canadian Province. BMC Psychiatry 2022; 22:516. [PMID: 35908052 PMCID: PMC9338516 DOI: 10.1186/s12888-022-04175-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/22/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The last decade has shown a remarkable increase in the rates of illicit opioid use in Canada and internationally, which is associated with large increases in opioid related morbidity and mortality. While the differences between methadone and buprenorphine/naloxone in terms of retention have been studied outside Canada, the unique location and design of this study, gives it a specific significance. OBJECTIVES This study aims to describe the relative treatment retention rates for first episode opioid replacement treatment between methadone and buprenorphine/naloxone for patients receiving daily witnessed dispensed medications in Nova Scotia. METHODS A longitudinal retrospective descriptive study analyzing secondary data from the Nova Scotia Prescription Monitoring Program on patients 18 years of age and older who started first episode opioid agonist therapy with methadone or buprenorphine/naloxone for opioid use disorder in Nova Scotia between 2014 and 2018. Treatment episode was defined as date of initial opioid agonist prescription until there is a gap of greater than 6 days without receiving opioid agonist medication at a pharmacy. RESULTS One thousand eight hundred sixty-seven of whom were analyzed as they had at least 1 day in treatment. There was significant treatment dropout within the first 2 weeks of treatment, which did not show a significant difference between OAT medication (23.4% of buprenorphine/naloxone; 22.2% methadone). Median duration of retention in treatment was 58 days for those treated with buprenorphine/naloxone and 101 days for patients treated with methadone. Multivariate cox proportional hazards model showed that buprenorphine/naloxone use as compared to methadone lead to increased hazard of treatment dropout by 62% (HR = 1.62). Hazard rate of treatment dropout for patients below 25 years of age was calculated. (HR 1.53). Median duration of retention in treatment for this subgroup of patients younger than age 25 was 37.5 days for patients treated with buprenorphine/naloxone and 69 days for patients treated with methadone. CONCLUSIONS Our data suggests that methadone is a numerically superior medication for opioid use disorder when the metric of treatment retention is viewed in isolation, for our population in Nova Scotia. However, the results should be interpreted carefully considering the number of limitations of this study. There are social/accessibility, pharmacologic/safety, and patient preference factors which are also key in decision making when prescribing opioid agonist therapy. These must all be considered when deciding on which medication to initiate for a patient beginning a new treatment episode with OAT for opioid use disorder. This study should stimulate further research into this important area in addiction medicine.
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Affiliation(s)
- Joseph Sadek
- Department of Psychiatry, Dalhousie University, 810 Maplewood Lane, Halifax, NS, B3H 4k3, Canada.
| | - Joseph Saunders
- grid.55602.340000 0004 1936 8200Department of Medicine, Dalhousie University, Halifax, NS Canada
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Clifton D, Ivey N, Poley S, O'Regan A, Raman SR, Frascino N, Hamilton S, Setji N. Implementation of a comprehensive hospitalist-led initiative to improve care for patients with opioid use disorder. J Hosp Med 2022; 17:427-436. [PMID: 35535562 PMCID: PMC9321616 DOI: 10.1002/jhm.12837] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/30/2022] [Accepted: 04/15/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND As opioid-related hospitalizations rise, hospitals must be prepared to evaluate and treat patients with opioid use disorder (OUD). We implemented a hospitalist-led program, Project Caring for patients with Opioid Misuse through Evidence-based Treatment (COMET) to address gaps in care for hospitalized patients with OUD. OBJECTIVE Implement evidence-based treatment for inpatients with OUD and refer to postdischarge care. DESIGN, SETTING, AND PARTICIPANTS Project COMET launched in July 2019 at Duke University Hospital (DUH), an academic medical center in Durham, NC. INTERVENTION, MAIN OUTCOMES, AND MEASURES We engaged key stakeholders, performed a needs assessment, and secured health system funding. We developed protocols to standardize OUD treatment and employed a social worker to facilitate postdischarge care. Electronic health records were utilized for data analysis. RESULTS COMET evaluated 512 patients for OUD during their index hospitalization from July 1, 2019 through June 30, 2021. Seventy-one percent of patients received medication for OUD (MOUD) during admission. Of those who received buprenorphine during admission, 64% received a discharge prescription. Of those who received methadone during admission, 83% of eligible patients were connected to a methadone clinic. Among all patients at DUH with OUD, MOUD use during hospitalization and at discharge increased in the post-COMET period compared to the pre-COMET period (p < .001 for both). CONCLUSION Our program is one of the first to demonstrate successful implementation of a hospitalist-led, comprehensive approach to caring for hospitalized patients with OUD and can serve as an example to other institutions seeking to implement life-saving, evidence-based treatment in this population.
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Affiliation(s)
- Dana Clifton
- Department of MedicineDivision of General Internal Medicine, Duke University School of MedicineDurhamNorth CarolinaUSA
- Department of PediatricsDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Noel Ivey
- Department of MedicineDivision of General Internal Medicine, Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Stephanie Poley
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Amy O'Regan
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Sudha R. Raman
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Nicole Frascino
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Shavone Hamilton
- Clinical Social Work, Duke University HospitalDurhamNorth CarolinaUSA
| | - Noppon Setji
- Department of MedicineDivision of General Internal Medicine, Duke University School of MedicineDurhamNorth CarolinaUSA
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Wyse JJ, McGinnis KA, Edelman EJ, Gordon AJ, Manhapra A, Fiellin DA, Moore BA, Korthuis PT, Kennedy AJ, Oldfield BJ, Gaither JR, Gordon KS, Skanderson M, Barry DT, Bryant K, Crystal S, Justice AC, Kraemer KL. Twelve-Month Retention in Opioid Agonist Treatment for Opioid Use Disorder Among Patients With and Without HIV. AIDS Behav 2022; 26:975-985. [PMID: 34495424 PMCID: PMC8840957 DOI: 10.1007/s10461-021-03452-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 12/22/2022]
Abstract
Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.
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Affiliation(s)
- Jessica J Wyse
- VA Portland Health Care System, Portland, OR, USA.
- School of Public Health, Oregon Health & Science University, Portland, OR, USA.
| | | | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ajay Manhapra
- Integrative Pain Recovery Service, Hampton VA Medical Center, Hampton, VA, USA
- APT Foundation, Pain Treatment Services, New Haven, CT, USA
| | - David A Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Brent A Moore
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - P Todd Korthuis
- Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Amy J Kennedy
- Los Angeles County Department of Health Services, Los Angeles, CA, USA
| | - Benjamin J Oldfield
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Julie R Gaither
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Kirsha S Gordon
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Declan T Barry
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- APT Foundation, Pain Treatment Services, New Haven, CT, USA
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, New Brunswick, NJ, USA
| | - Amy C Justice
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Kevin L Kraemer
- Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
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9
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Kurz M, Min JE, Dale LM, Nosyk B. Assessing the determinants of completing OAT induction and long-term retention: A population-based study in British Columbia, Canada. J Subst Abuse Treat 2022; 133:108647. [PMID: 34740484 PMCID: PMC9833672 DOI: 10.1016/j.jsat.2021.108647] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/16/2021] [Accepted: 10/13/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Pharmacological treatments for opioid use disorder are essential, life-saving medications, yet successful induction of them and long-term retention on them is limited in many settings. Induction into opioid agonist treatment (OAT) features the highest risk of mortality throughout the treatment course, and greatest risk of discontinuation. We aimed to identify determinants of completing OAT induction and, among those completing induction, time to OAT discontinuation in British Columbia (BC), Canada. METHODS We conducted a retrospective study using linked population-level health administrative databases to capture all individuals in BC receiving at least one OAT dispensation from January 1, 2008, to September 30, 2018. We constructed covariates capturing client demographics, clinical history, and characteristics of the treatment episode and the primary prescribing physician. We estimated a two-part model to identify determinants of the probability of completing induction using a generalized linear mixed model with logit link and the time to OAT discontinuation among those completing induction using a Cox proportional hazards frailty model. RESULTS We observed 220,474 OAT episodes (73.9% initiated with methadone, 24.7% with buprenorphine, and 1.4% with slow-release oral morphine) among 45,608 individuals over the study period. Less than 60% of all OAT episodes completed induction (59.0% for methadone episodes, 56.7% for buprenorphine/naloxone, 41.0% for slow-release oral morphine) and half of all episodes that completed induction reached the minimum effective dosage (51.0% for methadone episodes [60 mg/day], 48.2% for buprenorphine/naloxone [12 mg/day], 59.4% for slow-release oral morphine [240 mg/day]). In multiple regression analysis, the adjusted odds of completing induction with buprenorphine improved over time, exceeding that of methadone in 2018: 1.46 (1.40, 1.51). For those who completed induction, buprenorphine use was associated with shorter times to discontinuation throughout the study period, but the estimated rate of discontinuation decreased over time (adjusted hazard ratio, vs. methadone in 2008: 2.50 (2.35, 2.66); in 2018: 1.79 (1.74, 1.85)). CONCLUSION We found low rates of completing OAT induction and, for those who did complete it, low rates of reaching the minimum effective dose.
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Affiliation(s)
- Megan Kurz
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Laura M. Dale
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada,Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada,Corresponding author at: Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia, Canada. (B. Nosyk)
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10
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Kessler SH, Schwarz ES, Liss DB. Methadone vs. Buprenorphine for In-Hospital Initiation: Which Is Better for Outpatient Care Retention in Patients with Opioid Use Disorder? J Med Toxicol 2022; 18:11-18. [PMID: 34554396 PMCID: PMC8758885 DOI: 10.1007/s13181-021-00858-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 08/03/2021] [Accepted: 08/24/2021] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Currently, few hospitals provide medications for opioid use disorder (MOUD) to admitted patients with opioid use disorder (OUD). Data are needed to inform whether the choice of medication during hospitalization influences probability of retention in outpatient OUD treatment. METHODS This was a retrospective cohort analysis of patients who received a medical toxicology consult for OUD. Medical records were reviewed to determine if patients received MOUD and were referred to Engaging Patients in Care Coordination (EPICC), a service that connects hospitalized patients with OUD to outpatient care. Patients were stratified by the last form of MOUD they received in the hospital (methadone verses buprenorphine); retention in outpatient treatment was measured at 2 weeks, 30 days, and 12 weeks. The log-rank test was used to determine the difference in probabilities of retention in the methadone and buprenorphine groups. An event was defined as drop-out from outpatient treatment. RESULTS Of 267 total patients with medical toxicology consults for OUD, 155 received MOUD and referral to EPICC. One hundred six patients received buprenorphine and 46 received methadone. Three additional patients were excluded. The rate of retention in outpatient treatment for patients who received buprenorphine was 37%, 26%, and 13% and for patients who received methadone was 43%, 39%, and 35% at 2 weeks, 30 days, and 12 weeks, respectively. Methadone was associated with a statistically significant increased probability of retention in outpatient treatment as compared to buprenorphine (P < 0.01). CONCLUSION Despite the limitations of this retrospective study, in hospitalized patients who received MOUD, the probability of retention in outpatient treatment was higher in patients receiving methadone compared to buprenorphine.
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Affiliation(s)
- Skyler H Kessler
- Washington University in St. Louis School of Medicine, St. Louis, USA
| | - Evan S Schwarz
- Division of Toxicology, Department of Emergency Medicine, Washington University in St. Louis School of Medicine, 660 S. Euclid Ave. Campus, Box 8072, St. Louis, MO, 63110, USA
| | - David B Liss
- Division of Toxicology, Department of Emergency Medicine, Washington University in St. Louis School of Medicine, 660 S. Euclid Ave. Campus, Box 8072, St. Louis, MO, 63110, USA.
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11
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Comparing characteristics and outcomes of different opioid agonist treatment modalities among opioid-dependent federal men correctional populations in Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 100:103480. [PMID: 34656817 DOI: 10.1016/j.drugpo.2021.103480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 09/15/2021] [Accepted: 09/21/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Limited evidence exists in Canada on outcomes related to Opioid Agonist Treatment (OAT) and/or differences between OAT modalities among persons in correctional institutions. This study addresses this knowledge gap by examining key characteristics and outcomes of men in Canadian federal correctional institutions across treatment modalities. METHODS A retrospective cohort of men incarcerated in federal correctional institutions (N = 2833) were classified into four groups - three OAT participant groups: prescribed methadone (M-OAT), prescribed buprenorphine/naloxone (Suboxone®; S-OAT) and those who switched between the two OAT modalities at least once (X-OAT). The fourth group was a non-treatment comparison group (Non-OAT). Two-thirds of study participants were released and examined for post-release outcomes. Descriptive statistics and multi-variate Cox proportional hazards regression were used. RESULTS The X-OAT group was more likely than the other study groups to have positive urinalysis tests, disciplinary charges, or institutional security or behavioral incidents. Survival analysis indicated that the X-OAT had an adjusted hazard of a return to custody that was 57% greater than the other groups. CONCLUSIONS This study indicates that individuals switching OAT modalities are a more complex group needing additional supports, especially for community reintegration. Although few of the returns to custody were due to new offences, a third of participants in the OAT groups had their release revoked, indicating a high need population mostly due to their substance use.
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12
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Becker SJ, Murphy CM, Hartzler B, Rash CJ, Janssen T, Roosa M, Madden LM, Garner BR. Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics): A cluster-randomized type 3 hybrid effectiveness-implementation trial. Addict Sci Clin Pract 2021; 16:61. [PMID: 34635178 PMCID: PMC8505014 DOI: 10.1186/s13722-021-00268-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Opioid-related overdoses and harms have been declared a public health emergency in the United States, highlighting an urgent need to implement evidence-based treatments. Contingency management (CM) is one of the most effective behavioral interventions when delivered in combination with medication for opioid use disorder, but its implementation in opioid treatment programs is woefully limited. Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics) was funded by the National Institute on Drug Abuse to identify effective strategies for helping opioid treatment programs improve CM implementation as an adjunct to medication. Specific aims will test the impact of two different strategies on implementation outcomes (primary aim) and patient outcomes (secondary aims), as well as test putative mediators of implementation effectiveness (exploratory aim). METHODS A 3-cohort, cluster-randomized, type 3 hybrid design is used with the opioid treatment programs as the unit of randomization. Thirty programs are randomized to one of two conditions. The control condition is the Addiction Technology Transfer Center (ATTC) Network implementation strategy, which consists of three core approaches: didactic training, performance feedback, and on-going consultation. The experimental condition is an enhanced ATTC strategy, with the same core ATTC elements plus two additional theory-driven elements. The two additional elements are Pay-for-Performance, which aims to increase implementing staff's extrinsic motivations, and Implementation & Sustainment Facilitation, which targets staff's intrinsic motivations. Data will be collected using a novel, CM Tracker tool to document CM session delivery, session audio recordings, provider surveys, and patient surveys. Implementation outcomes include CM Exposure (number of CM sessions delivered per patient), CM Skill (ratings of CM fidelity), and CM Sustainment (number of patients receiving CM after removal of support). Patient outcomes include self-reported opioid abstinence and opioid-related problems (both assessed at 3- and 6-months post-baseline). DISCUSSION There is urgent public health need to improve the implementation of CM as an adjunct to medication for opioid use disorder. Consistent with its hybrid type 3 design, Project MIMIC is advancing implementation science by comparing impacts of these two multifaceted strategies on both implementation and patient outcomes, and by examining the extent to which the impacts of those strategies can be explained by putative mediators. TRIAL REGISTRATION This clinical trial has been registered with clinicaltrials.gov (NCT03931174). Registered April 30, 2019. https://clinicaltrials.gov/ct2/show/NCT03931174?term=project+mimic&draw=2&rank=1.
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Affiliation(s)
- Sara J. Becker
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Box G-S121-5, Providence, RI 02912 USA
| | - Cara M. Murphy
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Box G-S121-5, Providence, RI 02912 USA
| | - Bryan Hartzler
- Addictions, Drug, & Alcohol Institute, University of Washington, 1107 NE 45th Street, Suite 120, Seattle, WA 98105 USA
| | - Carla J. Rash
- Calhoun Cardiology Center - Behavioral Health, UConn Health, 263 Farmington Avenue, Farmington, CT 06030 USA
| | - Tim Janssen
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Box G-S121-5, Providence, RI 02912 USA
| | - Mat Roosa
- Roosa Consulting, LLC, 3 Bradford Drive, Syracuse, NY 13224 USA
| | - Lynn M. Madden
- APT Foundation, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
| | - Bryan R. Garner
- RTI International, 3040 E. Cornwallis Rd.Research Triangle Park, P.O. Box 12194, Durham, NC 27709 USA
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13
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Soyka M, Franke AG. Recent advances in the treatment of opioid use disorders–focus on long-acting buprenorphine formulations. World J Psychiatry 2021; 11:543-552. [PMID: 34631459 PMCID: PMC8474991 DOI: 10.5498/wjp.v11.i9.543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/06/2021] [Accepted: 08/04/2021] [Indexed: 02/06/2023] Open
Abstract
Oral methadone or sublingual buprenorphine are first-line medications for pharmacotherapy of opioid use disorders (OUDs). Three long-acting buprenorphine depot or implant formulations are currently available for the treatment of OUDs: (1) CAM 2038 (Buvidal) for subcutaneous weekly and monthly application; (2) RBP-6000 (Sublocade™) as a monthly depot formulation; and (3) A six-month buprenorphine implant [Probuphine™]. The pharmacology, clinical efficacy and prospects of these medications are discussed.
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Affiliation(s)
- Michael Soyka
- Psychiatric Hospital, University of Munich, München 80336, Germany
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14
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Factors Associated With Relapse in Individuals With Opioid Use Disorder Receiving Suboxone in Rural Areas. J Addict Nurs 2021; 32:20-26. [PMID: 33646714 DOI: 10.1097/jan.0000000000000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Opioid use disorder (OUD), including opioid misuse, abuse, and overdose, has evolved into a national crisis with a lasting effect on society, individuals, and health care systems. Although an office-based treatment of Suboxone combined with counseling is a viable option for individuals with OUD and has been shown to reduce utilization of medical services, the relapse rate among those individuals remains high. There is a need to investigate factors associated with relapse to tailor treatment programs in an effort to prevent relapse. This study aimed to examine factors associated with relapse in individuals with OUD receiving Suboxone. METHODS A convenience sample was recruited from an outpatient Suboxone facility located in a rural county of New York. Measures included urine drug testing obtained through the medical record, patterns of time to relapse as measured by the Time to Relapse Questionnaire, pain intensity, and a demographic questionnaire. Descriptive statistics, independent t test, and chi-square statistics were utilized for data analysis. RESULTS Forty-six patients participated in the study. Length of time in a Suboxone program, scores in sudden and long delay relapse, and the type of treatment program were statistically associated with relapse. CONCLUSION This study provided insight regarding factors contributing to relapse and different time-to-relapse styles that could be incorporated into clinical practice to help prevent relapse.
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15
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Krebs E, Homayra F, Min JE, MacDonald S, Gold L, Carter C, Nosyk B. Characterizing opioid agonist treatment discontinuation trends in British Columbia, Canada, 2012-2018. Drug Alcohol Depend 2021; 225:108799. [PMID: 34087747 DOI: 10.1016/j.drugalcdep.2021.108799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/24/2021] [Accepted: 03/27/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Given the elevated risk of mortality immediately following opioid agonist treatment (OAT) discontinuation, determining the frequency and timing of OAT discontinuation can help guide the planning of services to facilitate uninterrupted OAT. We sought to describe weekly and monthly trends in OAT episode discontinuations in British Columbia to determine the potential resource needs for implementing support services. METHODS This population-based retrospective study utilized a provincial-level linkage of health administrative databases to identify all people with opioid use disorder (PWOUD) who received OAT between 01/2012-08/2018. We defined OAT episodes as continuous medication dispensations without interruptions in prescribed doses lasting ≥5 days for methadone and ≥6 days for buprenorphine/naloxone. We derived the percentage of PWOUD discontinuing OAT every month and we considered weekly discontinuations between 09/2017-08/2018, accounting for weeks during which monthly income assistance payments from social service programs occurred. RESULTS Our study included 37,207 PWOUD discontinuing 158,027 OAT episodes. Discontinuations were relatively stable month-to-month, increasing from 10.6 % to 14.9 % (2012-2018). The monthly percentage of discontinuations was 21.2 % for buprenorphine/naloxone and 10.0 % for methadone. Weekly discontinuations were greater in income disbursement weeks (816; IQR: 752, 901) compared to other weeks (655; IQR: 615, 683; p < 0.01). CONCLUSIONS We identified a high, and stable rate of monthly OAT discontinuations and a consistently higher rate of discontinuing treatment among PWOUD accessing buprenorphine/naloxone. There is an urgent need to develop the evidence base for interventions to support OAT engagement and to improve clinical management of OUD to address the opioid-related overdose crisis.
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Affiliation(s)
- Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Fahmida Homayra
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Jeong E Min
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Sue MacDonald
- Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Leila Gold
- British Columbia Ministry of Mental Health and Addictions, Victoria, British Columbia, Canada
| | - Connie Carter
- British Columbia Ministry of Mental Health and Addictions, Victoria, British Columbia, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada.
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16
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Strout TD, Baumann MR, Wendell LT. Understanding ED Buprenorphine Initiation for Opioid Use Disorder: A Guide for Emergency Nurses. J Emerg Nurs 2021; 47:139-154. [PMID: 33390217 DOI: 10.1016/j.jen.2020.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 10/22/2022]
Abstract
Opioid use disorder is a critical public health problem that continues to broaden in scope, adversely affecting millions of people worldwide. Significant efforts have been made to expand access to medication therapy for opioid use disorder, in particular buprenorphine. As the emergency department is a critical point of access for many patients with opioid use disorder, the initiation of buprenorphine therapy in the emergency department is increasing, and emergency nurses should be familiar with the care of these vulnerable patients. The purpose of this article is to provide a clinical review of opioid use disorder and opioid withdrawal syndrome, medication treatments for opioid use disorder, best clinical practices for ED-initiated buprenorphine therapy, assessment of withdrawal symptoms, discharge considerations, and concerns for special populations. With expanded understanding of opioid use disorder, withdrawal, and available treatments, emergency nurses will be better prepared to deliver and support life-saving treatments for patients and families suffering from this disease. In addition, emergency nurses are well positioned to play an important role in public health advocacy around opioid use disorder, providing critical support for destigmatization and expanded access to safe and efficacious treatments.
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Mielau J, Vogel M, Gutwinski S, Mick I. New Approaches in Drug Dependence: Opioids. CURRENT ADDICTION REPORTS 2021; 8:298-305. [PMID: 34055568 PMCID: PMC8149259 DOI: 10.1007/s40429-021-00373-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 11/16/2022]
Abstract
Purpose of Review This article aims to provide an overview of standard and adjunctive treatment options in opioid dependence in consideration of therapy-refractory courses. The relevance of oral opioid substitution treatment (OST) and measures of harm reduction as well as heroin-assisted therapies are discussed alongside non-pharmacological approaches. Recent Findings Currently, recommendation can be given for OST with methadone, buprenorphine, slow-release oral morphine (SROM), and levomethadone. Heroin-assisted treatment using diamorphine shall be considered as a cost-effective alternative for individuals not responding to the afore-mentioned opioid agonists in order to increase retention and reduce illicit opioid use. The modalities of application and the additional benefits of long-acting formulations of buprenorphine should be sufficiently transferred to clinicians and the eligible patients; simultaneously methods to improve planning of actions and self- management need to be refined. Regarding common primary outcomes in research on opioid treatment, evidence of the effectiveness of adjunctive psychological interventions is scarce. Summary Maintaining a harm reduction approach in the treatment of opioid addiction, a larger range of formulations is available for the prescribers. Embedding the pharmacological, ideally individualized treatment into a holistic, structure-giving concept also requires a reduction of fragmentation of ancillary services available, drug policies, and treatment philosophies on a global scale.
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Affiliation(s)
- Juliane Mielau
- Department of Psychiatry and Psychotherapy, Psychiatric Hospital of Charité at St. Hedwig Hospital, Große Hamburger Straße 5- 11, 10115 Berlin, Germany
| | - Marc Vogel
- Department of Addictive Disorders, Psychiatric University Clinic Basel, Basel, Switzerland.,Department of Addictive Disorders, Psychiatric Services Thurgau, Muensterlingen, Switzerland
| | - Stefan Gutwinski
- Department of Psychiatry and Psychotherapy, Psychiatric Hospital of Charité at St. Hedwig Hospital, Große Hamburger Straße 5- 11, 10115 Berlin, Germany
| | - Inge Mick
- Department of Psychiatry and Psychotherapy, Psychiatric Hospital of Charité at St. Hedwig Hospital, Große Hamburger Straße 5- 11, 10115 Berlin, Germany
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18
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Kline A, Mattern D, Cooperman N, Williams JM, Dooley-Budsock P, Foglia R, Borys S. Opioid overdose in the age of fentanyl: Risk factor differences among subpopulations of overdose survivors. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 90:103051. [PMID: 33321284 DOI: 10.1016/j.drugpo.2020.103051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/06/2020] [Accepted: 11/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although fentanyl is the drug most frequently implicated in overdose deaths, the association between overdose risk and attitudes and behaviors surrounding fentanyl in opioid-using communities has remained understudied. Possible subpopulation differences in fentanyl-related overdose risk remain equally unexamined. This paper addresses these gaps by exploring the association between overdose and fentanyl-related attitudes/behaviors in three subpopulations of overdose survivors. METHODS In this cross-sectional study, we sampled 432 individuals who currently or recently used opioids from New Jersey methadone and acute residential detoxification programs. Using multinomial regression analysis, we compared overdose risk factors, including fentanyl-related attitudes/behaviors, of those who never overdosed with three subgroups of overdose survivors who experienced: 1. recent overdoses occurring after, but not before, fentanyl expansion; 2. past overdoses occurring before, but not after, fentanyl expansion; 3. persistent overdoses occurring before and after fentanyl expansion. RESULTS Forty percent of respondents had knowingly used fentanyl and 38% deliberately sought overdose-implicated drugs. Respondents with persistent overdoses represented under 10% of the sample but accounted for 44% of all lifetime overdoses (x̅ =8.03 vs. 1.71 for the full sample). This was also the only subgroup for whom PTSD (AOR=3.84; 95%CI=1.45-10.16; p=.01) and fentanyl-seeking (AOR=1.50; 95% CI=1.16-1.94; p=.01) were significant overdose risk factors. Those with recent overdoses engaged in frequent drug combining (AOR=2.28; 95% CI=1.19-6.98; p=.05), which could have led to inadvertent fentanyl use. Those with past overdoses were not at overdose risk from fentanyl-seeking or drug combining and had rates of methadone treatment comparable to rates of those with no overdoses. CONCLUSION Harm reduction strategies will need to address consumers' evolving drug preferences as fentanyl continues to saturate local drug markets. Targeting comprehensive interventions, including mental health treatment, to the small group of opioid users with longstanding overdose histories may reduce the burden of overdose in opioid-using communities.
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Affiliation(s)
- Anna Kline
- Rutgers-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, 317 George Street, New Brunswick, NJ 08901 United States.
| | - Dina Mattern
- Rutgers-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, 317 George Street, New Brunswick, NJ 08901 United States
| | - Nina Cooperman
- Rutgers-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, 317 George Street, New Brunswick, NJ 08901 United States
| | - Jill M Williams
- Rutgers-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, 317 George Street, New Brunswick, NJ 08901 United States
| | - Patricia Dooley-Budsock
- Rutgers-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, 317 George Street, New Brunswick, NJ 08901 United States
| | - Ralph Foglia
- Rutgers-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, 317 George Street, New Brunswick, NJ 08901 United States
| | - Suzanne Borys
- New Jersey Department of Human Services, Division of Addiction Services, 222 South Warren Street, PO Box 700, Trenton, NJ 08625-0700 United States
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Soyka M. Novel Long-Acting Buprenorphine Medications for Opioid Dependence: Current Update. PHARMACOPSYCHIATRY 2020; 54:18-22. [PMID: 33212514 DOI: 10.1055/a-1298-4508] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Opioid maintenance treatment with oral methadone or sublingual buprenorphine is the first-line treatment in opioid dependence. Three novel long-acting buprenorphine formulations have been approved or will be available soon: for subcutaneous weekly and monthly application, the depot formulations CAM 2038 (Buvidal®), the monthly depot formulation RBP-6000 (Sublocade™), and a 6-month buprenorphine implant (Probuphine™). Clinical data available so far on the efficacy of these 3 medications are given, and possible clinical implications are discussed.
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20
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Durand L, O'Driscoll D, Boland F, Keenan E, Ryan BK, Barry J, Bennett K, Fahey T, Cousins G. Do interruptions to the continuity of methadone maintenance treatment in specialist addiction settings increase the risk of drug-related poisoning deaths? A retrospective cohort study. Addiction 2020; 115:1867-1877. [PMID: 32034837 PMCID: PMC7540578 DOI: 10.1111/add.15004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/02/2019] [Accepted: 02/05/2020] [Indexed: 12/01/2022]
Abstract
AIMS To examine the risk of mortality associated with interruptions to the continuity of methadone maintenance treatment (MMT), including transfers between services, in opioid-dependent individuals attending specialist addiction services. DESIGN Retrospective cohort study using addiction services and primary care dispensing records, the National Methadone Register and National Drug-Related Death Index (NDRDI). SETTING Geographically defined population in Dublin, Ireland. PARTICIPANTS A total of 2899 people prescribed and dispensed methadone in specialist addiction services between January 2010 and December 2015. There were five exposure groups: weeks 1-4 following transfer between treatment providers; weeks 1-4 out of treatment; weeks 5-52 out of treatment; weeks 1-4 of treatment initiation; and weeks 5+ of continuous treatment (reference category). MEASUREMENTS Primary outcome: drug-related poisoning (DRP) deaths. Secondary outcome: all-cause mortality (ACM). Mortality rates calculated by dividing number of deaths (DRP; ACM) in exposure groups by person-years exposure. Unadjusted and adjusted Poisson regression (covariates age, sex, incarceration, methadone dose and comorbidities) estimated differences in mortality rates. FINDINGS There were 154 ACM deaths, 55 (35.7%) identified as DRP deaths. No deaths were observed in the first month following transfer between treatment providers. The risk of DRP mortality was highest in weeks 1-4 out of treatment [adjusted relative risk (aRR = 4.04, 95% confidence interval (CI) = 1.43-11.43, P = 0.009] and weeks 1-4 of treatment initiation (ARR = 3.4, 95% CI = 1.2-9.64, P = 0.02). Similarly, risk of ACM was highest in weeks 1-4 out of treatment (ARR = 11.78, 95% CI = 7.73-17.94, P < 0.001), weeks 1-4 of treatment initiation (aRR = 5.11, 95% CI = 2.95-8.83, P < 0.001) and weeks 5-52 off treatment (aRR = 2.04, 95% CI = 1.2-3.47, P = 0.009). CONCLUSIONS Interruptions to the continuity of methadone maintenance treatment by treatment provider do not appear to be periods of risk for drug-related poisoning or all-cause mortality deaths. Risk of drug related poisoning and all-cause mortality deaths appears to be greatest during the first 4 weeks of treatment initiation/re-initiation and after treatment cessation.
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Affiliation(s)
- Louise Durand
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | | | - Fiona Boland
- HRB Centre for Primary Care ResearchRoyal College of Surgeons in IrelandDublinIreland
| | - Eamon Keenan
- HSE National Social Inclusion Office, Stewarts HospitalDublinIreland
| | - Benedict K. Ryan
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Joseph Barry
- Department of Public Health and Primary CareTrinity College DublinIreland
| | - Kathleen Bennett
- Division of Population Health SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Tom Fahey
- Department of General Practice and HRB Centre for Primary Care ResearchRoyal College of Surgeons in IrelandDublinIreland
| | - Gráinne Cousins
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
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21
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Piske M, Thomson T, Krebs E, Hongdilokkul N, Bruneau J, Greenland S, Gustafson P, Karim ME, McCandless LC, Maclure M, Platt RW, Siebert U, Socías ME, Tsui JI, Wood E, Nosyk B. Comparative effectiveness of buprenorphine-naloxone versus methadone for treatment of opioid use disorder: a population-based observational study protocol in British Columbia, Canada. BMJ Open 2020; 10:e036102. [PMID: 32912944 PMCID: PMC7482450 DOI: 10.1136/bmjopen-2019-036102] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Despite a recent meta-analysis including 31 randomised controlled trials comparing methadone and buprenorphine for the treatment of opioid use disorder, important knowledge gaps remain regarding the long-term effectiveness of different treatment modalities across individuals, including rigorously collected data on retention rates and other treatment outcomes. Evidence from real-world data represents a valuable opportunity to improve personalised treatment and patient-centred guidelines for vulnerable populations and inform strategies to reduce opioid-related mortality. Our objective is to determine the comparative effectiveness of methadone versus buprenorphine/naloxone, both overall and within key populations, in a setting where both medications are simultaneously available in office-based practices and specialised clinics. METHODS AND ANALYSIS We propose a retrospective cohort study of all adults living in British Columbia receiving opioid agonist treatment (OAT) with methadone or buprenorphine/naloxone between 1 January 2008 and 30 September 2018. The study will draw on seven linked population-level administrative databases. The primary outcomes include retention in OAT and all-cause mortality. We will determine the effectiveness of buprenorphine/naloxone vs methadone using intention-to-treat and per-protocol analyses-the former emulating flexible-dose trials and the latter focusing on the comparison of the two medication regimens offered at the optimal dose. Sensitivity analyses will be used to assess the robustness of results to heterogeneity in the patient population and threats to internal validity. ETHICS AND DISSEMINATION The protocol, cohort creation and analysis plan have been approved and classified as a quality improvement initiative exempt from ethical review (Providence Health Care Research Institute and the Simon Fraser University Office of Research Ethics). Dissemination is planned via conferences and publications, and through direct engagement and collaboration with entities that issue clinical guidelines, such as professional medical societies and public health organisations.
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Affiliation(s)
- Micah Piske
- Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Trevor Thomson
- Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Emanuel Krebs
- Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Natt Hongdilokkul
- Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Julie Bruneau
- Centre hospitalier de l'Université de Montréal, CRCHUM, Montreal, Quebec, Canada
- Département de médecine de famille et de médecine d'urgence, Universite de Montreal, Montreal, Quebec, Canada
| | - Sander Greenland
- Department of Epidemiology and Department of Statistics, UCLA, Los Angeles, California, USA
| | - Paul Gustafson
- Department of Statistics, UBC, Vancouver, British Columbia, Canada
| | - M Ehsan Karim
- School of Population and Public Health, UBC, Vancouver, British Columbia, Canada
- Providence Health Care Research Institute, Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Lawrence C McCandless
- Department of Statstics and Actuarial Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, UBC, Vancouver, British Columbia, Canada
| | - Robert W Platt
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Uwe Siebert
- Department of Health Policy and Management, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Tirol, Austria
- Oncotyrol - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - M Eugenia Socías
- BC Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, Faculty of Medicine, UBC, Vancouver, Briitish Columbia, Canada
| | - Judith I Tsui
- Department of Medicine, Section of General Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Evan Wood
- BC Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, Faculty of Medicine, UBC, Vancouver, Briitish Columbia, Canada
| | - Bohdan Nosyk
- Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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22
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Piske M, Zhou H, Min JE, Hongdilokkul N, Pearce LA, Homayra F, Socias ME, McGowan G, Nosyk B. The cascade of care for opioid use disorder: a retrospective study in British Columbia, Canada. Addiction 2020; 115:1482-1493. [PMID: 31899565 DOI: 10.1111/add.14947] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/16/2019] [Accepted: 12/20/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS The 'cascade of care' framework, measuring attrition at various stages of care engagement, has been proposed to guide the public health response to the opioid overdose public health emergency in British Columbia, Canada. We estimated the cascade of care for opioid use disorder and identified factors associated with care engagement for people with opioid use disorder (PWOUD) provincially. DESIGN Retrospective study using a provincial-level linkage of four health administrative databases. SETTING AND PARTICIPANTS All PWOUD in BC from 1 January 1996 to 30 November 2017. MEASUREMENTS The eight-stage cascade of care included diagnosed PWOUD, ever on opioid agonist treatment (OAT), recently on OAT, currently on OAT and retained on OAT: ≥ 1, ≥ 3, ≥ 12 and ≥ 24 months). Health-care use, homelessness and other demographics were obtained from physician billing records, hospitalizations, and drug dispensation records. Receipt of income assistance was indicated by enrollment in Pharmacare Plan C. FINDINGS A total of 55 470 diagnosed PWOUD were alive at end of follow-up. As of 2017, a majority of the population (n = 39 456; 71%) received OAT during follow-up; however, only 33% (n = 18 519) were currently engaged in treatment and 16% (n = 8960) had been retained for at least 1 year. Compared with those never on OAT, those currently engaged in OAT were more likely to be aged under 45 years [adjusted odds ratio (aOR) = 1.75, 95% confidence interval (CI) = 1.64, 1.89], male (aOR = 1.72, 95% CI = 1.64, 1.82), with concurrent substance use disorders (aOR = 2.56, 95% CI = 2.44, 2.70), hepatitis C virus (HCV) (aOR = 1.22, 95% CI = 1.14, 1.33) and either homeless or receiving income-assistance (aOR = 4.35, 95% CI = 4.17, 4.55). Regular contact with the health-care system-either in out-patient or acute care settings-was common among PWOUD not engaged in OAT, regardless of time since diagnosis or treatment discontinuation. CONCLUSIONS People with opioid use disorder in British Columbia, Canada show high levels of out-patient care prior to diagnosis. Younger age, male sex, urban residence, lower income level and homelessness appear to be independently associated with increased opioid agonist treatment engagement.
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Affiliation(s)
- Micah Piske
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Haoxuan Zhou
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Jeong E Min
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | | | | | | | - M Eugenia Socias
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,BC Centre on Substance Use, Vancouver, BC, Canada
| | - Gina McGowan
- British Columbia Ministry of Mental Health and Addictions, Victoria, BC, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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23
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Kelty E, Hulse G, Joyce D, Preen DB. Impact of Pharmacological Treatments for Opioid Use Disorder on Mortality. CNS Drugs 2020; 34:629-642. [PMID: 32215842 DOI: 10.1007/s40263-020-00719-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of pharmacological treatments for opioid use disorders, including methadone, buprenorphine and naltrexone has been associated with a reduction in mortality compared with illicit opioid use. However, these treatments can also contribute significantly to the risk of death. The opioid agonists methadone and buprenorphine achieve clinical efficacy in patients with an opioid use disorder through suppressing craving and diminishing the effectiveness of illicit opioid doses, while the antagonist naltrexone blocks the action of opioids. Pharmacological differences between opioid pharmacotherapies then create different temporal patterns of protection and mortality risk, different risks of relapse to illicit opioid use, and variations in direct and indirect toxicity, which are revealed in clinical and epidemiological studies. Induction onto methadone and the cessation of oral naltrexone treatment are associated with an elevated risk of opioid poisoning, which is not apparent in patients treated with buprenorphine or sustained-release naltrexone. Beyond drug-related mortality, these pharmacotherapies can impact a participant's risk of death. Buprenorphine may also have some advantages over methadone in patients with depressive disorders or cardiovascular abnormalities. Naltrexone, which is also commonly prescribed to manage problem alcohol use, may reduce deaths in chronic co-alcohol users. Understanding these pharmacologically driven patterns then guides the judicious choice of drug and dosing schedule and the proactive risk management that is crucial to minimising the risk of death in treatment.
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Affiliation(s)
- Erin Kelty
- School of Population and Global Health, The University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA, 6009, Australia.
| | - Gary Hulse
- Division of Psychiatry, Medical School, The University of Western Australia, Perth, WA, Australia.,Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia
| | - David Joyce
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - David B Preen
- School of Population and Global Health, The University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA, 6009, Australia
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24
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Donroe JH, Bhatraju EP, Tsui JI, Edelman EJ. Identification and Management of Opioid Use Disorder in Primary Care: an Update. Curr Psychiatry Rep 2020; 22:23. [PMID: 32285215 DOI: 10.1007/s11920-020-01149-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs. RECENT FINDINGS The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.
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Affiliation(s)
- Joseph H Donroe
- Yale School of Medicine, 1450 Chapel Street, Office MOB211, New Haven, CT, 06511, USA.
| | | | - Judith I Tsui
- University of Washington School of Medicine, Seattle, WA, USA
| | - E Jennifer Edelman
- Yale School of Medicine, 1450 Chapel Street, Office MOB211, New Haven, CT, 06511, USA.,Yale Schools of Medicine and Public Health, E.S. Harkness Memorial Hall, Building A, 367 Cedar Street, Ste Suite 401, New Haven, CT, 06510, USA
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25
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Carroll KM, Weiss RD. The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2020; 17:183-192. [PMID: 32021588 DOI: 10.1176/appi.focus.17206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
(Reprinted with permission from Am J Psychiatry 2017;174:738-747).
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Affiliation(s)
- Kathleen M Carroll
- Department of Psychiatry, Yale University School of Medicine, West Haven, Conn.; the Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Mass.; and the Department of Psychiatry, Harvard Medical School, Boston
| | - Roger D Weiss
- Department of Psychiatry, Yale University School of Medicine, West Haven, Conn.; the Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Mass.; and the Department of Psychiatry, Harvard Medical School, Boston
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26
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Homayra F, Hongdilokkul N, Piske M, Pearce LA, Zhou H, Min JE, Krebs E, Nosyk B. Determinants of selection into buprenorphine/naloxone among people initiating opioid agonist treatment in British Columbia. Drug Alcohol Depend 2020; 207:107798. [PMID: 31927163 DOI: 10.1016/j.drugalcdep.2019.107798] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Studies assessing the comparative effectiveness of methadone versus buprenorphine/naloxone for opioid use disorder in real-world settings are rare - challenged by structural differences in delivery across settings and factors influencing treatment selection. We identified determinants of selection into buprenorphine/naloxone and quantified contributions of individual and provider-level covariates in a setting delivering both medications within the same healthcare settings. METHODS Utilizing linked health administrative datasets, we conducted a retrospective cohort study of people with opioid use disorder (PWOUD) receiving opioid agonist treatment (OAT) in British Columbia, Canada, from 2008-2017. Determinants of buprenorphine/naloxone selection were identified using a generalized linear mixed model with random intercept terms for providers and individuals. We determined the influence of individual demographics, clinical history, measures of provider experience and preference, and dates of key policy changes. RESULTS A total of 39,605 individuals experienced 178,976 OAT episodes (methadone:139,439(77.9 %);buprenorphine/naloxone:39,537(22.1 %)). Male sex, less OAT experience, younger age, mental health conditions and chronic pain were associated with higher odds of buprenorphine/naloxone prescription. For providers, higher client-attachment, more complex OAT case-mixes, and higher buprenorphine/naloxone prescribing-preference were also associated with higher odds of buprenorphine/naloxone prescription. Observed individual-level covariates explained 9.7 % of variance in odds of buprenorphine/naloxone selection, while observed provider-level covariates explained 20.0 %. Controlling for covariates, residual unmeasured between-individual variance accounted for 18.5 % of the explained variation in the odds of buprenorphine/naloxone selection, while unmeasured between-provider variance accounted for 28.4 %. CONCLUSION Provider characteristics were more influential in selection of buprenorphine/naloxone over methadone informing subsequent analyses of comparative effectiveness of these regimens.
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Affiliation(s)
- F Homayra
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - N Hongdilokkul
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - M Piske
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - L A Pearce
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - H Zhou
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - J E Min
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - E Krebs
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - B Nosyk
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 9706, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
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27
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Saunders EC, Moore SK, Walsh O, Metcalf SA, Budney AJ, Scherer E, Marsch LA. Perceptions and preferences for long-acting injectable and implantable medications in comparison to short-acting medications for opioid use disorders. J Subst Abuse Treat 2020; 111:54-66. [PMID: 32076361 DOI: 10.1016/j.jsat.2020.01.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aim Treatment for opioid use disorders has recently evolved to include long-acting injectable and implantable formulations of medications for opioid use disorder (MOUD). Incorporating patient preferences into treatment for substance use disorders is associated with increased motivation and treatment satisfaction. This study sought to assess treatment preferences for long-acting injectable and implantable MOUD as compared to short-acting formulations among individuals with OUD. Methods We conducted qualitative, semi-structured telephone interviews with forty adults recruited from across the United States through Craigslist advertisements and flyers posted in treatment programs. Eligible participants scored a two or greater on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool, indicative of a past-year OUD. Interviews were transcribed, coded, and thematically analyzed. Results Twenty-four participants (60%) currently or previously had been prescribed MOUD. Sixteen participants (40%) expressed general opposition to MOUD, citing concerns that MOUD is purely financial gain for pharmaceutical companies and/or a "band aid" solution replacing one drug with another, rather than a path to abstinence. Some participants expressed personal preference for long-acting injectable (n = 16/40: 40%) and implantable formulations (n = 12/40: 30%) over short-acting formulations. About half of the participants were not willing to use injectables (n = 19/40: 48%) or implantables (n = 22/40: 55%), preferring short-acting formulations. Mixed evaluations of long- and short-acting MOUD focused on considerations of medication-related beliefs (privacy, concern over an embedded foreign body), the medication-related burden (convenience, provision of structure and support, medication administration, potential side effects), and medication-taking practices (potential for non-prescribed use, control over dosage, and duration of treatment). Conclusions Though many participants personally prefer short-acting to long-acting MOUD, some were open to including long-acting formulations in the range of options for those with OUD. Participants felt long-acting formulations may reduce medication-related burden and the risk of diversion. Conversely, participants expressed concern about invasive administration and loss of control over their treatment. Results suggest support for expanded access to a variety of formulations of MOUD. The use of shared decision making may also help patients select the formulation best aligned with their experiences, values, and treatment goals.
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Affiliation(s)
- Elizabeth C Saunders
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| | - Sarah K Moore
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire, USA
| | - Olivia Walsh
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire, USA
| | - Stephen A Metcalf
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire, USA
| | - Alan J Budney
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire, USA
| | - Emily Scherer
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire, USA
| | - Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire, USA
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28
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Rozylo J, Mitchell K, Nikoo M, Durante SE, Barbic SP, Lin D, Mathias S, Azar P. Case report: Successful induction of buprenorphine/naloxone using a microdosing schedule and assertive outreach. Addict Sci Clin Pract 2020; 15:2. [PMID: 31941547 PMCID: PMC6964069 DOI: 10.1186/s13722-020-0177-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 01/04/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The requirement for moderate withdrawal prior to initiation can be a barrier to buprenorphine/naloxone induction. CASE PRESENTATION We aimed to use a microdosing regimen to initiate regular dosing of buprenorphine/naloxone in a high-risk patient with a history of failed initiations due, in part, to withdrawal symptoms. Using an assertive outreach model and a buprenorphine/naloxone microdosing schedule, we initiated treatment of an individual's opioid use disorder. There was a successful buprenorphine/naloxone microdosing induction as the team reached a therapeutic dose of buprenorphine/naloxone. Including the induction period, the medication was used consistently for 4 weeks. CONCLUSIONS A microdosing schedule can be used to induce a patient onto buprenorphine/naloxone with no apparent withdrawal; gradually reducing illicit substance use. This case report builds on previous literature, highlighting ways to minimize barriers to induction of buprenorphine/naloxone, using a microdosing schedule and assertive outreach. Given the safety profile of buprenorphine and its potential to be a lifesaving intervention, a larger study of microdosing is indicated.
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Affiliation(s)
| | - Keren Mitchell
- University of British Columbia, Vancouver, BC, Canada
- Inner City Youth Program, Providence Health Care, Vancouver, BC, Canada
- Foundry, Providence Health Care, Vancouver, BC, Canada
- St Paul's Hospital, Vancouver, BC, Canada
| | - Mohammadali Nikoo
- University of British Columbia, Vancouver, BC, Canada
- Addiction and Concurrent Disorders Group, Institute of Mental Health, University of British Columbia, Vancouver, BC, Canada
| | - S Elise Durante
- Inner City Youth Program, Providence Health Care, Vancouver, BC, Canada
- Foundry, Providence Health Care, Vancouver, BC, Canada
| | - Skye P Barbic
- University of British Columbia, Vancouver, BC, Canada
- Inner City Youth Program, Providence Health Care, Vancouver, BC, Canada
- Foundry, Providence Health Care, Vancouver, BC, Canada
- St Paul's Hospital, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Daniel Lin
- University of British Columbia, Vancouver, BC, Canada
- Inner City Youth Program, Providence Health Care, Vancouver, BC, Canada
- Foundry, Providence Health Care, Vancouver, BC, Canada
- St Paul's Hospital, Vancouver, BC, Canada
| | - Steve Mathias
- University of British Columbia, Vancouver, BC, Canada
- Inner City Youth Program, Providence Health Care, Vancouver, BC, Canada
- Foundry, Providence Health Care, Vancouver, BC, Canada
- St Paul's Hospital, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Pouya Azar
- University of British Columbia, Vancouver, BC, Canada.
- Inner City Youth Program, Providence Health Care, Vancouver, BC, Canada.
- Foundry, Providence Health Care, Vancouver, BC, Canada.
- St Paul's Hospital, Vancouver, BC, Canada.
- Vancouver General Hospital, DHCC, Floor 8-2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
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29
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Wiercigroch D, Sheikh H, Hulme J. A rapid access to addiction medicine clinic facilitates treatment of substance use disorder and reduces substance use. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2020; 15:4. [PMID: 31931831 PMCID: PMC6958640 DOI: 10.1186/s13011-019-0250-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 12/30/2019] [Indexed: 01/14/2023]
Abstract
Background Substance use is prevalent in Canada, yet treatment is inaccessible. The Rapid Access to Addiction Medicine (RAAM) clinic opened at the University Health Network (UHN) in January 2018 as part of a larger network of addictions clinics in Toronto, Ontario, to enable timely, low barrier access to medical treatment for substance use disorder (SUD). Patients attend on a walk-in basis without requiring an appointment or referral. We describe the RAAM clinic model, including referral patterns, patient demographics and substance use patterns. Secondary outcomes include retention in treatment and changes in both self-reported and objective substance use. Methods The Electronic Medical Record at the clinic was reviewed for the first 26 weeks of the clinic’s operation. We identified SUD diagnoses, referral source, medications prescribed, retention in care and self-reported substance use. Results The clinic saw 64 unique patients: 66% had alcohol use disorder (AUD), 39% had opiate use disorder (OUD) and 20% had stimulant use disorder. Fifty-five percent of patients were referred from primary care providers, 30% from the emergency department and 11% from withdrawal management services. Forty-two percent remained on-going patients, 23% were discharged to other care and 34% were lost to follow-up. Gabapentin (39%), naltrexone (39%), and acamprosate (15%) were most frequently prescribed for AUD. Patients with AUD reported a significant decrease in alcohol consumption at their most recent visit. Most patients (65%) with OUD were prescribed buprenorphine, and most patients with OUD (65%) had a negative urine screen at their most recent visit. Conclusion The RAAM model provides low-barrier, accessible outpatient care for patients with substance use disorder and facilitates the prescription of evidence-based pharmacotherapy for AUD and OUD. Patients referred by their primary care physician and the emergency department demonstrated a reduction in median alcohol consumption and high rates of opioid abstinence.
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Affiliation(s)
- David Wiercigroch
- Faculty of Medicine, University of Toronto, 1 King's College Cir, Toronto, Ontario, M5S 1A8, Canada. .,Global Health Emergency Medicine, Toronto General Hospital, 200 Elizabeth Street, 12NU-1320, Toronto, ON, M5G 2C4, Canada.
| | - Hasan Sheikh
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, Ontario, M5G 1V7, Canada.,Emergency Department, University Health Network, 200 Elizabeth Street, R. Fraser Elliott Building, Ground Floor, Room 480, Toronto, ON, M5G 2C4, Canada
| | - Jennifer Hulme
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, Ontario, M5G 1V7, Canada.,Emergency Department, University Health Network, 200 Elizabeth Street, R. Fraser Elliott Building, Ground Floor, Room 480, Toronto, ON, M5G 2C4, Canada
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30
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Bell J, Strang J. Medication Treatment of Opioid Use Disorder. Biol Psychiatry 2020; 87:82-88. [PMID: 31420089 DOI: 10.1016/j.biopsych.2019.06.020] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 06/25/2019] [Accepted: 06/25/2019] [Indexed: 12/19/2022]
Abstract
Opioid use disorder (OUD) is a chronic, relapsing condition, often associated with legal, interpersonal, and employment problems. Medications demonstrated to be effective for OUD are methadone (a full opioid agonist), buprenorphine (a partial agonist), and naltrexone (an opioid antagonist). Methadone and buprenorphine act by suppressing opioid withdrawal symptoms and attenuating the effects of other opioids. Naltrexone blocks the effects of opioid agonists. Oral methadone has the strongest evidence for effectiveness. Longer duration of treatment allows restoration of social connections and is associated with better outcomes. Treatments for OUD may be limited by poor adherence to treatment recommendations and by high rates of relapse and increased risk of overdose after leaving treatment. Treatment with methadone and buprenorphine has the additional risk of diversion and misuse of medication. New depot and implant formulations of buprenorphine and naltrexone have been developed to address issues of safety and problems of poor treatment adherence. For people with OUD who do not respond to these treatments, there is accumulating evidence for supervised injectable opioid treatment (prescribing pharmaceutical heroin). Another medication mode of minimizing risk of overdose is take-home naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose, and take-home naloxone programs aim to prevent fatal overdose. All medication-assisted treatment is limited by lack of access and by stigma. In seeking to stem the rising toll from OUD, expanding access to approved treatment such as methadone, for which there remains the best evidence of efficacy, may be the most useful approach.
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Affiliation(s)
- James Bell
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
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Emergency Department Initiation of Buprenorphine for Opioid Use Disorder: Current Status, and Future Potential. CNS Drugs 2019; 33:1147-1154. [PMID: 31552608 DOI: 10.1007/s40263-019-00667-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients experiencing the consequences of opioid use often present to the emergency department (ED) at times of crisis, such as following overdose or when in withdrawal. This highlights the important role of the ED in recognizing opioid use disorder and engaging these patients into ongoing treatment. Given the limited ability of the healthcare system to provide timely addiction treatment, initiation of therapy in the ED, with referral to long-term care, is associated with improved outcomes. The primary evidence-based treatment used in EDs for this indication is buprenorphine. Although clinicians may find the initiation of buprenorphine therapy daunting, it is straightforward and well-tolerated, and many of the barriers are surmountable. This article addresses these barriers, which include stigma, complicated pharmacology, and confusing regulations, and provides a basis for the use of buprenorphine in acute care clinical practice.
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Evans EA, Yoo C, Huang D, Saxon AJ, Hser YI. Effects of access barriers and medication acceptability on buprenorphine-naloxone treatment utilization over 2 years: Results from a multisite randomized trial of adults with opioid use disorder. J Subst Abuse Treat 2019; 106:19-28. [PMID: 31540607 PMCID: PMC6756169 DOI: 10.1016/j.jsat.2019.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/03/2019] [Accepted: 08/06/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Nationwide efforts seek to address the opioid epidemic by increasing access to medications for opioid use disorder (OUD), particularly with buprenorphine. A poorly understood challenge is that among individuals with OUD who do receive buprenorphine, many do not adhere to the pharmacotherapy long enough to achieve sustained benefits. We aimed to identify factors associated with buprenorphine treatment utilization over time. METHODS We used random-intercept modeling to identify factors associated with buprenorphine treatment utilization over 2 years after first follow-up by 789 individuals with OUD who had participated in a multi-site randomized clinical trial of buprenorphine compared to methadone. Key predictors were participants' reports of buprenorphine treatment accessibility and acceptability (assessed at first follow-up) and their interaction effects, controlling for baseline randomization status, sociodemographics, and other covariates. RESULTS Approximately 9.3-11.2% of participants utilized buprenorphine treatment over the 2 years of follow-up. Interaction effects indicated that individuals who perceived buprenorphine to be both accessible and acceptable were most likely to use buprenorphine during follow-up, controlling for other factors. In contrast, individuals who perceived buprenorphine to be unacceptable were least likely to use buprenorphine, regardless the level of perceived access to the medication. Buprenorphine treatment utilization was also negatively associated with Hispanic ethnicity, West coast context, and cumulative months receiving methadone treatment and incarceration during follow-up. CONCLUSIONS To engage more individuals with OUD in long-term treatment with buprenorphine, interventions should target buprenorphine treatment acceptability, in addition to increasing buprenorphine access, and tailor efforts to meet the needs of vulnerable populations. TRIAL REGISTRATION The START Follow-up Study on ClinicalTrials.gov (NCT01592461).
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Affiliation(s)
- Elizabeth A Evans
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, 312 Arnold House, 715 North Pleasant St. Amherst, MA 01003, USA.
| | - Caroline Yoo
- UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, 11075 Santa Monica Blvd. Ste 200, Los Angeles, CA 90024. USA.
| | - David Huang
- UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, 11075 Santa Monica Blvd. Ste 200, Los Angeles, CA 90024. USA.
| | - Andrew J Saxon
- Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA.
| | - Yih-Ing Hser
- UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, 11075 Santa Monica Blvd. Ste 200, Los Angeles, CA 90024. USA.
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Borodovsky JT, Levy S, Fishman M, Marsch LA. Buprenorphine Treatment for Adolescents and Young Adults With Opioid Use Disorders: A Narrative Review. J Addict Med 2019; 12:170-183. [PMID: 29432333 PMCID: PMC5970018 DOI: 10.1097/adm.0000000000000388] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
: In the past decade, a new cohort of adolescents and young adults with opioid use disorders (OUD) has emerged. While medications and psychosocial treatments are available, few adolescents and young adults with OUD can access and remain in treatment. Effective, practical, and scalable treatment paradigms for this young population are needed. Buprenorphine is a medication with unique pharmacological and regulatory characteristics that make it a promising component of adolescent and young adult OUD treatment models. Three randomized controlled trials and multiple observational studies have evaluated the use of buprenorphine to treat this population. However, data from these studies have not been consolidated into an up-to-date summary that may be useful to clinicians. The objective of this narrative review is to inform clinical practice by summarizing results of primary and secondary analyses from randomized controlled clinical trials and observational studies that have evaluated the use of buprenorphine to treat adolescents and young adults with OUD. Based on results from these studies, we encourage the conceptualization of OUD among youth as a chronic medical condition requiring a long-term management strategy. This includes treatment with buprenorphine in conjunction with medication-prescribing protocols that do not necessarily require daily clinic attendance for observed medication adherence. However, more study of treatment delivery models, addressing such issues as medication adherence and intensity requirements, is needed to determine practices that optimize outcomes for youth.
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Affiliation(s)
- Jacob T. Borodovsky
- Center for Technology and Behavioral Health, Dartmouth Geisel School
of Medicine, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice,
Dartmouth Geisel School of Medicine, Lebanon, NH
| | - Sharon Levy
- Adolescent Substance Abuse Program, Boston Children's
Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Marc Fishman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins
University School of Medicine, Baltimore, MD
- Maryland Treatment Centers, Baltimore, MD
| | - Lisa A. Marsch
- Center for Technology and Behavioral Health, Dartmouth Geisel School
of Medicine, Lebanon, NH
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Manhapra A, Stefanovics E, Rosenheck R. Initiating opioid agonist treatment for opioid use disorder nationally in the Veterans Health Administration: Who gets what? Subst Abus 2019; 41:110-120. [PMID: 31403914 DOI: 10.1080/08897077.2019.1640831] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background: Despite substantial benefits associated with opioid agonist treatment (OAT) with buprenorphine and methadone for opioid use disorder (OUD), only a small proportion of patients with OUD initiate OAT. There is a lack of studies addressing the correlates of OAT initiation among patients with OUD. Methods: Using Veterans Health Administration (VHA) national administrative data, we identified veterans with OUD who started OAT with either buprenorphine or methadone maintenance treatment (MMT) in fiscal year (FY) 2012 (first prescription of buprenorphine or first methadone clinic visit after the first 60 days of FY) and those who received no OAT that year. Multivariate logistic regression models including sociodemographic characteristics, diagnoses, and service and psychotropic drug use variables were used to identify independent predictors of OAT initiation. Results: Greater age (10-year increments; odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.0.9-0.97) and black race (OR: 0.46, 95% CI: 0.38-0.55) were associated with lower odds of being started on buprenorphine compared with no OAT, but not with MMT initiation. Veterans with cocaine and anxiolytic-sedative hypnotic use disorders had higher odds of being started on both buprenorphine and methadone compared with no OAT. Receipt of any mental health inpatient treatment was associated with higher odds of being started on buprenorphine but not methadone. Overall, we were unable to identify a robust set of patient characteristics associated with initiation of OAT. Conclusion: This study points out the stark reality that in the middle of an opioid crisis, we have very little insight into which patients with OUD initiate OAT.
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Affiliation(s)
- Ajay Manhapra
- VA New England Mental Illness Research and Education Center, West Haven, Connecticut, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,Advanced PACT Pain Clinic, VA Hampton Medical Center, Hampton, Virginia, USA.,Department of Physical Medicine and Rehabilitation, Eastern Virginia Medical School, Norfolk, Virginia, USA.,Department of Psychiatry, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Elina Stefanovics
- VA New England Mental Illness Research and Education Center, West Haven, Connecticut, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robert Rosenheck
- VA New England Mental Illness Research and Education Center, West Haven, Connecticut, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
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Chang HY, Krawczyk N, Schneider KE, Ferris L, Eisenberg M, Richards TM, Lyons BC, Jackson K, Weiner JP, Saloner B. A predictive risk model for nonfatal opioid overdose in a statewide population of buprenorphine patients. Drug Alcohol Depend 2019; 201:127-133. [PMID: 31207453 PMCID: PMC6713520 DOI: 10.1016/j.drugalcdep.2019.04.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Predicting which individuals who are prescribed buprenorphine for opioid use disorder are most likely to experience an overdose can help target interventions to prevent relapse and subsequent consequences. METHODS We used Maryland prescription drug monitoring data from 2015 to identify risk factors for nonfatal opioid overdoses that were identified in hospital discharge records in 2016. We developed a predictive risk model for prospective nonfatal opioid overdoses among buprenorphine patients (N = 25,487). We estimated a series of models that included demographics plus opioid, buprenorphine and benzodiazepine prescription variables. We applied logistic regression to generate performance measures. RESULTS About 3.24% of the study cohort had ≥1 nonfatal opioid overdoses. In the model with all predictors, odds of nonfatal overdoses among buprenorphine patients were higher among males (OR = 1.39, 95% CI:1.21-1.62) and those with more buprenorphine pharmacies (OR = 1.19, 95% CI:1.11-1.28), 1+ buprenorphine prescription paid by Medicaid (OR = 1.21, 95% CI:1.02-1.48), Medicare (OR = 1.93, 95% CI:1.63-2.43), or a commercial plan (OR = 1.98, 95% CI:1.30-2.89), 1+ opioid prescription paid by Medicare (OR = 1.30, 95% CI:1.03-1.68), and more benzodiazepine prescriptions (OR = 1.04, 95% CI:1.02-1.05). The odds were lower among those with longer days of buprenorphine (OR = 0.64, 95% CI:0.60-0.69) or opioid (OR = 0.79, 95% CI:0.65-0.95) supply. The model had moderate predictive ability (c-statistic = 0.69). CONCLUSIONS Several modifiable risk factors, such as length of buprenorphine treatment, may be targets for interventions to improve clinical care and reduce harms. This model could be practically implemented with common prescription-related information and allow payers and clinical systems to better target overdose risk reduction interventions, such as naloxone distribution.
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Affiliation(s)
- Hsien-Yen Chang
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; Johns Hopkins Center for Population Health Information Technology, Baltimore, MD, USA; Johns Hopkins Center for Drug Safety and Effectiveness, Baltimore, MD, USA.
| | - Noa Krawczyk
- Johns Hopkins Bloomberg School of Public Health, Department of Mental Health, Baltimore, MD, USA.
| | - Kristin E Schneider
- Johns Hopkins Bloomberg School of Public Health, Department of Mental Health, Baltimore, MD, USA.
| | - Lindsey Ferris
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; The Chesapeake Regional Information System for our Patients, Baltimore, MD, USA.
| | - Matthew Eisenberg
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA.
| | - Tom M Richards
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; Johns Hopkins Center for Population Health Information Technology, Baltimore, MD, USA.
| | - B Casey Lyons
- Maryland Department of Health, Public Health Services, Office of PDMP and Overdose Prevention Applied Data Programs, Baltimore, MD, USA.
| | - Kate Jackson
- Maryland Department of Health, Public Health Services, Office of PDMP and Overdose Prevention Applied Data Programs, Baltimore, MD, USA.
| | - Jonathan P Weiner
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; Johns Hopkins Center for Population Health Information Technology, Baltimore, MD, USA.
| | - Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA.
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Meinhofer A, Williams AR, Johnson P, Schackman BR, Bao Y. Prescribing decisions at buprenorphine treatment initiation: Do they matter for treatment discontinuation and adverse opioid-related events? J Subst Abuse Treat 2019; 105:37-43. [PMID: 31443889 DOI: 10.1016/j.jsat.2019.07.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/11/2019] [Accepted: 07/19/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Buprenorphine is a highly effective medication treatment for opioid use disorder (OUD) that can be prescribed in multiple treatment settings. Treatment retention, however, remains a challenge. In this study, we examined the association of days of supply as well as daily dosage of the initial buprenorphine prescription with treatment discontinuation and adverse opioid-related events following buprenorphine initiation. METHODS 2011 to 2015 Health Care Cost Institute commercial claims data were analyzed for individuals aged 18-64 years initiating buprenorphine treatment (N = 17,158). Treatment discontinuation was defined as a gap of 30 days or more in buprenorphine use within 180 days of initiation. Adverse opioid-related events were defined as having at least one emergency department visit or inpatient admission involving opioid poisoning, dependence or abuse within 360 days of initiation. We conducted multivariate logistic regressions to estimate adjusted odds ratios of outcomes associated with daily dose (≤4 mg vs. >4 mg) and days of supply (≤7, 8-15, 16-27, or ≥ 28 days) of the initial buprenorphine prescription. RESULTS Over one-half (55%) of individuals discontinued buprenorphine within 180 days and 13% experienced at least one adverse opioid-related event within 360 days of initiation. Both a lower initial dose [≤4 mg, OR = 1.79, p < 0.01] and fewer initial days of supply [≤7 days vs. ≥28 days, OR = 1.32, p < 0.01] [8-15 days vs. ≥28 days, OR = 1.22, p < 0.01] were associated with increased odds of discontinuation. While a lower initial dose was not associated with adverse events, fewer initial days of supply were associated with a higher risk of adverse events, even after controlling for treatment discontinuation. CONCLUSION In this population of commercially insured, non-elderly adults, we found that fewer initial days of supply as well as a lower initial dose were associated with increased likelihood of treatment discontinuation, highlighting the importance of prescribing decisions when initiating buprenorphine for OUD.
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Affiliation(s)
- Angélica Meinhofer
- Weill Cornell Medicine, Department of Healthcare Policy & Research, New York, NY, United States of America.
| | - Arthur Robin Williams
- Columbia University, Department of Psychiatry, New York, NY, United States of America; New York State Psychiatric Institute, New York, NY, United States of America
| | - Phyllis Johnson
- Weill Cornell Medicine, Department of Healthcare Policy & Research, New York, NY, United States of America
| | - Bruce R Schackman
- Weill Cornell Medicine, Department of Healthcare Policy & Research, New York, NY, United States of America
| | - Yuhua Bao
- Weill Cornell Medicine, Department of Healthcare Policy & Research, New York, NY, United States of America
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Buprenorphine in the United States: Motives for abuse, misuse, and diversion. J Subst Abuse Treat 2019; 104:148-157. [PMID: 31370979 DOI: 10.1016/j.jsat.2019.07.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 07/11/2019] [Accepted: 07/11/2019] [Indexed: 12/25/2022]
Abstract
Opioid use disorder (OUD) and its consequences are a major public health concern. The partial agonist buprenorphine is a safe and effective treatment for OUD, but concerns about abuse, misuse, and diversion of buprenorphine have been raised. This narrative review examined the rates and motives for use of illicit buprenorphine in the United States. Findings from the 17 included studies suggest the majority of study participants using illicit buprenorphine do so for reasons related to misuse (to manage opioid withdrawal symptoms or achieve or maintain abstinence from other opioids). A smaller percentage of study respondents reported using buprenorphine for reasons related to abuse (to get high). There appears to be a gap between need for buprenorphine and access to adequate treatment. Attenuation of policy-related barriers and adoption of appropriate buprenorphine use by the treatment community are critical tools in the continued effort to reduce the burdens associated with OUD.
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Bishop B, Gilmour J, Deering D. Readiness and recovery: Transferring between methadone and buprenorphine/naloxone for the treatment of opioid use disorder. Int J Ment Health Nurs 2019; 28:226-236. [PMID: 30019812 DOI: 10.1111/inm.12523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2018] [Indexed: 11/27/2022]
Abstract
Long-acting opioids are prescribed as part of treatment for opioid use disorders; methadone and buprenorphine are well researched and commonly prescribed for the treatment of opioid use disorder. Meta-analysis suggests that buprenorphine has a slightly poorer retention rate in treatment as compared to methadone. Benefits of buprenorphine/naloxone include greater ease in ceasing treatment and less use of illicit opioids while in treatment as compared to methadone. There are a number of qualitative and mixed-method studies that ask patients about their experiences of methadone maintenance and buprenorphine maintenance treatment. This research aimed to understand perspectives of receiving buprenorphine/naloxone for the treatment of opioid use disorder. A qualitative descriptive approach was used. Seven participants with a current diagnosis of opioid use disorder treated with buprenorphine/naloxone were interviewed. Thematic analysis extracted four themes: drivers for opioid substitution treatment change; readiness for buprenorphine/naloxone substitution treatment; absence of effect from buprenorphine/naloxone; and an increased sense of citizenship on buprenorphine/naloxone. This study identified a number of factors influencing participants' decision-making in transferring between methadone and buprenorphine/naloxone for the treatment of their opioid use disorder. Methadone was preferred by those seeking sedation and wishing to continue using other opioids, and buprenorphine/naloxone was most effective for participants no longer wishing to experience sedation and seeing opioid abstinence as an end point in their recovery. Changing treatment expectations are important to consider when determining medication selection and highlight the importance of quality information when determining the most suitable medication for the treatment of opioid use disorder.
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Steer CD, Macleod J, Tilling K, Lim AG, Marsden J, Millar T, Strang J, Telfer M, Whitaker H, Vickerman P, Hickman M. The impact of opiate substitution treatment on mortality risk in drug addicts: a natural experiment study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background
Opiate substitution treatment (OST) is the main treatment for people addicted to heroin and other opioid drugs. However, there is limited information on how the delivery of this treatment affects mortality risk.
Objectives
To investigate the associations of mortality risk with periods during treatment and following cessation of treatment, medication type, co-prescription of other medication and dosing regimens during titration and detoxification. The trends with time of prescribed medication, dose and treatment duration were also explored.
Design
Prospective longitudinal observational study.
Setting
UK primary care between 1998 and 2014.
Participants
A total of 12,780 patients receiving methadone, buprenorphine or dihydrocodeine.
Main outcome measures
All-cause mortality relating to 657 deaths and drug-related poisoning relating to 113 deaths.
Data sources
Clinical Practice Research Datalink with linked information on cause of death from the Office for National Statistics.
Results
For both outcomes, the lowest mortality risk was observed after 4 weeks of treatment and the highest risk was observed in the first 4 weeks following cessation of treatment [e.g. for drug-related poisoning, incidence rate ratio (IRR) 8.15, 95% confidence interval (CI) 5.45 to 12.19]. There was evidence that the treatment period risks varied with OST medication. The largest difference in risk was for the first 4 weeks of treatment for both outcomes, with patients on buprenorphine being at lower risk than those on methadone (e.g. for drug-related poisoning, IRR 0.08, 95% CI 0.01 to 0.48). The co-prescription of benzodiazepines was associated with linearly increasing the risk of drug-related deaths by dose (IRR 2.02, 95% CI 1.66 to 2.47), whereas z-drugs (zolpidem, zopiclone and zaleplon) were associated with increased risk of both all-cause (IRR 1.83, 95% CI 1.59 to 2.12) and drug-related (IRR 3.31, 95% CI 2.45 to 4.47) mortality. There was weak evidence that higher initial and final doses were associated with increased all-cause mortality risk. In the first 4 weeks of treatment, the risk increased by 4% for each 5-mg increment in methadone dose (1-mg increase in buprenorphine) (hazard ratio 1.04, 95% CI 1.00 to 1.09). In the first 4 weeks after treatment ceased, a similar increment in final dose increased the risk by 3% (hazard ratio 1.03, 95% CI 0.99 to 1.07). There were too few deaths to evaluate the effects on drug-related poisoning. The proportion of OST patients receiving buprenorphine increased between 1998 and 2006. Median treatment duration was consistently shorter for buprenorphine than for methadone for each year studied (overall median duration of 48 and 106 days, respectively).
Limitations
As this was an observational study, the possibility remains of bias from unmeasured factors, which covariate adjustment and inverse probability weighting can eliminate only partially.
Conclusions
Using buprenorphine as an alternative to methadone may not reduce mortality overall despite resulting in lower IRRs from shorter treatment duration. Clinical guidance needs to consider strengthening warnings about the co-prescription of a range of drugs for OST patients.
Future work
Our analyses need to be replicated using other clinical data sets in the UK and in other countries. New interventions and trials are required to investigate improving the retention of OST patients in primary care.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Colin D Steer
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - John Macleod
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kate Tilling
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Aaron G Lim
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - John Marsden
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Tim Millar
- Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Heather Whitaker
- Department of Mathematics and Statistics, The Open University, Milton Keynes, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Sofuoglu M, DeVito EE, Carroll KM. Pharmacological and Behavioral Treatment of Opioid Use Disorder. PSYCHIATRIC RESEARCH AND CLINICAL PRACTICE 2018. [PMCID: PMC9175946 DOI: 10.1176/appi.prcp.20180006] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: Opioid use disorder (OUD) in the United States has surged, with an estimated 2.5 million needing treatment. The aim of this article is to provide a clinical overview of the key pharmacological and behavioral treatments for OUD. Methods: A nonsystematic review of the literature was conducted to investigate OUD treatments, including their mechanism of action, efficacy, clinical guidelines in the United States, and consideration of frequently occurring comorbid conditions. Results: Food and Drug Administration (FDA)–approved pharmacotherapies for OUD include methadone, buprenorphine, and naltrexone, each of which has different actions on opioid receptors. Although these medications all show efficacy in some dosages and formulations, barriers to accessibility may be most pronounced for methadone, whereas treatment retention poses greater challenges for naltrexone and, to a lesser extent, buprenorphine. Lofexidine, an α2‐adrenergic agonist, has recently been approved by the FDA for treatment of opioid withdrawal symptoms. OUD is commonly treated with medication‐assisted treatment (MAT), which offers pharmacotherapy in the context of counseling and/or behavioral treatments. Behavioral therapies, rarely offered as stand‐alone treatments for OUD, are generally used in the context of MAT, in structured settings or to prevent relapse after detoxification and stabilization. The aim of behavioral interventions is to improve medication compliance and target problems not addressed with medication alone. Individuals with OUD commonly have other comorbid psychiatric and substance use conditions, which are not exclusionary for initiating MAT but should be carefully evaluated and monitored because they may reduce treatment effectiveness. Conclusions: MAT is the first‐line treatment for patients with OUD and should be provided in combination with behavioral interventions. Treatment retention remains challenging in this population. Future studies should focus on approaches that will serve the complex needs of patients with OUD, including those with comorbid psychiatric and substance use conditions.
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Affiliation(s)
- Mehmet Sofuoglu
- Yale University School of MedicineDepartment of Psychiatry
- VA Connecticut Healthcare SystemWest HavenCT
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Schiavon S, Hodgin K, Sellers A, Word M, Galbraith JW, Dantzler J, Cropsey KL. Medical, psychosocial, and treatment predictors of opioid overdose among high risk opioid users. Addict Behav 2018; 86:51-55. [PMID: 29884422 DOI: 10.1016/j.addbeh.2018.05.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 05/23/2018] [Accepted: 05/29/2018] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Drug overdoses are the leading cause of accidental death in the United States. It is imperative to explore predictors of opioid overdose in order to facilitate targeted treatment and prevention efforts. The present study was conducted as an exploratory examination of the factors associated with having a past opioid overdose. METHODS Participants (N = 244) from substance treatment facilities, inpatient services following ER admittance, or involved within the drug court system and who reported opioid use in the past 6 months were recruited in this study. Measures of opioid use and history were used to determine characteristics associated with previous experience of a non-fatal opioid overdose. RESULTS Opioid users who were Caucasian and used a combination of prescription opioids and heroin were more likely to have experienced a prior overdose. Opioid user characteristics associated with greater odds of experiencing a prior overdose included: witnessing a friend overdose (OR 4.21), having chronic hepatitis C virus (HCV) infection (OR 2.44), reporting a higher frequency of buprenorphine treatment episodes (OR 1.55), and having a higher frequency of witnessing others overdose (OR 1.42). Greater frequency of methadone treatment episodes was related to decreased odds of experiencing an overdose (OR 0.67). CONCLUSION Overall, this study demonstrated certain demographic and drug use factors associated with elevated risk for an overdose. Understanding the risk factors associated with drug overdose can lead to targeted naloxone training and distribution to prevent fatal overdoses.
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Hadland SE, Bagley SM, Rodean J, Silverstein M, Levy S, Larochelle MR, Samet JH, Zima BT. Receipt of Timely Addiction Treatment and Association of Early Medication Treatment With Retention in Care Among Youths With Opioid Use Disorder. JAMA Pediatr 2018; 172:1029-1037. [PMID: 30208470 PMCID: PMC6218311 DOI: 10.1001/jamapediatrics.2018.2143] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/30/2018] [Indexed: 12/21/2022]
Abstract
Importance Retention in addiction treatment is associated with reduced mortality for individuals with opioid use disorder (OUD). Although clinical trials support use of OUD medications among youths (adolescents and young adults), data on timely receipt of buprenorphine hydrochloride, naltrexone hydrochloride, and methadone hydrochloride and its association with retention in care in real-world treatment settings are lacking. Objectives To identify the proportion of youths who received treatment for addiction after diagnosis and to determine whether timely receipt of OUD medications is associated with retention in care. Design, Setting, and Participants This retrospective cohort study used enrollment data and complete health insurance claims of 2.4 million youths aged 13 to 22 years from 11 states enrolled in Medicaid from January 1, 2014, to December 31, 2015. Data analysis was performed from August 1, 2017, to March 15, 2018. Exposures Receipt of OUD medication (buprenorphine, naltrexone, or methadone) within 3 months of diagnosis of OUD compared with receipt of behavioral health services alone. Main Outcomes and Measures Retention in care, with attrition defined as 60 days or more without any treatment-related claims. Results Among 4837 youths diagnosed with OUD, 2752 (56.9%) were female and 3677 (76.0%) were non-Hispanic white. Median age was 20 years (interquartile range [IQR], 19-21 years). Overall, 3654 youths (75.5%) received any treatment within 3 months of diagnosis of OUD. Most youths received only behavioral health services (2515 [52.0%]), with fewer receiving OUD medications (1139 [23.5%]). Only 34 of 728 adolescents younger than 18 years (4.7%; 95% CI, 3.1%-6.2%) and 1105 of 4109 young adults age 18 years or older (26.9%; 95% CI, 25.5%-28.2%) received timely OUD medications. Median retention in care among youths who received timely buprenorphine was 123 days (IQR, 33-434 days); naltrexone, 150 days (IQR, 50-670 days); and methadone, 324 days (IQR, 115-670 days) compared with 67 days (IQR, 14-206 days) among youths who received only behavioral health services. Timely receipt of buprenorphine (adjusted hazard ratio, 0.58; 95% CI, 0.52-0.64), naltrexone (adjusted hazard ratio, 0.54; 95% CI, 0.43-0.69), and methadone (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.47) were each independently associated with lower attrition from treatment compared with receipt of behavioral health services alone. Conclusions and Relevance Timely receipt of buprenorphine, naltrexone, or methadone was associated with greater retention in care among youths with OUD compared with behavioral treatment only. Strategies to address the underuse of evidence-based medications for youths with OUD are urgently needed.
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Affiliation(s)
- Scott E. Hadland
- Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Sarah M. Bagley
- Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | | | - Michael Silverstein
- Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Sharon Levy
- Adolescent Substance Use and Addictions Program, Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Marc R. Larochelle
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Jeffrey H. Samet
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Bonnie T. Zima
- Semel Institute for Neuroscience and Human Behavior, UCLA (University of California, Los Angeles), Los Angeles
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Kenney SR, Anderson BJ, Bailey GL, Stein MD. Buprenorphine treatment formulations: Preferences among persons in opioid withdrawal management. J Subst Abuse Treat 2018; 94:55-59. [PMID: 30243418 PMCID: PMC6152924 DOI: 10.1016/j.jsat.2018.08.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND In the current study, we examined factors predicting willingness to receive buprenorphine treatment and preferences for various buprenorphine formulations (oral, injection, implant) among persons in opioid withdrawal management. METHODS Participants were three hundred thirty-eight persons entering brief inpatient opioid withdrawal management programs at two sites. We used t-tests and Pearson χ2 - tests of independence to compare participants willing and unwilling to be prescribed buprenorphine in the future. Among persons willing to receive buprenorphine, we used multinomial logistic regression to estimate the adjusted effects of potential correlates of type of buprenorphine formulation preferred. RESULTS Participants averaged 33.9 (±9.5) years of age, 70.4% were male, 82.8% were White, and 11.0% were Latino/a. In all, 55.6% of participants had been prescribed buprenorphine in the past, and 54.7% were willing to use prescribed buprenorphine in the future. Those reporting past month illicit buprenorphine use and prior overdose were more willing to use prescribed buprenorphine. Of these (n = 180), most preferred daily buprenorphine formulations (tablet or film) (48.6%) over a weekly or monthly injection (23.1%) or bi-annual implant (28.3%). CONCLUSIONS Past buprenorphine prescription does not predict future willingness to restart. Among those willing to use buprenorphine, newer formulations of buprenorphine appealed to more than half of the participants.
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Affiliation(s)
- Shannon R Kenney
- Behavioral Medicine Department, Butler Hospital, Providence, RI 02906, United States of America; Warren Alpert Medical School of Brown University, Providence, RI, 02912, United States of America.
| | - Bradley J Anderson
- Behavioral Medicine Department, Butler Hospital, Providence, RI 02906, United States of America
| | - Genie L Bailey
- Warren Alpert Medical School of Brown University, Providence, RI, 02912, United States of America; Stanley Street Treatment & Resources, Inc, Fall River, MA 02720, United States of America
| | - Michael D Stein
- Behavioral Medicine Department, Butler Hospital, Providence, RI 02906, United States of America; Boston University School of Public Health, Boston, MA 02118, United States of America
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Hickman M, Steer C, Tilling K, Lim AG, Marsden J, Millar T, Strang J, Telfer M, Vickerman P, Macleod J. The impact of buprenorphine and methadone on mortality: a primary care cohort study in the United Kingdom. Addiction 2018; 113:1461-1476. [PMID: 29672985 PMCID: PMC6282737 DOI: 10.1111/add.14188] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/28/2017] [Accepted: 02/05/2018] [Indexed: 01/18/2023]
Abstract
AIMS To estimate whether opioid substitution treatment (OST) with buprenorphine or methadone is associated with a greater reduction in the risk of all-cause mortality (ACM) and opioid drug-related poisoning (DRP) mortality. DESIGN Cohort study with linkage between clinical records from Clinical Practice Research Datalink and mortality register. SETTING UK primary care. PARTICIPANTS A total of 11 033 opioid-dependent patients who received OST from 1998 to 2014, followed-up for 30 410 person-years. MEASUREMENTS Exposure to methadone (17 373, 61%) OST episodes or buprenorphine (9173, 39%) OST episodes. ACM was available for all patients; information on cause of death and DRP was available for 5935 patients (54%) followed-up for 16 363 person-years. Poisson regression modelled mortality by treatment period with an interaction between OST type and treatment period (first 4 weeks on OST, rest of time off OST, first 4 weeks off OST, rest of time out of OST censored at 12 months) to test whether ACM or DRP differed between methadone and buprenorphine. Inverse probability weights were included to adjust for confounding and balance characteristics of patients prescribed methadone or buprenorphine. FINDINGS ACM and DRP rates were 1.93 and 0.53 per 100 person-years, respectively. DRP was elevated during the first 4 weeks of OST [incidence rate ratio (IRR) = 1.93 95% confidence interval (CI) = 0.97-3.82], the first 4 weeks off OST (IRR = 8.15, 95% CI = 5.45-12.19) and the rest of time out of OST (IRR = 2.13, 95% CI = 1.47-3.09) compared with mortality risk from 4 weeks to end of treatment. Patients on buprenorphine compared with methadone had lower ACM rates in each treatment period. After adjustment, there was evidence of a lower DRP risk for patients on buprenorphine compared with methadone at treatment initiation (IRR = 0.08, 95% CI = 0.01-0.48) and rest of time on treatment (IRR = 0.37, 95% CI = 0.17-0.79). Treatment duration (mean and median) was shorter on buprenorphine than methadone (173 and 40 versus 363 and 111, respectively). Model estimates suggest that there was a low probability that methadone or buprenorphine reduced the number of DRP in the population: 28 and 21%, respectively. CONCLUSIONS In UK general medical practice, opioid substitution treatment with buprenorphine is associated with a lower risk of all-cause and drug-related poisoning mortality than methadone. In the population, buprenorphine is unlikely to give greater overall protection because of the relatively shorter duration of treatment.
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Affiliation(s)
- Matthew Hickman
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Colin Steer
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Kate Tilling
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Aaron G. Lim
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - John Marsden
- Addictions Department, Institute of Psychiatry, Psychiatry and NeuroscienceKing's College LondonLondonUK
| | - Tim Millar
- Centre for Mental Health and Safety, School of Health SciencesThe University of ManchesterManchesterUK
| | - John Strang
- Addictions Department, Institute of Psychiatry, Psychiatry and NeuroscienceKing's College LondonLondonUK
| | | | - Peter Vickerman
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - John Macleod
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
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Abstract
: A long-acting buprenorphine subdermal implant, Probuphine, was approved by the Food and Drug Administration (FDA) in May 2016, for the maintenance treatment of patients with opioid-use disorder. Long-acting implants offer the potential benefits of improved medication adherence, consistent daily dosing, and reduced risk of medication diversion. Sets of 4 implants are typically inserted for a period of 6 months and then removed. Similar technology has been successfully utilized in implantable formulations of birth control medications; however, there is currently little clinical experience involving buprenorphine implants that have remained in the body for extended periods of time. This is a case report involving an early clinical study subject who had been lost to follow-up at the time of the original study because of incarceration. Despite the protracted duration of time since initial implantation, all 4 implants remained easily palpable, and displayed little physical deterioration or tissue infiltration. All implants were able to be removed using the standard explant technique of midline incision and limited tissue dissection. While extending length of treatment beyond the indicated 6-month period is not being espoused, this case demonstrates that although situations may arise where implants may remain in an individual for longer than the intended dosing period, implants may be removed safely despite remaining implanted for longer than intended.
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Soper R, Appajosyula S, Deximo C. Decline in Buprenorphine/Naloxone Prescriptions in a State Medicaid Population Following Formulary Conversion from Suboxone to Bunavail. Adv Ther 2018; 35:457-466. [PMID: 29623562 DOI: 10.1007/s12325-018-0696-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION A large, statewide, fee-for-service Medicaid plan recently (October 2015) executed a complete switch from sublingual buprenorphine-naloxone [(SLBN), Suboxone®] to buccal buprenorphine-naloxone [(BBN), Bunavail®] on its preferred drug formulary. This complete formulary switch provided an opportunity to assess dynamic changes in prescribing patterns, patient/physician acceptance, and indices of potential misuse/diversion. METHODS For the period January 1, 2015 through December 31, 2016, two datasets were analyzed: prescriptions and associated costs for buprenorphine-naloxone (BN) products and urine toxicology test results for patients in the Medicaid plan. The dataset comprised 1370 unique providers ordering 643,225 prescriptions for opioid addiction therapy. Patient and order volumes, and the rate of monthly positive laboratory values for opioid molecules and cocaine were reviewed. A targeted survey of physicians treating opioid-dependent patients with state Medicaid plan coverage was also conducted. RESULTS Upon plan conversion to BBN, there was a rapid increase in monthly BBN prescriptions mirrored by a rapid decrease in SLBN prescriptions. Peak in BBN prescriptions (2633 in November 2015) was approximately 60% lower than peak in SLBN prescriptions (6531 in July 2015). An unexpected finding was a 68% reduction of the overall BN market, indicating that many BN prescriptions were abandoned. The reduction was associated with quarterly cost savings to the Medicaid plan of approximately $3.5 million. Toxicology results indicated a reduction in drug positivity (defined as positivity for cocaine and/or any opioids except buprenorphine and methadone) from 13-16% in 2015 to less than 10% in 2016. Heroin positivity decreased from approximately 9% in December 2015 to an average of less than 1% during the last quarter of 2016, while positivity for norbuprenorphine, the major metabolite of buprenorphine, showed a marked increase in 2016 vs 2015. Among physicians who responded to the targeted survey most rated BBN as more difficult to abuse or misuse than SLBN. CONCLUSION The rapid reduction in the overall BN market following a complete formulary switch from SLBN to BBN was associated with quarterly savings of $3.5 million for the state Medicaid plan. Toxicology data suggest that this cost saving was realized in the context of improved physician and patient adherence to treatment protocols. The changing market dynamics can potentially be explained by a number of contributory factors, including a reduction of diversion and illicit distribution of BN following formulary conversion. These results are considered hypothesis-generating and future research should systematically compare the propensity for diversion and abuse of BN products using various epidemiological tracking tools. FUNDING BioDelivery Sciences International, Inc.
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Van Baelen L, De Ridder K, Antoine J, Gremeaux L. Longitudinal pharmacoepidemiological and health services research for substance users in treatment: protocol of the Belgian TDI-IMA linkage. ACTA ACUST UNITED AC 2018; 76:3. [PMID: 29321922 PMCID: PMC5759192 DOI: 10.1186/s13690-017-0249-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/08/2017] [Indexed: 11/10/2022]
Abstract
Background Not much is known about the health seeking behavior of people with substance use disorders before they enter specialized treatment and afterwards. This paper explains in detail the protocol that has been followed to establish the Belgian TDI-IMA-database, which is linking two separate databases: the Treatment Demand Indicator (TDI) and the database of the Intermutualistic Agency (IMA). The Treatment Demand Indicator is measuring incidence of people with substance use disorders entering drug treatment. The IMA-database covers data, collected in the framework of the compulsory Belgian health care and benefits insurance program, on reimbursed medication and the use of reimbursed health services. The linkage results in pharmacoepidemiological and health service data for people who were in treatment for substance use disorders and for a group of comparators. Methods The TDI-database was linked to the IMA-database for the period between 01/01/2008 and 31/12/2017, based on the national identification number of patients who have been in alcohol or drug treatment between 01/01/2011 and 31/12/2014. Through this linkage, pharmacoepidemiological and health service data became available for at least 3 years before the first registered episode in the TDI-database till at least 3 years after the first episode. For each person in TDI four comparators, who were not in specialized treatment, were matched on age, sex and place of residence. Discussion The TDI-IMA-database allows for an analysis of health seeking behavior and health care pathways of people before and after they entered specialized alcohol and drug treatment. The presented protocol could be used in other European countries to establish a linkage between existing health databases. This will allow for a better understanding of the health care needs of patients with substance use disorders.
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Affiliation(s)
- Luk Van Baelen
- Department of Public Health and Surveillance, Scientific Institute of Public Health, Brussels, Belgium, Rue Juliette Wytsmanstraat, 14, 1050 Brussels, Belgium
| | - Karin De Ridder
- Department of Public Health and Surveillance, Scientific Institute of Public Health, Brussels, Belgium, Rue Juliette Wytsmanstraat, 14, 1050 Brussels, Belgium
| | - Jérôme Antoine
- Department of Public Health and Surveillance, Scientific Institute of Public Health, Brussels, Belgium, Rue Juliette Wytsmanstraat, 14, 1050 Brussels, Belgium
| | - Lies Gremeaux
- Department of Public Health and Surveillance, Scientific Institute of Public Health, Brussels, Belgium, Rue Juliette Wytsmanstraat, 14, 1050 Brussels, Belgium
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Hui D, Weinstein ZM, Cheng DM, Quinn E, Kim H, Labelle C, Samet JH. Very early disengagement and subsequent re-engagement in primary care Office Based Opioid Treatment (OBOT) with buprenorphine. J Subst Abuse Treat 2017; 79:12-19. [PMID: 28673522 PMCID: PMC5522736 DOI: 10.1016/j.jsat.2017.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/11/2017] [Accepted: 05/15/2017] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Patients with opioid use disorder often require multiple treatment attempts before achieving stable recovery. Rates of disengagement from buprenorphine are highest in the first month of treatment and termination of buprenorphine therapy results in return to use rates as high as 90%. To better characterize these at-risk patients, this study aims to describe: 1) the frequency and characteristics of patients with very early disengagement (≤1month) from Office Based Opioid Treatment (OBOT) with buprenorphine and 2) the frequency and characteristics of patients who re-engage in care at this same OBOT clinic within 2years, among the subset of very early disengagers. METHODS This is a retrospective cohort study of adult patients enrolled in a large urban OBOT program. Descriptive statistics were used to characterize the sample and the proportion of patients with very early (≤1month) disengagement and their re-engagement. Multivariable logistic regression models were used to identify patient characteristics associated with the outcomes of very early disengagement and re-engagement. Potential predictors included: sex, age, race/ethnicity, education, employment, opioid use history, prior substance use treatments, urine drug testing, and psychiatric diagnoses. RESULTS Overall, very early disengagement was unusual, with only 8.4% (104/1234) of patients disengaging within the first month. Among the subset of very early disengagers with 2years of follow-up, the proportion who re-engaged with this OBOT program in the subsequent 2years was 11.9% (10/84). Urine drug test positive for opiates within the first month (AOR: 2.01, 95% CI: 1.02-3.93) was associated with increased odds of very early disengagement. Transferring from another buprenorphine prescriber (AOR: 0.09, 95% CI: 0.01-0.70) was associated with decreased odds of very early disengagement. No characteristics were significantly associated with re-engagement. CONCLUSIONS Early disengagement is uncommon; however, continued opioid use appeared to be associated with higher odds of treatment disengagement and these patients may warrant additional support. Re-engagement was uncommon, suggesting the need for a more formal explicit system to encourage and facilitate re-engagement among patients who disengage.
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Affiliation(s)
- David Hui
- Boston University School of Medicine, 72 East Concord St., Boston, MA 02118, United States.
| | - Zoe M Weinstein
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, United States.
| | - Debbie M Cheng
- Boston University School of Public Health, Department of Biostatistics, 801 Massachusetts Avenue, 3rd Floor, Boston, MA 02118, United States.
| | - Emily Quinn
- Boston University School of Public Health, Data Coordinating Center, 85 East Newton St, M921, Boston, MA 02118, United States.
| | - Hyunjoong Kim
- Boston University School of Medicine, 72 East Concord St., Boston, MA 02118, United States.
| | - Colleen Labelle
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, United States.
| | - Jeffrey H Samet
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, United States; Boston University School of Public Health, Department of Community Health Sciences, 801 Massachusetts Avenue, 4th Floor, Boston, MA 02118, United States.
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Trowbridge P, Weinstein ZM, Kerensky T, Roy P, Regan D, Samet JH, Walley AY. Addiction consultation services - Linking hospitalized patients to outpatient addiction treatment. J Subst Abuse Treat 2017; 79:1-5. [PMID: 28673521 PMCID: PMC6035788 DOI: 10.1016/j.jsat.2017.05.007] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 05/05/2017] [Accepted: 05/09/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Approximately 15% of hospitalized patients have an active substance use disorder (SUD). Starting treatment for SUD, including medications, during acute hospitalizations can engage patients in addiction care. In July 2015, the Boston Medical Center Addiction Consult Service (ACS), began providing inpatient diagnostic, management, and discharge linkage consultations. We describe this implementation. METHODS The ACS staff recorded SUDs diagnoses and medication recommendations and tracked follow-up data for affiliated outpatient office-based addiction clinics and methadone maintenance programs. We assessed the number of consults, SUDs diagnoses, medications recommended and initiated, and outpatient addiction clinic follow-up. RESULTS Over 26weeks, the BMC ACS completed 337 consults: 78% had an opioid use disorder (UD), 37% an alcohol UD, 28% a cocaine UD, 9% a benzodiazepine UD, 3% a cannabinoid (including K2) UD, and <1% a methamphetamine UD. Methadone was initiated in 70 inpatients and buprenorphine in 40 inpatients. Naltrexone was recommended 45 times (for opioid UD, alcohol UD, or both). Of the patients initiated on methadone, 76% linked to methadone clinic, with 54%, 39%, and 29% still retained at 30, 90, and 180days, respectively. For buprenorphine, 49% linked to clinic, with 39%, 27%, and 18% retained at 30, 90, and 180days, respectively. For naltrexone, 26% linked to clinic, all with alcohol UD alone. CONCLUSIONS A new inpatient addiction consultation service diagnosed and treated hospitalized patients with substance use disorders and linked them to outpatient addiction treatment care. Initiating addiction medications, particularly opioid agonists, was feasible in the inpatient setting. Optimal linkage and retention of hospitalized patients to post-discharge addiction care warrants further innovation and program development.
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Affiliation(s)
- Paul Trowbridge
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine & Boston Medical Center, 801 Massachusetts Avenue, Boston, USA; Spectrum Health Center for Integrative Medicine, 75 Sheldon Blvd SE, Grand Rapids, MI, USA.
| | - Zoe M Weinstein
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine & Boston Medical Center, 801 Massachusetts Avenue, Boston, USA
| | - Todd Kerensky
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine & Boston Medical Center, 801 Massachusetts Avenue, Boston, USA
| | - Payel Roy
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine & Boston Medical Center, 801 Massachusetts Avenue, Boston, USA
| | - Danny Regan
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine & Boston Medical Center, 801 Massachusetts Avenue, Boston, USA
| | - Jeffrey H Samet
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine & Boston Medical Center, 801 Massachusetts Avenue, Boston, USA; Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, USA
| | - Alexander Y Walley
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine & Boston Medical Center, 801 Massachusetts Avenue, Boston, USA
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Abstract
OBJECTIVE Although counseling is a required part of office-based buprenorphine treatment of opioid use disorders, the nature of what constitutes appropriate counseling is unclear and controversial. The authors review the literature on the role, nature, and intensity of behavioral interventions in office-based buprenorphine treatment. METHOD The authors conducted a review of randomized controlled studies testing the efficacy of adding a behavioral intervention to buprenorphine maintenance treatment. RESULTS Four key studies showed no benefit from adding a behavioral intervention to buprenorphine plus medical management, and four studies indicated some benefit for specific behavioral interventions, primarily contingency management. The authors examined the findings from the negative trials in the context of six questions: 1) Is buprenorphine that effective? 2) Is medical management that effective? 3) Are behavioral interventions that ineffective in this population? 4) How has research design affected the results of studies of buprenorphine plus behavioral treatment? 5) What do we know about subgroups of patients who do and those who do not seem to benefit from behavioral interventions? 6) What should clinicians aim for in terms of treatment outcome in buprenorphine maintenance? CONCLUSIONS High-quality medical management may suffice for some patients, but there are few data regarding the types of individuals for whom medical management is sufficient. Physicians should consider a stepped-care model in which patients may begin with relatively nonintensive treatment, with increased intensity for patients who struggle early in treatment. Finally, with 6-month retention rates seldom exceeding 50% and poor outcomes following dropout, we must explore innovative strategies for enhancing retention in buprenorphine treatment.
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Affiliation(s)
- Kathleen M. Carroll
- Department of Psychiatry, Yale University School of Medicine, 950 Campbell Avenue, MIRECC 151D, West Haven, CT 06516, 203-932-5711 x 7403,
| | - Roger D. Weiss
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill St. Belmont, MA 02478, 617-855-2242, , Department of Psychiatry, Harvard Medical School, Boston, MA 02215
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