1
|
Weber AN, Trebach J, Brenner MA, Thomas MM, Bormann NL. Managing Opioid Withdrawal Symptoms During the Fentanyl Crisis: A Review. Subst Abuse Rehabil 2024; 15:59-71. [PMID: 38623317 PMCID: PMC11016949 DOI: 10.2147/sar.s433358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/05/2024] [Indexed: 04/17/2024] Open
Abstract
Illicitly manufactured fentanyl (IMF) is a significant contributor to the increasing rates of overdose-related deaths. Its high potency and lipophilicity can complicate opioid withdrawal syndromes (OWS) and the subsequent management of opioid use disorder (OUD). This scoping review aimed to collate the current OWS management of study populations seeking treatment for OWS and/or OUD directly from an unregulated opioid supply, such as IMF. Therefore, the focus was on therapeutic interventions published between January 2010 and November 2023, overlapping with the period of increasing IMF exposure. A health science librarian conducted a systematic search on November 13, 2023. A total of 426 studies were screened, and 173 studies were reviewed at the full-text level. Forty-nine studies met the inclusion criteria. Buprenorphine and naltrexone were included in most studies with the goal of transitioning to a long-acting injectable version. Various augmenting agents were tested (buspirone, memantine, suvorexant, gabapentin, and pregabalin); however, the liberal use of adjunctive medication and shortened timelines to initiation had the most consistently positive results. Outside of FDA-approved medications for OUD, lofexidine, gabapentin, and suvorexant have limited evidence for augmenting opioid agonist initiation. Trials often have low retention rates, particularly when opioid agonist washout is required. Neurostimulation strategies were promising; however, they were developed and studied early. Precipitated withdrawal is a concern; however, the rates were low and adequately mitigated or managed with low- or high-dose buprenorphine induction. Maintenance treatment continues to be superior to detoxification without continued management. Shorter induction protocols allow patients to initiate evidence-based treatment more quickly, reducing the use of illicit or non-prescribed substances.
Collapse
Affiliation(s)
| | - Joshua Trebach
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA
| | - Marielle A Brenner
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Nicholas L Bormann
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
2
|
Beauchamp GA, Laubach LT, Esposito SB, Yazdanyar A, Roth P, Lauber P, Allen J, Boateng N, Shaak S, Burmeister DB. Implementation of a Medication for Addiction Treatment (MAT) and Linkage Program by Leveraging Community Partnerships and Medical Toxicology Expertise. J Med Toxicol 2020; 17:176-184. [PMID: 33146875 DOI: 10.1007/s13181-020-00813-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/09/2020] [Accepted: 09/14/2020] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Implementing a hospital medication for addiction treatment (MAT) and a linkage program can improve care for patients with substance use disorder (SUD); however, lack of hospital funding and brick and mortar SUD resources are potential barriers to feasibility. METHODS This study assesses the feasibility of implementation of a SUD linkage program. Components of the program include a county-funded hospital opioid support team (HOST), a hospital-employed addiction recovery specialist (ARS), and a medical toxicology MAT induction service and maintenance program. Data for linkage by HOST, ARS, and MAT program were tracked from July 2018 to December 2019. RESULTS From July 2018 through December 2019, 1834 patients were linked to treatment: 1536 by HOST and 298 by the ARS. The most common disposition categories for patients linked by HOST were 16.73% to medically monitored detoxification, 9.38% to intensive outpatient, and 8.59% to short-term residential treatment. Among patients linked by the ARS, 65.66% were linked to outpatient treatment and 9.43% were linked directly to inpatient treatment. A total of 223 patients managed by the ARS were started on MAT by medical toxicology and linked to outpatient MAT clinic: 72.68% on buprenorphine/naloxone, 24.59% on naltrexone, 1.09% buprenorphine, and 0.55% acamprosate. CONCLUSION Implementing a MAT and linkage program in the ED and hospital setting was feasible. Leveraging medical toxicology expertise as well as community and funding partnerships was crucial to successful implementation.
Collapse
Affiliation(s)
- Gillian A Beauchamp
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA. .,Department of Emergency and Hospital Medicine, Division of Medical Toxicology, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA.
| | - Lexis T Laubach
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Samantha B Esposito
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Paige Roth
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Priyanka Lauber
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Jamie Allen
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Nathan Boateng
- Air Products Center for Connected Care and Innovation, Lehigh Valley Health Network, Allentown, PA, USA
| | - Samantha Shaak
- Department of Community Health, Lehigh Valley Health Network, Allentown, PA, USA
| | - David B Burmeister
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| |
Collapse
|
3
|
Weisshaar S, Brandt L, Litschauer B, Sheik-Rezaei S, Moser L, Nirnberger G, Kühberger E, Bauer U, Firbas C, Gouya G, Wolzt M, Fischer G. Dose-dependent naloxone-induced morphine withdrawal symptoms in opioid-dependent males-a double-blinded, randomized study. Br J Clin Pharmacol 2020; 86:1610-1619. [PMID: 32145041 PMCID: PMC7373709 DOI: 10.1111/bcp.14271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 11/01/2019] [Accepted: 02/26/2020] [Indexed: 12/28/2022] Open
Abstract
Aims Oral opioid preparations combined with naloxone are intended to induce a transient acute withdrawal syndrome to avoid intravenous misuse. This trial aimed to establish an appropriate morphine–naloxone dose ratio for an abuse‐deterrent oral opioid formulation. Methods In a randomized, double‐blinded, 2 × 2 cross‐over trial, 43 patients with opioid use disorder were challenged with intravenous morphine HCl Ph.Eur. (75 mg; [morphine mono]) or morphine HCl Ph.Eur. and naloxone HCl Ph.Eur. at ratios of 100:1 (75 mg: 0.75 mg; [morphine–naloxone 100:1]) or 200:1 (75 mg: 0.375 mg; [morphine–naloxone 200:1]). Acute naloxone‐induced opioid withdrawal was evaluated using subjective (Short Opiate Withdrawal Scale–German [SOWS‐G]) and observer‐rated (Objective Opiate Withdrawal Scale [OOWS], Wang scale) questionnaires, and physiological parameters. For statistical analysis, the area under the curve between baseline and 20 minutes after drug administration of the outcome variables was calculated. Results Intravenous morphine–naloxone caused rapid withdrawal symptoms. Coadministration of naloxone dose‐dependently (morphine–naloxone 100:1 > morphine–naloxone 200:1) increased SOWS‐G, OOWS and Wang Scale area under the curve when compared to morphine mono, respectively (all P < .0001). A similar response was detectable for changes of pupil diameter. Blood pressure and respiratory rate changed heterogeneously, and heart rate was unaltered by morphine without or with naloxone. Conclusion Morphine–naloxone 100:1 effectively suppresses the pleasurable effects of intravenous morphine and results in an aversive withdrawal reaction. A lower naloxone concentration as used in morphine–naloxone 200:1 does not appear to be appropriate to prevent intravenous morphine misuse.
Collapse
Affiliation(s)
- Stefan Weisshaar
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Laura Brandt
- Department of Applied Psychology: Work, Education & Economy, Faculty of Psychology, University of Vienna, Vienna, Austria.,Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Brigitte Litschauer
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Safoura Sheik-Rezaei
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Laura Moser
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | | | | | - Christa Firbas
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Ghazaleh Gouya
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Michael Wolzt
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Gabriele Fischer
- Center for Public Health, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
4
|
Nisavic M, Flores EJ, Heng M, Kontos NJ, Quijije N. Case 26-2019: A 27-Year-Old Woman with Opioid Use Disorder and Suicidal Ideation. N Engl J Med 2019; 381:763-771. [PMID: 31433925 DOI: 10.1056/nejmcpc1904043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Mladen Nisavic
- From the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Massachusetts General Hospital, and the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Harvard Medical School - both in Boston
| | - Efren J Flores
- From the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Massachusetts General Hospital, and the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Harvard Medical School - both in Boston
| | - Marilyn Heng
- From the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Massachusetts General Hospital, and the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Harvard Medical School - both in Boston
| | - Nicholas J Kontos
- From the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Massachusetts General Hospital, and the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Harvard Medical School - both in Boston
| | - Nadia Quijije
- From the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Massachusetts General Hospital, and the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Harvard Medical School - both in Boston
| |
Collapse
|
5
|
Muller AE, Bjørnestad R, Clausen T. Dissatisfaction with opioid maintenance treatment partly explains reported side effects of medications. Drug Alcohol Depend 2018; 187:22-28. [PMID: 29626742 DOI: 10.1016/j.drugalcdep.2018.02.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Drop-out is a core problem in opioid maintenance treatment (OMT), but patients' reactions to and acceptance of the various OMT medications are insufficiently investigated. In Norway, there has been vocal patient resistance to the newest medication, buprenorphine-naloxone (BNX), and complaints have focused on the side effect profile. There has been no comparison of patient satisfaction and side effects of the three most common OMT medications. AIM To compare patient satisfaction with OMT and side effects of BNX, buprenorphine monopreparate (BUP), and methadone (MET) as reported by patients. METHODS Data were drawn from a national peer-to-peer survey developed by a patient advocacy group. The survey engaged more than 1000 OMT patients, corresponding to one seventh of OMT patients in Norway. The associations between side effects, treatment satisfaction, and patient characteristics were tested in multinomial logistic regressions. RESULTS High patient satisfaction with OMT overall was reported despite lower satisfaction with medication itself and widely prevalent side effects. Among each medication group, dissatisfaction with medications or OMT in general along with poor health status increased the relative risk ratio of reporting the heaviest side effect burden. MET users reported the highest side effect burden and BNX users the lightest, but BNX users were more dissatisfied with their medication. CONCLUSIONS Side effects are a concern for nearly all OMT patients, and they do not appear to accumulate with age or length of treatment. BNX users' dissatisfaction with their medication is of particular concern, and expectations and preferences of medication may be influencing their dissatisfaction.
Collapse
Affiliation(s)
- Ashley Elizabeth Muller
- Norwegian Centre for Addiction Research, Institute for Clinical Medicine, University of Oslo, Postboks 1039 Blindern, 0315 Oslo, Norway.
| | | | - Thomas Clausen
- Norwegian Centre for Addiction Research, Institute for Clinical Medicine, University of Oslo, Postboks 1039 Blindern, 0315 Oslo, Norway
| |
Collapse
|
6
|
Smyth BP, Elmusharaf K, Cullen W. Opioid substitution treatment and heroin dependent adolescents: reductions in heroin use and treatment retention over twelve months. BMC Pediatr 2018; 18:151. [PMID: 29728088 PMCID: PMC5936020 DOI: 10.1186/s12887-018-1137-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 04/30/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Opioid dependence is a major health concern across the world and does also occur in adolescents. While opioid substitution treatment (OST) has been thoroughly evaluated in adult populations, very few studies have examined its use in adolescents. There are concerns that OST is underutilised in adolescents with heroin dependence. We sought to measure changes in drug use among adolescents receiving OST and also to examine treatment attrition during the first 12 months of this treatment. METHODS We included all heroin dependent patients aged under 18.5 years commencing OST at one outpatient multidisciplinary adolescent addiction treatment service in Dublin, Ireland. Psycho-social needs were also addressed during treatment. Drug use was monitored by twice weekly urine drugs screens (UDS). Change in the proportion of UDS negative for heroin was examined using the Wilcoxon signed rank test. Attrition was explored via a Cox Regression multivariate analysis. RESULTS OST was commenced by 120 patients (51% female and mean age 17.3 years). Among the 39 patients who persisted with OST until month 12, heroin abstinence was 21% (95% confidence interval [CI] = 9-36%) at month three and it was 46% (95% CI = 30-63%) at month 12. Heroin use declined significantly from baseline to month three (p < 0.001) and from month three to month 12 (p = 0.01). Use of other drugs did not change significantly. People using cocaine during month 12 were more likely to be also using heroin (p = 0.02). Unplanned exit occurred in 25% patients by 120 days. The independent predictors of attrition were having children, single parent family of origin, not being in an intimate relationship with another heroin user and evidence of cocaine use just before treatment entry. CONCLUSIONS We found that heroin dependent adolescent patients achieved significant reductions in heroin use within three months of starting OST and this improved further after a year of treatment, about half being heroin abstinent at that stage. Patient drop out from treatment remains a challenge, as it is in adults. Cocaine use before and during treatment may be a negative prognostic factor.
Collapse
Affiliation(s)
- Bobby P. Smyth
- Department of Public Health and Primary Care, Trinity College Dublin, Dublin 2, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
- National Drug Treatment Centre, 30/31 Pearse St, Dublin 2, Ireland
- HSE Addiction Service, Bridge House, Cherry Orchard Hospital, Dublin 10, Ireland
| | - Khalifa Elmusharaf
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Walter Cullen
- Academic General Practice, School of Medicine, University College Dublin, Belfield, Dublin 4 Ireland
| |
Collapse
|
7
|
Walker R, Logan TK, Chipley QT, Miller J. Characteristics and experiences of buprenorphine-naloxone use among polysubstance users. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2018; 44:595-603. [PMID: 29693427 DOI: 10.1080/00952990.2018.1461876] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND With a rise in overdoses and medical emergencies related to opioids, buprenorphine-naloxone (bup-nx) is seen as a preferred treatment for opioid dependence. However, the research examining experiences with bup-nx among polysubstance users who may or may not be opioid dependent has been limited. OBJECTIVES The purpose of the study was to examine use, characteristics of users, and experiences of bup-nx use among polysubstance users entering drug-free recovery programs. METHODS This study examined secondary data on 896 opioid or opiate user individuals (53.4% male) collected by drug-free, self-help-based residential recovery centers during intake. RESULTS One-quarter of users said bup-nx helped them with their substance use while 75% of bup-nx users reported that bup-nx either had no effect or a negative effect on their drug problems. Of the very few (4%-7%) obtaining bup-nx solely through a prescription, over 90% reported relief from withdrawal. However, over 80% of those who obtained bup-nx through illicit means reported using bup-nx until their preferred drug could be obtained and used it for its euphoriant effect. Three groups of opioid users were created including one group with no bup-nx use, one with lifetime but not recent bup-nx use, and one with recent (past 6 month) use. There were differences in substance use patterns and characteristics of bup-nx experiences between the different groups. CONCLUSIONS Results suggest that the views of bup-nx by individuals in drug-free recovery centers are varied, with many seeing bup-nx as not unlike other opioids while others report bup-nx as self-medication.
Collapse
Affiliation(s)
- Robert Walker
- a Department of Behavioral Science and the Center on Drug and Alcohol Research, College of Medicine , University of Kentucky , Lexington , KY, USA
| | - T K Logan
- a Department of Behavioral Science and the Center on Drug and Alcohol Research, College of Medicine , University of Kentucky , Lexington , KY, USA
| | - Quintin T Chipley
- b Health Sciences Center Campus, School of Medicine, Medical Student Affairs , University of Louisville , Louisville , KY, USA
| | - Jaime Miller
- a Department of Behavioral Science and the Center on Drug and Alcohol Research, College of Medicine , University of Kentucky , Lexington , KY, USA
| |
Collapse
|
8
|
Ettienne EB, Chapman E, Maneno M, Ofoegbu A, Wilson B, Settles-Reaves B, Clarke M, Dunston G, Rosenblatt K. Pharmacogenomics-guided policy in opioid use disorder (OUD) management: An ethnically-diverse case-based approach. Addict Behav Rep 2017; 6:8-14. [PMID: 29450233 PMCID: PMC5800559 DOI: 10.1016/j.abrep.2017.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 05/03/2017] [Accepted: 05/06/2017] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Opioid use disorder (OUD) is characterized by a problematic pattern of opioid use leading to clinically-significant impairment or distress. Opioid agonist treatment is an integral component of OUD management, and buprenorphine is often utilized in OUD management due to strong clinical evidence for efficacy. However, interindividual genetic differences in buprenorphine metabolism may result in variable treatment response, leaving some patients undertreated and at increased risk for relapse. Clinical pharmacogenomics studies the effect that inherited genetic variations have on drug response. Our objective is to demonstrate the impact of pharmacogenetic testing on OUD management outcomes. METHODS We analyzed a patient who reported discomfort at daily buprenorphine dose of 24 mg, which was a mandated daily maximum by the pharmacy benefits manager. Regular urine screenings were conducted to detect the presence of unauthorized substances, and pharmacogenetic testing was used to determine the appropriate dose of buprenorphine for OUD management. RESULTS At the 24 mg buprenorphine daily dose, the patient had multiple relapses with unauthorized substances. Pharmacogenetic testing revealed that the patient exhibited a cytochrome P450 3A4 ultrarapid metabolizer phenotype, which necessitated a higher than recommended daily dose of buprenorphine (32 mg) for adequate OUD management. The patient exhibited a reduction in the number of relapses on the pharmacogenetic-based dose recommendation compared to standard dosing. CONCLUSION Pharmacogenomic testing as clinical decision support helped to individualize OUD management. Collaboration by key stakeholders is essential to establishing pharmacogenetic testing as standard of care in OUD management.
Collapse
Key Words
- APA, American Psychiatric Association
- ASAM, American Society of Addiction Medicine
- ASIPP, American Society of Interventional Pain Physicians
- Buprenorphine
- CDC, Centers for Disease Control and Prevention
- CLIA, Clinical Laboratory Improvement Amendments
- CYP3A4, cytochrome P450 3A4
- DSM-V, Diagnostic and Statistical Manual of Mental Disorders, 5th edition
- EM, extensive metabolizer
- IM, intermediate metabolizer
- NSDUH, National Survey on Drug Use and Health
- OAT, opioid agonist treatment
- OUD, opioid use disorder
- Opioid agonist treatment
- Opioid use disorder
- PBM, pharmacy benefits manager
- PD, pharmacodynamics
- PHM, Population Health Management
- PK, pharmacokinetics
- PM, poor metabolizer
- Pharmacogenomics
- Policy
- SUD, substance use disorder
- UM, ultrarapid metabolizer
- WHO, World Health Organization
Collapse
Affiliation(s)
- Earl B. Ettienne
- Howard University College of Pharmacy, 2300 4th St NW, Washington, DC 20059, United States
| | - Edwin Chapman
- Department of Psychiatry & Behavioral Health Sciences, Howard University Hospital, 2041 Georgia Avenue, NW, Suite 5B01, Washington, DC 20060, United States
| | - Mary Maneno
- Howard University College of Pharmacy, 2300 4th St NW, Washington, DC 20059, United States
| | - Adaku Ofoegbu
- Howard University College of Pharmacy, 2300 4th St NW, Washington, DC 20059, United States
| | - Bradford Wilson
- National Human Genome Center at Howard University, 2041 Georgia Ave. NW, Washington, DC 20060, United States
| | - Beverlyn Settles-Reaves
- Howard University Department of Community and Family Medicine, Towers Building, Suite 3600, 2041 Georgia Ave NW, Washington, DC 20060, United States
| | - Melissa Clarke
- National Human Genome Center at Howard University, 2041 Georgia Ave. NW, Washington, DC 20060, United States
| | - Georgia Dunston
- National Human Genome Center at Howard University, 2041 Georgia Ave. NW, Washington, DC 20060, United States
| | - Kevin Rosenblatt
- Consultative Genomics, PLLC, 5909 West Loop South, Suite 310, Bellaire, TX 77401, United States
| |
Collapse
|
9
|
Treatment Outcome Comparison Between Telepsychiatry and Face-to-face Buprenorphine Medication-assisted Treatment for Opioid Use Disorder: A 2-Year Retrospective Data Analysis. J Addict Med 2017; 11:138-144. [PMID: 28107210 DOI: 10.1097/adm.0000000000000287] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To retrospectively review clinic records to assess the difference between face-to-face and telepsychiatry buprenorphine medication-assisted treatment (MAT) programs for the treatment of opioid use disorder on 3 outcomes: additional substance use, average time to achieve 30 and 90 consecutive days of abstinence, and treatment retention rates at 90 and 365 days. METHODS Medical records of patients (N = 100) who were participating in telepsychiatry and in face-to-face group-based outpatient buprenorphine MAT programs were reviewed and assessed using descriptive statistical analysis. RESULTS In comparison with the telepsychiatry MAT group, the face-to-face MAT group showed no significant difference in terms of additional substance use, time to 30 days (P = 0.09) and 90 days of abstinence (P = 0.22), or retention rates at 90 and 365 days (P = 0.99). CONCLUSIONS We did not find any significant statistical difference between telepsychiatry buprenorphine MAT intervention through videoconference and face-to-face MAT treatment in our Comprehensive Opioid Addiction Treatment model for individuals diagnosed with opioid use disorder in terms of additional substance use, average time to 30 and 90 days of abstinence, and treatment retention rates.
Collapse
|
10
|
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.
Collapse
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.
| |
Collapse
|
11
|
Maremmani I, Rolland B, Somaini L, Roncero C, Reimer J, Wright N, Littlewood R, Krajci P, Alho H, D'Agnone O, Simon N. Buprenorphine dosing choices in specific populations: review of expert opinion. Expert Opin Pharmacother 2016; 17:1727-31. [PMID: 27376622 DOI: 10.1080/14656566.2016.1209486] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Treatment of opioid dependence with buprenorphine improves outcomes. Typical dosing ranges for all patients from clinical evidence and as defined in the product information are wide. For specific groups with complex clinical scenarios, there is no clear consensus on dosing choices to achieve best possible outcomes. AREAS COVERED The doses of buprenorphine used in 6 European countries was reviewed. A review of published evidence supported rapid induction with buprenorphine and the benefits of higher doses but did not identify clearly useful guidance on dosing choices for groups with complex clinical scenarios. An expert group of physicians with experience in addiction care participated in a discussion meeting to share clinical practice experience and develop a consensus on dosing choices. EXPERT OPINION There was general agreement that treatment outcomes can be improved by optimising buprenorphine doses in specific subgroups. Specific groups in whom buprenorphine doses may be too low and who could have better outcomes with optimised dosing were identified on the basis of clinical practice experience. These groups include people with severe addiction, high tolerance to opioids, and psychiatric comorbidities. In these groups it is recommended to review dosing choices to ensure buprenorphine dosing is sufficient.
Collapse
Affiliation(s)
- Icro Maremmani
- a Department of Neurosciences, Santa Chiara University Hospital , University of Pisa , Pisa , Italy
| | - Benjamin Rolland
- b Departments of Addiction Medicine and Pharmacology, INSERM , University Hospital of Lille , Lille , France
| | | | - Carlos Roncero
- d Addiction and Dual Diagnosis Unit, Department of Psychiatry , Vall d'Hebron Hospital , Barcelona , Spain
| | - Jens Reimer
- e Director at Centre for Interdisciplinary Addiction Research , University Medical Centre Hamburg-Eppendorf, Martini Strasse , Germany
| | - Nat Wright
- f Spectrum Community Health CIC , Wakefield , UK
| | | | - Peter Krajci
- h Division of Mental Health and Addiction, Department of Substance Use Disorder Treatment , Oslo University Hospital , Oslo , Norway
| | - Hannu Alho
- i HA, Clinicum, University of Helsinki and University Hospital , Helsinki , Finland
| | - Oscar D'Agnone
- j Faculty of Medical and Human Sciences, Institute of Brain Behaviour and Mental Health , University of Manchester , Manchester , UK
| | - Nicolas Simon
- k Service de Pharmacologie Clinique, Sainte Marguerite Hospital , Marseille , France.,l Department of Clinical Pharmacology , Medical School of Marseilles , Marseille , France.,m Aix Marseille University, INSERM, UMR 912 IRD, SESSTIM , Marseille , France
| |
Collapse
|
12
|
Webster L, Hjelmström P, Sumner M, Gunderson EW. Efficacy and safety of a sublingual buprenorphine/naloxone rapidly dissolving tablet for the treatment of adults with opioid dependence: A randomized trial. J Addict Dis 2016; 35:325-338. [DOI: 10.1080/10550887.2016.1195608] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
13
|
Timko C, Schultz NR, Cucciare MA, Vittorio L, Garrison-Diehn C. Retention in medication-assisted treatment for opiate dependence: A systematic review. J Addict Dis 2015; 35:22-35. [PMID: 26467975 DOI: 10.1080/10550887.2016.1100960] [Citation(s) in RCA: 309] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Retention in medication-assisted treatment among opiate-dependent patients is associated with better outcomes. This systematic review (55 articles, 2010-2014) found wide variability in retention rates (i.e., 19%-94% at 3-month, 46%-92% at 4-month, 3%-88% at 6-month, and 37%-91% at 12-month follow-ups in randomized controlled trials), and identified medication and behavioral therapy factors associated with retention. As expected, patients who received naltrexone or buprenorphine had better retention rates than patients who received a placebo or no medication. Consistent with prior research, methadone was associated with better retention than buprenorphine/naloxone. And, heroin-assisted treatment was associated with better retention than methadone among treatment-refractory patients. Only a single study examined retention in medication-assisted treatment for longer than 1 year, and studies of behavioral therapies may have lacked statistical power; thus, studies with longer-term follow-ups and larger samples are needed. Contingency management showed promise to increase retention, but other behavioral therapies to increase retention, such as supervision of medication consumption, or additional counseling, education, or support, failed to find differences between intervention and control conditions. Promising behavioral therapies to increase retention have yet to be identified.
Collapse
Affiliation(s)
- Christine Timko
- a Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System , Palo Alto , California , USA.,b Department of Psychiatry and Behavioral Sciences , Stanford University School of Medicine , Stanford , California , USA
| | - Nicole R Schultz
- c Department of Psychology , Auburn University , Auburn , Alabama , USA
| | - Michael A Cucciare
- d Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System , North Little Rock , Arkansas , USA.,e VA South Central (VISN 16) Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System , North Little Rock , Arkansas , USA.,f Department of Psychiatry , University of Arkansas for Medical Sciences , Little Rock , Arkansas , USA
| | - Lisa Vittorio
- g Research Service, Veterans Affairs Boston Heathcare System , Brockton , Massachusetts , USA
| | - Christina Garrison-Diehn
- a Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System , Palo Alto , California , USA.,b Department of Psychiatry and Behavioral Sciences , Stanford University School of Medicine , Stanford , California , USA.,h Geriatric Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System , Palo Alto , California , USA
| |
Collapse
|
14
|
Metz VE, Brandt L, Unger A, Fischer G. Substance abuse/dependence treatment: a European perspective. Subst Abus 2015; 35:309-20. [PMID: 24766667 DOI: 10.1080/08897077.2014.909377] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
During the past decade, substantial progress has been made in the field of addiction medicine in Europe, particularly regarding the development of new treatment interventions, resulting in a wide range of therapeutic options for patients with substance use disorders. However, not all interventions are evidence based. Patients with cannabis and cocaine/amphetamine use disorders and special patient populations especially lack evidence-based treatment recommendations. Many patients undergo treatment that has not been scientifically evaluated for quality and efficacy. Moreover, there are large disparities regarding availability and treatment access across Europe, with the new member states of the European Union (EU) reporting long waiting lists and low treatment coverage. Even in Austria, which ranks among the countries with relatively high treatment coverage and good diversification of treatment in opioid maintenance therapy due to the availability of methadone, buprenorphine, and slow-release oral morphine (SROM), a considerable population of untreated or inadequately treated patients exists. Treatment for substance use disorders in Europe still has scope for improvement in terms of treatment availability and access, which is ideally provided by further development and implementation of evidence-based interventions.
Collapse
Affiliation(s)
- Verena E Metz
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | | | | | | |
Collapse
|
15
|
Soyka M. New developments in the management of opioid dependence: focus on sublingual buprenorphine-naloxone. Subst Abuse Rehabil 2015; 6:1-14. [PMID: 25610012 PMCID: PMC4293937 DOI: 10.2147/sar.s45585] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Opioid maintenance therapy is a well-established first-line treatment approach in opioid dependence. Buprenorphine, a partial opioid agonist, has been found by numerous studies to be an effective and safe medication in the treatment of opioid dependence. At present, buprenorphine is available as a monodrug or in a fixed 4:1 ratio combination with naloxone. A diminished risk of diversion and abuse for the buprenorphine-naloxone combination is likely but not firmly established. Conventional formulations are given sublingually to avoid the hepatic first-pass effect. A novel film tablet is available only in the US and Australia. Other novel, sustained-release formulations (implant, depot) are currently being developed and tested. Recent studies, including a Cochrane meta-analysis, suggest that the retention with buprenorphine is lower than for methadone, but that buprenorphine may be associated with less drug use. Higher doses of buprenorphine are associated with better retention rates. Buprenorphine has a ceiling effect at the opioid receptor with regard to respiratory depression, and may cause fewer fatal intoxications than methadone. Possible antidepressant effects of buprenorphine and its use in comorbid psychiatric patients has not been studied in much detail. Clinical implications are discussed.
Collapse
Affiliation(s)
- Michael Soyka
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-Universität, Munich, Germany
- Private Hospital Meiringen, Meiringen, Switzerland
| |
Collapse
|
16
|
Buprenorphine maintenance and mu-opioid receptor availability in the treatment of opioid use disorder: implications for clinical use and policy. Drug Alcohol Depend 2014; 144:1-11. [PMID: 25179217 PMCID: PMC4252738 DOI: 10.1016/j.drugalcdep.2014.07.035] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 07/24/2014] [Accepted: 07/26/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Sublingual formulations of buprenorphine (BUP) and BUP/naloxone have well-established pharmacokinetic and pharmacodynamic profiles, and are safe and effective for treating opioid use disorder. Since approvals of these formulations, their clinical use has increased. Yet, questions have arisen as to how BUP binding to mu-opioid receptors (μORs), the neurobiological target for this medication, relate to its clinical application. BUP produces dose- and time-related alterations of μOR availability but some clinicians express concern about whether doses higher than those needed to prevent opioid withdrawal symptoms are warranted, and policymakers consider limiting reimbursement for certain BUP dosing regimens. METHODS We review scientific data concerning BUP-induced changes in μOR availability and their relationship to clinical efficacy. RESULTS Withdrawal suppression appears to require ≤50% μOR availability, associated with BUP trough plasma concentrations ≥1 ng/mL; for most patients, this may require single daily BUP doses of 4 mg to defend against trough levels, or lower divided doses. Blockade of the reinforcing and subjective effects of typical doses of abused opioids require <20% μOR availability, associated with BUP trough plasma concentrations ≥3 ng/mL; for most individuals, this may require single daily BUP doses >16 mg, or lower divided doses. For individuals attempting to surmount this blockade with higher-than-usual doses of abused opioids, even larger BUP doses and <10% μOR availability would be required. CONCLUSION For these reasons, and given the complexities of studies on this issue and comorbid problems, we conclude that fixed, arbitrary limits on BUP doses in clinical care or limits on reimbursement for this care are unwarranted.
Collapse
|
17
|
Soyka M. Buprenorphine–naloxone buccal soluble film for the treatment of opioid dependence: current update. Expert Opin Drug Deliv 2014; 12:339-47. [DOI: 10.1517/17425247.2014.953479] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
18
|
Respiratory effects of buprenorphine/naloxone alone and in combination with diazepam in naive and tolerant rats. Toxicol Lett 2014; 228:75-84. [DOI: 10.1016/j.toxlet.2014.04.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 04/09/2014] [Accepted: 04/10/2014] [Indexed: 11/18/2022]
|
19
|
Abstract
This paper is the thirty-fifth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2012 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).
Collapse
Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
| |
Collapse
|
20
|
Soyka M. Buprenorphine and buprenorphine/naloxone soluble-film for treatment of opioid dependence. Expert Opin Drug Deliv 2012; 9:1409-17. [DOI: 10.1517/17425247.2012.729574] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
21
|
Brailoiu GC, Deliu E, Hooper R, Dun NJ, Undieh AS, Adler MW, Benamar K, Brailoiu E. Agonist-selective effects of opioid receptor ligands on cytosolic calcium concentration in rat striatal neurons. Drug Alcohol Depend 2012; 123:277-81. [PMID: 22196236 PMCID: PMC3321394 DOI: 10.1016/j.drugalcdep.2011.11.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 11/12/2011] [Accepted: 11/29/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Buprenorphine is an opioid receptor ligand whose mechanism of action is incompletely understood. METHODS Using Ca(2+) imaging, we assessed the effects of buprenorphine, β-endorphin, and morphine on cytosolic Ca(2+) concentration [Ca(2+)](i), in rat striatal neurons. RESULTS Buprenorphine (0.01-1 μM) increased [Ca(2+)](i) in a dose-dependent manner in a subpopulation of rat striatal neurons. The effect of buprenorphine was largely reduced by naloxone, a non-selective opioid receptor antagonist, but not by μ, κ, δ or NOP-selective antagonists. β-Endorphin (0.1 μM) increased [Ca(2+)](i) with a lower amplitude and slower time course than buprenorphine. Similar to buprenorphine, the effect of β-endorphin was markedly decreased by naloxone, but not by opioid-selective antagonists. Morphine (0.1-10 μM), did not affect [Ca(2+)](i) in striatal neurons. CONCLUSIONS Our results suggest that buprenorphine and β-endorphin act on a distinct type/subtype of plasmalemmal opioid receptors or activate intracellular opioid-like receptor(s) in rat striatal neurons.
Collapse
Affiliation(s)
- G. Cristina Brailoiu
- Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, 19140
| | - Elena Deliu
- Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, 19140
| | - Robert Hooper
- Department of Biochemistry, Temple University School of Medicine, Philadelphia, PA, 19140
| | - Nae J. Dun
- Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, 19140
| | - Ashiwel S. Undieh
- Laboratory of Integrative Neuropharmacology, Department of Pharmaceutical Sciences, Thomas Jefferson University School of Pharmacy, Philadelphia, PA 19107
| | - Martin W. Adler
- Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, 19140
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, 19140
| | - Khalid Benamar
- Center for Substance Abuse Research, Temple University School of Medicine, Philadelphia, PA, 19140
- Correspondence to: Khalid Benamar () or Eugen Brailoiu ()
| | - Eugen Brailoiu
- Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, 19140
- Correspondence to: Khalid Benamar () or Eugen Brailoiu ()
| |
Collapse
|