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Jones M, Guirguis A, Watkins A, Bradshaw C, Mohamed L, Schifano F. Obstacles to treatment retention in opioid use disorder: An international substance use disorder treatment worker survey. Hum Psychopharmacol 2023; 38:e2882. [PMID: 37776029 DOI: 10.1002/hup.2882] [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: 04/12/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION Treatment retention is associated with better outcomes and reduced risk amongst people experiencing opioid use disorder (OUD). Despite this, treatment retention remains low amongst this population. METHODS We carried out an international cross-sectional survey of substance use disorder (SUD) treatment service workers. We aimed to understand the barriers to treatment retention in the context of OUD from the provider perspective, identify differences in response preference between professional groups, and describe regional differences in treatment provision. RESULTS We report data from 497 respondents based in the USA and the UK. Personality disorders, low motivation to change and social problems were the most often reported obstacles to retention. Comorbid SUD, hepatitis and HIV were not reported as often as expected. We identified associations between professional groups and response preferences related to comorbid SUD, low motivation, living arrangements and communication difficulties. UK respondents used behavioural treatments more than their US counterparts. US respondents more often reported using objective methods of measuring retention such as urine analysis, compared to their UK counterparts. DISCUSSION The findings from this survey suggest that regional differences exist between US and UK based SUD treatment service workers. Personality disorders represented the most often experienced obstacles to treatment retention amongst patients with OUD, with mental health and social problems more often reported than comorbid drug problems or physical health problems. Statistically significant relationships exist between professional group and obstacles reported. These data may be used to identify additional training needs amongst SUD treatment service staff.
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Affiliation(s)
| | | | | | | | - Lily Mohamed
- Cwm Taf Morgannwg University Health Board, Abercynon, UK
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Morse JD, Anderson BJ, Gastine S, Wong ICK, Standing JF. Pharmacokinetic modeling and simulation to understand diamorphine dose-response in neonates, children, and adolescents. Paediatr Anaesth 2022; 32:716-726. [PMID: 35212432 DOI: 10.1111/pan.14425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/19/2022] [Accepted: 02/21/2022] [Indexed: 11/28/2022]
Abstract
Pharmacokinetic-pharmacodynamic modeling and simulation can facilitate understanding and prediction of exposure-response relationships in children with acute or chronic pain. The pharmacokinetics of diamorphine (diacetylmorphine, heroin), a strong opioid, remain poorly quantified in children and dose is often guided by clinical acumen. This tutorial demonstrates how a model to describe intranasal and intravenous diamorphine pharmacokinetics can be fashioned from a model for diamorphine disposition in adults and a model describing morphine disposition in children. Allometric scaling and maturation models were applied to clearances and volumes to account for differences in size and age between children and adults. The utility of modeling and simulation to gain insight into the analgesic exposure-response relationship is demonstrated. The model explains reported observations, can be used for interrogation, interpolated to determine equianalgesia and inform future clinical studies. Simulation was used to illustrate how diamorphine is rapidly metabolized to morphine via its active metabolite 6-monoacetylmorphine, which mediates an early dopaminergic response accountable for early euphoria. Morphine formation is then responsible for the slower, prolonged analgesic response. Time-concentration profiles of diamorphine and its metabolites reflected disposition changes with age and were used to describe intravenous and intranasal dosing regimens. These indicated that morphine exposure in children after intranasal diamorphine 0.1 mg.kg-1 was similar to that after intranasal diamorphine 5 mg in adults. A target concentration of morphine 30 μg.L-1 can be achieved by a diamorphine intravenous infusion in neonates 14 μg.kg-1 .h-1 , in a 5-year-old child 42 μg.kg-1 .h-1 and in an 15 year-old-adolescent 33 μg.kg-1 .h-1 .
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Affiliation(s)
- James D Morse
- Department of Pharmacology & Clinical Pharmacology, Auckland University, Auckland, New Zealand
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Silke Gastine
- Infection, Immunity, and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Ian C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Joseph F Standing
- Infection, Immunity, and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
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Eberhart L, Geldner G, Huljic S, Marggraf K, Keller T, Koch T, Kranke P. A non-interventional comparative study of the 20:1 combination of cafedrine/theodrenaline versus ephedrine for the treatment of intra-operative arterial hypotension: the 'HYPOTENS' study design and rationale. Curr Med Res Opin 2018; 34:953-961. [PMID: 29415580 DOI: 10.1080/03007995.2018.1438379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 01/24/2018] [Accepted: 01/29/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare the effectiveness of 20:1 cafedrine/theodrenaline approved for use in Germany to ephedrine in the restoration of arterial blood pressure and on post-operative outcomes in patients with intra-operative arterial hypotension of any origin under standard clinical practice conditions. METHODS AND RESULTS 'HYPOTENS' is a national, multi-center, prospective, open-label, two-armed, non-interventional study. Effectiveness and post-operative outcome following cafedrine/theodrenaline or ephedrine therapy will be evaluated in two cohorts of hypotensive patients. Cohort A includes patients aged ≥50 years with ASA-classification 2-4 undergoing non-emergency surgical procedures under general anesthesia. Cohort B comprises patients undergoing Cesarean section under spinal anesthesia. Participating surgical departments will be assigned to a treatment arm by routinely used anti-hypotensive agent. To minimize bias, matched department pairs will be compared in a stratified selection process. The composite primary end-point is the lower absolute deviation from individually determined target blood pressure (IDTBP) and the incidence of heart rate ≥100 beats/min in the first 15 min. Secondary end-points include incidence and degree of early post-operative delirium (cohort A), severity of fetal acidosis in the newborn (cohort B), upper absolute deviation from IDTBP, percentage increase in systolic blood pressure, and time to IDTBP. CONCLUSION This open-label, non-interventional study design mirrors daily practice in the treatment of patients with intra-operative hypotension and ensures full treatment decision autonomy with respect to each patient's individual condition. Selection of participating sites by a randomization process addresses bias without interfering with the non-interventional nature of the study. First results are expected in 2018. ClinicalTrials.gov identifier: NCT02893241; DRKS identifier: DRKS00010740.
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Affiliation(s)
- Leopold Eberhart
- a Department of Anaesthesiology and Intensive Care , Philipps-Universität Marburg , Marburg , Germany
| | - Götz Geldner
- b Clinic for Intensive Care, Emergency Medicine and Pain Therapy , Klinikum Ludwigsburg , Ludwigsburg , Germany
| | | | | | | | - Tilo Koch
- a Department of Anaesthesiology and Intensive Care , Philipps-Universität Marburg , Marburg , Germany
| | - Peter Kranke
- f Department of Anaesthesia and Critical Care , University Hospital Würzburg , Würzburg , Germany
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Rhodes E, Andreae M, Bourgiose T, Indyk D, Rhodes R, Sacks H. Stakeholders’ Views on Barriers to Research on Controlled Substances. THE JOURNAL OF CLINICAL ETHICS 2016. [DOI: 10.1086/jce2016274308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Rhodes E, Andreae M, Bourgiose T, Indyk D, Rhodes R, Sacks H. Stakeholders' Views on Barriers to Research on Controversial Controlled Substances. THE JOURNAL OF CLINICAL ETHICS 2016; 27:308-321. [PMID: 28001138 PMCID: PMC5559713 DOI: 10.3109/15360288.2010.529988] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Many diseases and disease symptoms still lack effective treatment. At the same time, certain controversial Schedule I drugs, such as heroin and cannabis, have been reputed to have considerable therapeutic potential for addressing significant medical problems. Yet, there is a paucity of U.S. clinical studies on the therapeutic uses of controlled drugs. For example, people living with HIV/AIDS experience a variety of disease- and medication-related symptoms. Their chronic pain is intense, frequent, and difficult to treat. Nevertheless, clinical trials of compassionate management for their chronic symptoms, which should be a research priority, are stymied. We employed qualitative methods to develop an understanding of the barriers to research on potential therapeutic uses of Schedule I drugs so that they might be addressed. We elicited the perspectives of key stakeholder groups that would be involved in such studies: people living with HIV/AIDS, clinicians, and members of institutional review boards. As we identified obstacles to research, we found that all of the stakeholder groups arrived at the same conclusion, that clinical research on the therapeutic potential of these drugs is ethically required.
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Affiliation(s)
- Evelyn Rhodes
- Icahn School of Medicine at Mt. Sinai, One Gustave L. Levy Place, Box 1076, Annenberg 12-42, New York, New York 10029 USA.
| | - Michael Andreae
- Albert Einstein College of Medicine, Montefiore Medical Center, 111 E 210th St., Bronx, New York 10467 USA
| | | | - Debbie Indyk
- Icahn School of Medicine at Mt. Sinai, One Gustave L. Levy Place, Box 1076, Annenberg 12-42, New York, New York 10029 USA
| | - Rosamond Rhodes
- Icahn School of Medicine at Mt. Sinai, One Gustave L. Levy Place, Box 1076, Annenberg 12-42, New York, New York 10029 USA
| | - Henry Sacks
- Icahn School of Medicine at Mt. Sinai, One Gustave L. Levy Place, Box 1076, Annenberg 12-42, New York, New York 10029 USA
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Andreae MH, Rhodes E, Bourgoise T, Carter GM, White RS, Indyk D, Sacks H, Rhodes R. An Ethical Exploration of Barriers to Research on Controlled Drugs. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:36-47. [PMID: 26982922 PMCID: PMC4849133 DOI: 10.1080/15265161.2016.1145282] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
We examine the ethical, social, and regulatory barriers that may hinder research on therapeutic potential of certain controversial controlled substances like marijuana, heroin, or ketamine. Hazards for individuals and society and potential adverse effects on communities may be good reasons for limiting access and justify careful monitoring of these substances. Overly strict regulations, fear of legal consequences, stigma associated with abuse and populations using illicit drugs, and lack of funding may, however, limit research on their considerable therapeutic potential. We review the surprisingly sparse literature and address the particular ethical concerns pertinent to research with illicit and addictive substances, such as undue inducement, informed consent, therapeutic misconception, and risk to participants, researchers, and institutions. We consider the perspectives of key research stakeholders and explore whether they may be infected with bias. We conclude by proposing an empirical research agenda to provide an evidentiary basis for ethical reasoning.
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Pecoraro A, Ma M, Woody GE. The science and practice of medication-assisted treatments for opioid dependence. Subst Use Misuse 2012; 47:1026-40. [PMID: 22676570 DOI: 10.3109/10826084.2012.663292] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This paper briefly reviews the evolution of opioid addiction treatment from humanitarian to scientific and evidence-based, the evidence bases supporting major medication-assisted treatments and adjunctive psychosocial techniques, as well as challenges faced by clinicians and treatment providers seeking to provide those treatments. Attitudes, politics, policy, and financial issues are discussed.
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Affiliation(s)
- Anna Pecoraro
- Perelman School of Medicine, University of Pennsylvania, 150 S.Independence Mall West, Philadelphia, PA 19106-3414, USA
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Niscola P, Sorrentino F, Scaramucci L, de Fabritiis P, Cianciulli P. Pain syndromes in sickle cell disease: an update. PAIN MEDICINE 2009; 10:470-80. [PMID: 19416438 DOI: 10.1111/j.1526-4637.2009.00601.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Pain has a critical role in the management of sickle cell disease (SCD). Patients may suffer from several pain syndromes, which may be or not may be associated with other clinical complications, such as anemia, organ failures, and infections. DESIGN Data for review were identified by using PubMed to search MEDLINE, limiting the search to abstract/articles in English, Italian, French, and Dutch. The key words pain, sickle cell disease, anemia, hemoglobin, hemoglobinopathy, analgesics, opioids, morphine, acetaminophen, paracetamol, nonsteroidal anti-inflammatory drugs, hematology, and quality of life were variously combined in the title, abstract, and key word search list. The abstract database of most hematological congresses and the bibliographies of most relevant articles were also considered. RESULTS There are two major types of SCD pain: acute and chronic. Sometimes, mixed and neuropathic pain can be also observed. Acute pain is mostly related to vaso-occlusion. Chronic pain may be due to some SCD complications, such as leg ulcers and avascular necrosis. CONCLUSIONS Pain management in the SCD setting needs multidisciplinary approaches, given the several syndromes and the pathogenic mechanisms that are likely involved. Pain management is not standardized and often difficult, so that many patients with SCD are still poorly treated. Further efforts to develop care plans and treatment protocols as well as management guidelines are required.
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Abstract
This paper is the 28th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over a quarter-century of research. It summarizes papers published during 2005 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, neurophysiology and transmitter release (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, 65-30 Kissena Blvd., Flushing, NY 11367, USA.
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Niscola P, Scaramucci L, Romani C, Giovannini M, Maurillo L, del Poeta G, Cartoni C, Arcuri E, Amadori S, De Fabritiis P. Opioids in pain management of blood-related malignancies. Ann Hematol 2006; 85:489-501. [PMID: 16572325 DOI: 10.1007/s00277-005-0062-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2005] [Accepted: 12/01/2005] [Indexed: 10/24/2022]
Abstract
Opioids are basic analgesics used in the treatment of moderate to severe pain in patients affected by blood-related malignancies. They should be sequentially administered according to the World Health Organisation scale for cancer pain. Initial treatment and titration with opioids should be based on immediate-release preparations, to be administered at appropriate intervals in order to relieve pain and to satisfy the individual opioid requirement. Once a relatively good pain control has been achieved, a slow release formulation at equivalent doses can be given. Most patients can be adequately managed using oral formulation opioids. However, a small group, such as those presenting severe mucositis or requiring a rapid pain relief, should be managed by intravenous continuous infusion and/or by a patient-controlled analgesia system; while for patients in the community, there are distinct advantages to using the subcutaneous route. Other available routes of administration for opioids, can be used in selected circumstances, including rectal, transdermal, epidural, intrathecal and intramuscular. The invasive neuraxial route has a very limited role in patients with haematological malignancies, given the high risk of infection and bleeding. Through a close observation and a careful management, opioid-related side effects can be effectively prevented and treated. This article reviews the principles of opioid therapy and how opioids can be adapted for patients with pain due to haematological malignancies.
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Affiliation(s)
- Pasquale Niscola
- Hematology Division, Sant'Eugenio Hospital, Tor Vergata University, Via dell'Umanesimo 10, 00144, Rome, Italy.
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