The Impact of Misuse and Diversion of Opioid Substitution Treatment Medicines: Evidence Review and Expert Consensus

Supervised on-site dosing in injectable opioid agonist treatment-considering the patient perspective. Findings from a cross-sectional interview study in two German cities

BACKGROUND

Injectable opioid agonist treatment (iOAT) is an effective option to support people living with opioid use disorder (OUD) who have not sufficiently benefitted from oral OAT. However, iOAT has been criticised based on theoretical and practical grounds for its dosing policies: Current regulations demand supervised, on-site application and require patients to frequently visit their treatment facility. The current study aims to investigate how patients experience on-site application and derive strategies to enhance the acceptability and effectiveness of iOAT-delivery.

METHODS

This article is based on semi-structured interviews with 27 individuals currently or previously in iOAT in two German outpatient iOAT-clinics. We undertook an inductive qualitative content analysis, which included blinded, independent coding and the analysis of individual cases.

RESULTS

Comments regarding on-site application and daily visits to the clinic were grouped into positive and negative aspects, iOAT as the best alternative option, facilitators of daily visits, and suggestions for improvement. Positive aspects took the factors stability and social support in regard. Negative aspects ranged from general inconveniences to major impediments to individuals' daily lives and towards achieving psychosocial goals. Participants reported rigorous adherence to iOAT's treatment regime, often due to a perceived lack of alternative options. Meeting iOAT's demands was eased by the patients' coping-strategies and through facilitating measures implemented by iOAT-clinics. Despite acknowledgement of the potential detriments from easing regulations, take-home arrangements were frequently suggested by participants to improve iOAT.

CONCLUSIONS

Being required to attend the clinic for supervised iOAT-application is not experienced uniformly. While clinics can support their patients to cope with strict regulations, alternative approaches to iOAT-application should be considered to accommodate patients' individual needs. Examples from other treatment modalities (e.g., remote supervision and delivery services) might aid to reconcile individualisation while providing adequate safety measures and improve iOAT in the long term.

Challenges Faced and Coping Strategies Adopted by Injecting Drug Users during COVID-19 Lockdown-A Qualitative Study

Background

The lockdown due to COVID-19 pandemic has adversely affected the lives of vulnerable population, including the injecting drug users (IDUs). The objective of the study was to document the coping mechanism adopted by IDUs and suggest measures to mitigate the adverse effects, if similar situation were to arise in future.

Materials and Methods

A qualitative study was conducted at the Targeted Intervention Non-Government Organizations catering to IDUs in Delhi and Ghaziabad district of Uttar Pradesh. Four focus group discussions among 41 IDUs and 7 key informant interviews of the NGO staff were conducted in the study. The Hindi recordings were coded and the data analysis was performed manually using grounded theory approach.

Results

We found that the lockdown affected the lives of most of the IDUs and they found it difficult to access the harm reduction services. To cope with this, many IDUs started following alternate methods to support the drug habits. There was an increase in reuse of needles and syringes.

Conclusion

The lockdown during COVID-19 and the resulting challenges negatively impacted the physical and mental health of the IDUs. We recommend that in any similar future scenario, travel pass may be issued to the IDUs and the TI-NGO personnel.

Long-Acting Buprenorphine Formulations as a New Strategy for the Treatment of Opioid Use Disorder

Long-acting buprenorphine formulations have been recently marketed for the Opioid Agonist Treatment (OAT) of opioid use disorder (OUD) associated with medical, social, and psychological support. Their duration of action ranges from one week up to 6 months. The non-medical use of opioids is increasing with a parallel rise in lethal overdoses. Methadone and buprenorphine are the standard treatment for opioid dependence. Methadone Maintenance Treatment (MMT) is widely recognized as one of the most effective ways of reducing the risks of overdose, crime, and transmission of HIV (Human Immunodeficiency Virus) in people who use opioids; however, its effectiveness has been hindered by low rates of uptake and retention in treatment. Furthermore, both methadone and buprenorphine are widely diverted and misused. Thus, a crucial aspect of treating OUD is facilitating patients' access to treatment while minimizing substance-related harm and improving quality of life. The newly developed long-acting buprenorphine formulations represent a significant change in the paradigm of OUD treatment, allowing an approach individualized to patients' needs. Strengths of this individualized approach are improved adherence (lack of peaks and troughs in blood concentrations) and a reduced stigma since the patient doesn't need to attend their clinic daily or nearly daily, thus facilitating social and occupational integrations as the quality of life. However, less frequent attendance at the clinic should not affect the patient-physician relationship. Therefore, teleconsulting or digital therapeutic services should be developed in parallel. In addition, diversion and intravenous misuse of buprenorphine are unlikely due to the characteristics of these formulations. These features make this approach of interest for treating OUD in particular settings, such as subjects staying or when released from prison or those receiving long-term residential treatment for OUD in the therapeutic communities. The long-lasting formulations of buprenorphine can positively impact the OUD treatment and suggest future medical and logistic developments to maximize their personalized management and impact.

Evaluating the feasibility of prolonged-release buprenorphine formulations as an alternative to daily opioid agonist therapy regardless of prior treatment adherence: a pilot study

BACKGROUND

Effective opioid agonist therapy (OAT) depends on good patient adherence. However, the daily, supervised administration of standard OAT represents a significant burden to patients and often drives poor adherence. Prolonged-release buprenorphine (PRB) formulations may mitigate some of this burden, enabling clinic visits to be substantially reduced. For treatment guidelines to be effective, the likely benefit of a transition to PRB therapy in different patient populations must be established.

METHODS

The aim was to determine the feasibility of assessing PRB as an alternative to daily OAT in two groups: those currently adhering well to daily OAT (group 1, N = 5) and those not currently showing adherence or a positive response to daily OAT (group 2, N = 10). This open-label, prospective, non-controlled pilot study was conducted at the Kaleidoscope Drug Project in South Wales, UK. Participants were assessed for history, drug use, psychosocial assessment scores, and clinical severity at baseline and after 6 months of treatment. Primary outcomes were the feasibility of assessing PRB as an alternative to daily OAT and the acceptability of PRB therapy in each group. Secondary outcomes were treatment response, on-top drug use, psychosocial measures, and assessment of clinical severity.

RESULTS

Participants from both groups demonstrated high levels of participation with assessment protocols at both baseline and 6-month follow-up, indicating study feasibility. PRB treatment was acceptable to the majority of participants, with all of group 1 and 70% of group 2 adhering to PRB therapy for the duration of the study and opting to persist with PRB therapy over other OAT options after study completion. All participants who remained on treatment demonstrated marked improvements in psychosocial and clinical severity assessment scores, with some returning to employment or education. On-top drug use remained absent in group 1 and was reduced in group 2.

CONCLUSIONS

Evaluation of transition of participants from daily OAT to PRB therapy was shown to be feasible, acceptable, and effective across both groups. A larger randomised controlled trial is warranted, particularly to assess PRB therapy in participants with a history of poor treatment engagement, as the need for therapy is greater in this group and their management is associated with higher costs of care.

Clients' experiences on North America's first take-home injectable opioid agonist treatment (iOAT) program: a qualitative study

BACKGROUND

To support public health measures during the COVID-19 pandemic, oral opioid agonist treatment (OAT) take-home doses were expanded in Western countries with positive results. Injectable OAT (iOAT) take-home doses were previously not an eligible option, and were made available for the first time in several sites to align with public health measures. Building upon these temporary risk-mitigating guidelines, a clinic in Vancouver, BC continued to offer two of a possible three daily doses of take-home injectable medications to eligible clients. The present study explores the processes through which take-home iOAT doses impacted clients' quality of life and continuity of care in real-life settings.

METHODS

Three rounds of semi-structured qualitative interviews were conducted over a period of seventeen months beginning in July 2021 with eleven participants receiving iOAT take-home doses at a community clinic in Vancouver, British Columbia. Interviews followed a topic guide that evolved iteratively in response to emerging lines of inquiry. Interviews were recorded, transcribed, and then coded using NVivo 1.6 using an interpretive description approach.

RESULTS

Participants reported that take-home doses granted them the freedom away from the clinic to have daily routines, form plans, and enjoy unstructured time. Participants appreciated the greater privacy, accessibility, and ability to engage in paid work. Furthermore, participants enjoyed greater autonomy to manage their medication and level of engagement with the clinic. These factors contributed to greater quality of life and continuity of care. Participants shared that their dose was too essential to divert and that they felt safe transporting and administering their medication off-site. In the future, all participants would like more accessible treatment such as access longer take-home prescriptions (e.g., one week), the ability to pick-up at different and convenient locations (e.g., community pharmacies), and a medication delivery service.

CONCLUSIONS

Reducing the number of daily onsite injections from two or three to only one revealed the diversity of rich and nuanced needs that added flexibility and accessibility in iOAT can meet. Actions such as licencing diverse opioid medications/formulations, medication pick-up at community pharmacies, and a community of practice that supports clinical decisions are necessary to increase take-home iOAT accessibility.

Provider experiences with relaxing restrictions on take-home medications for opioid use disorder during the COVID-19 pandemic: A qualitative systematic review

BACKGROUND

Historical restrictions on take-home medications for opioid use disorder have generated considerable debate. The COVID-19 pandemic shifted the perceived risks and benefits of daily clinic attendance and led to widespread policy reform, creating an unprecedented opportunity to explore the impact of more flexible prescribing. We conducted a qualitative systematic review to synthesize the evidence on providers' experiences with relaxing restrictions on take-home doses of medications prescribed for opioid use disorder during the COVID-19 pandemic.

METHODS

The protocol for this systematic review was registered in PROSPERO (CRD42022360589; https://www.crd.york.ac.uk/prospero/). From Sept.-Nov. 2022, we searched Medline, Embase, CINAHL, PsycInfo, Web of Science, the Cochrane Register of Controlled Trials, and the grey literature from 2020 onward. Studies were eligible for inclusion if they used qualitative methods to investigate providers' experiences with relaxed restrictions on take-home medications for opioid use disorder during the COVID-19 pandemic. We appraised study quality using the CASP qualitative checklist and used thematic synthesis and GRADE-CERQual to synthesize the results.

RESULTS

We retrieved 13 articles representing 11 studies. Six were conducted in the United States and most focused on changes to methadone treatment. Providers' experiences with increased flexibilities around take-homes were broadly positive, despite widespread initial concern over client safety and the potential for medication misuse. For a small number of providers, concerns about diversion were a specific manifestation of more general unease with loss of control over clients and the treatment process. Most providers appreciated increased flexibilities and described them as enabling more individualized, person-centered care.

CONCLUSION

Our findings support the continuation of flexibilities around take-homes and demonstrate that regulations and policies that reduce flexibility around take-homes conflict with person-centered approaches to care. Stronger guidance and support from professional regulatory agencies may help increase uptake of flexibilities around take-homes.

The Impact of Parental Opioid Use Disorder on Children in Rural Texas

The impact of opioid use disorder (OUD) on children is of increasing concern to providers and communities and is yet to be fully understood. Children and families in rural areas are particularly vulnerable due to decreased access to care, lower socioeconomic status, and lower rates of health insurance coverage. This qualitative secondary data analysis of transcripts from interviews with community stakeholders specifically examined responses when asked how parental OUD impacted children in their rural communities. Methods and Materials: As part of a larger community assessment, 11 focus group and three individual interviews with a variety of stakeholders most likely to encounter those with or at risk for substance use disorder from a predominately rural region of Texas were held in October of 2019. During one-hour sessions a scripted interview guide was used to ask open-ended questions to identify the prevalence and impact of OUD within the community. Transcripts of recorded interviews were coded by three researchers using conventional content analysis focusing on discussion of how parental OUD impacted children in their rural communities. Codes were classified into themes based on consensus. Results: Identified themes were (1) Community Concern for Families; (2) Impaired Parents, Neglected Children, and (3) Intergenerational Normalization of Substance Misuse. Conclusions: The impact of parental OUD and SUD was a concern for participants. Findings have implications for strategies to prevent and mitigate adverse outcomes for children and families in rural areas.

Misuse of Over the Counter and Prescription Only Medication by Adults Accessing Specialist Treatment Services in the UK: A Narrative Synthesis

Background:

Concerns about the misuse of over the counter (OTC) and prescription only medication (POM) are due to their impact upon physical/mental wellbeing, drug interactions and drug-related deaths. Improving an understanding of the pattern of use by people accessing specialist substance misuse services (SMSs) should enable improvements to treatment provision.

Aim:

To review the literature on the misuse of OTC/POM among adults accessing SMS, including the pattern of use, types of medication and associated characteristics.

Methods:

This review is reported in line with PRISMA. The protocol has been registered on PROSPERO (CRD42020135216) and separately published. A search of Cochrane, OVID Medline, Pubmed, Scopus and Web of Science databases and grey literature was undertaken. Only English language publications outlining OTC/POM misuse by adults in receipt of psychological/pharmacological interventions for substance misuse were included. Two reviewers conducted the title, abstract and full-text reviews using predetermined selection criteria and a piloted data extraction form to ensure a consistent approach. A third reviewer resolved disagreements and the Mixed Methods Appraisal Tool assessed for bias. Ethical approval was not required.

Results:

Thirteen studies with notable heterogeneity were included in the narrative synthesis after non-UK-based and ineligible publications were excluded, from the 143 potentially relevant papers. To reduce bias all studies were included in the analysis and GRADE-CERQual was applied. ‘High confidence’ was identified for all review findings, despite moderate methodological limitations. Antihistamine, benzodiazepine and opioid misuse was mentioned most frequently. Usage patterns and supply sources varied. Adverse consequences and polypharmacy are concerning. Withdrawal symptoms perpetuated misuse, often alongside illicit substance use, comorbid psychiatric/pain disorders and street drug shortages.

Conclusion:

OTC/POM misuse is common amongst adults accessing SMS. A renewed approach to withdrawal management is required. The limited number of studies may impact on generalisability but allowed for a more detailed review. Restricting to UK studies improved relevance due to drug market variations and availability of medicines in different countries. Further UK-based research on OTC/POM misuse in SMS is needed to build upon the current paucity in the published literature.

The use of diverted pharmaceutical opioids is associated with reduced risk of fentanyl exposure among people using unregulated drugs in Vancouver, Canada

BACKGROUND

Although non-medical use of pharmaceutical opioids (POs) is associated with a number of risks, in the context of the opioid-overdose crisis, it may have the secondary benefit of decreasing the risk of exposure to more potent opioids from unregulated sources. The aim of this study was to assess the effects of using diverted POs on fentanyl exposure.

METHODS

Using data from two prospective community-recruited cohorts of people who use drugs (PWUD) in Vancouver, Canada, we estimated the independent relationship between using diverted POs and fentanyl exposure (assessed through urine drug test [UDT]) between 2016 and 2018. We also explored if participant characteristics modified this relationship.

RESULTS

Over the study period, among 1150 participants, 241 (21.0%) reported using diverted POs in 292 (12.8%) occasions. In adjusted analyses, PWUD using diverted POs had decreased odds of fentanyl exposure (Adjusted odds ratio [AOR] = 0.70, 95% CI: 0.52-0.94). The reduced odds of fentanyl exposure persisted among participants with morphine positive UDT (AOR = 0.57, 95% CI: 0.40-0.82), but not among those with negative morphine UDT (AOR = 0.91, 95% CI: 0.54-1.55).

CONCLUSION

PWUD using diverted POs in our sample were 30% less likely to be exposed to fentanyl. This reduced likelihood was primarily observed among PWUD with morphine positive UDT, which could partially be explained by longer duration of action and lower street cost of slow-release oral morphine relative to other POs and fentanyl. Findings suggest that access to a regulated supply of pharmaceutical-grade opioids may serve to reduce fentanyl-related harms.

[Opioids substitution therapy: A respect for the dignity of the human person]

The Opioid substitution treatment (OST) has been highly argumentative in ways that raise important ethical issues. The stigma in treating opioid addiction continues to be a major barrier to effective management plan. It prevents individuals from seeking treatment and is associated with poor mental and physical health. OST are considered to improve outcomes in opioid dependency. They are legitimate therapeutic options because they comply with the four principles of bioethics: autonomy, no maleficence, beneficence and justice. OST plan should conceived in a way that outcomes only giving a medication to the patient. It has many ethical aspects that should be valued: fairness, respect and solidarity. However, OST may be misused or diverted, resulting in negative treatment outcomes, here comes the important role of the multidisciplinary treatment plan to contain and prevent from misuse. We will be discussing in this paper the ethical aspect of the OST and the values that should be promoted, in order to cherish and enhance the dignity of the human being, by replacing a deadly disease with a chronic one giving the patient a chance to lead a normal life.

Misuse of medication in adult substance misuse services: a systematic review protocol

INTRODUCTION

There is a growing concern about the misuse of over the counter (OTC) and prescription only medication (POM) because of the impact on physical and mental health, drug interactions, overdoses and drug-related deaths. These medicines include opioid analgesics, anxiolytics such as pregabalin and diazepam and antidepressants. This protocol outlines how a systematic review will be undertaken (during June 2021), which aims to examine the literature on the pattern of OTC and POM misuse among adults who are accessing substance misuse treatment services. It will include the types of medication being taken, prevalence and demographic characteristics of people who access treatment services.

METHODS AND ANALYSIS

An electronic search will be conducted on the Cochrane, OVID Medline, Pubmed, Scopus and Web of Science databases as well as grey literature. Two independent reviewers will conduct the initial title and abstract screenings, using predetermined criteria for inclusion and exclusion. If selected for inclusion, full-text data extraction will be conducted using a pilot-tested data extraction form. A third reviewer will resolve disagreements if consensus cannot be reached. Quality and risk of bias assessment will be conducted for all included studies. A qualitative synthesis and summary of the data will be provided. If possible, a meta-analysis with heterogeneity calculation will be conducted; otherwise, Synthesis Without Meta-analysis will be undertaken for quantitative data. The reporting of this protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

ETHICS AND DISSEMINATION

Ethical approval is not required. Findings will be peer reviewed, published and shared verbally, electronically and in print, with interested clinicians and policymakers.

PROSPERO REGISTRATION NUMBER

CRD42020135216.

Executive Summary of the Focused Update of the ASAM National Practice Guideline for the Treatment of Opioid Use Disorder

: A Focused Update of the ASAM National Practice Guideline for the Treatment of Opioid Use Disorder is published in the current issue of the Journal of Addiction Medicine. The focused update included a search of Medline's PubMed database from January 1, 2014 to September 27, 2018, as well as a search of the grey literature (archives of the Clinical Guideline Clearinghouse, and key agency and society websites) for new practice guidelines and relevant systematic reviews addressing the use of medications and psychosocial treatments in the treatment of opioid use disorder, including within special populations. The search identified 11 practice guidelines and 35 systematic reviews that informed the subsequent RAND/UCLA Appropriateness Method (RAM) process employed to facilitate the focused update by a National Guideline Committee of addiction experts. New and updated recommendations were included if they were considered: (a) clinically meaningful and applicable to a broad range of clinicians treating addiction involving opioid use; and (b) urgently needed to ensure the Practice Guideline reflects the current state of the science for the existing recommendations, aligns with other relevant practice guidelines, and reflects newly approved medications and formulations.

Take home injectable opioids for opioid use disorder during and after the COVID-19 Pandemic is in urgent need: a case study

Background

In North America the opioid poisoning crisis currently faces the unprecedented challenges brought by the COVID-19 pandemic, further straining people and communities already facing structural and individual vulnerabilities. People with opioid use disorder (OUD) are facing unique challenges in response to COVID-19, such as not being able to adopt best practices (e.g., physical distancing) if they’re financially insecure or living in shelters (or homeless). They also have other medical conditions that make them more likely to be immunocompromised and at risk of developing COVID-19. In response to the COVID-19 public health emergency, national and provincial regulatory bodies introduced guidance and exemptions to mitigate the spread of the virus. Among them, clinical guidance for prescribers were issued to allow take home opioid medications for opioid agonist treatment (OAT). Take Home for injectable opioid agonist treatment (iOAT) is only considered within a restrictive regulatory structure, specific to the pandemic. Nevertheless, this risk mitigation guidance allowed carries, mostly daily dispensed, to a population that would not have access to it prior to the pandemic. In this case it is presented and discussed that if a carry was possible during the pandemic, then the carry could continue post COVID-19 to address a gap in our approach to individualize care for people with OUD receiving iOAT.

Case presentation

Here we present the first case of a patient in Canada with long-term OUD that received take home injectable diacetylmorphine to self-isolate in an approved site after being diagnosed with COVID-19 during a visit to the emergency room where he was diagnosed with cellulitis and admitted to receive antibiotics.

Conclusion

In the present case we demonstrated that it is feasible to provide iOAT outside the community clinic with no apparent negative consequences. Improving upon and making permanent these recently introduced risk mitigating guidance during COVID-19, have the potential not just to protect during the pandemic, but also to address long-overdue barriers to access evidence-based care in addiction treatment.

Risk of PTSD Due to the COVID-19 Pandemic Among Patients in Opioid Substitution Treatment

Background: The impact of the COVID-19 pandemic on the mental health of patients suffering from addictive disorders is of major concern. This study aimed to explore the presence and potential increase in post-traumatic stress disorder (PTSD) symptoms, depression, and anxiety since the beginning of the pandemic for patients in opioid substitution therapy (OST). Methods: This cross-sectional survey study evaluated a clinical sample of patients in OST (N = 123). Symptoms of post-traumatic stress disorder (PTSD) due to the COVID-19 pandemic were assessed by an adapted version of the impact of event scale (IES-R), resulting in two subgroups of low and high risk for PTSD. The depression, anxiety, and stress scale (DASS-21) was applied to collect data on the respective symptoms, and changes since the onset of the pandemic were reported on separate scales. Sociodemographic and COVID-19 related factors, as well as data on craving, consumption patterns, concomitant use, and the drug market were further assessed. Results: A binary logistic regression analysis confirmed the impact of self-perceived higher burden by psychological and economic factors on the elevated risk for PTSD due to the pandemic. The high-risk PTSD group also showed higher levels of depression, anxiety and stress, as well as a more pronounced deterioration in these symptoms since the pandemic. While reported levels of craving did not differ between the two groups, the high-risk PTSD group indicated a significantly higher increase in craving since the crisis, when compared to the low-risk group. Discussion: Our findings demonstrate elevated levels of clinical symptoms among patients in OST, with more than a quarter of patients found at risk for PTSD due to the COVID-19 pandemic. Furthermore, about 30-50% of our patients reported concerning levels of depression, anxiety, or stress. Special attention should be drawn to these findings, and potential deterioration of the situation should be addressed by health care facilities. Particularly, psychological, and financial burden due to the crisis were identified as factors increasing the risk for PTSD. These factors can easily be evaluated during routine anamneses, and might be a valuable source of information, when special attention is needed.

Medicine misuse: A systematic review and proposed hierarchical terminology

AIMS

Although medicine misuse is a public health issue, it has multiple meanings in the medical literature. This study aimed to characterize, classify and identify the most appropriate definitions of medicine misuse.

METHODS

A systematic review was performed in Medline, ISI Web of Science, SocINDEX, PsycInfo, PsycArticles and Psychological and Behavioral Sciences Collection, using keywords related to "misuse", "appropriateness" and "medicine" between 1 November 2008 and 25 August 2020. Additional searches were conducted in websites of regulatory agencies and public health institutions. Two authors independently selected studies providing both definitions and examples of misuse, while a third resolved disagreements. Definitions were used to propose a hierarchical classification based on initiator, intent, purpose and context of medicine misuse. The study is registered on PROSPERO: CRD42018115789.

RESULTS

Of 3404 identified records, 51 were included. A total of 71 definitions and 74 examples of misuse were retrieved. When the prescriber is initiator and according to intent, potential medicine misuse referred to "intentional or unintentional prescribing not in line with clinical evidence". Based on context, they could prescribe medicines not clinically justified, i.e. overprescribing, or prescribe indicated medicines incorrectly, i.e. misprescribing. Among other groups of definitions, those overlapping with drug abuse or medication use errors were considered out-of-scope.

CONCLUSION

This systematic review provides a comprehensive overview of the terms and definitions used to characterize medicine misuse and could serve as a basis for a terminology that makes clear distinctions between misuse, abuse and errors.

Population Pharmacokinetics of a Monthly Buprenorphine Depot Injection for the Treatment of Opioid Use Disorder: A Combined Analysis of Phase II and Phase III Trials

Background

BUP-XR (a.k.a. RBP-6000 or SUBLOCADE™) is an extended-release subcutaneous buprenorphine formulation for the treatment of opioid use disorder. BUP-XR was designed to provide sustained buprenorphine exposure throughout the monthly dosing interval, at concentrations sufficient to control all aspects of the disease (withdrawal, craving, and blockade of opioid subjective effects).

Objectives

To characterize the population pharmacokinetics of BUP-XR based on phase II and phase III data and to evaluate whether target therapeutic concentrations were reached with the dosing regimens evaluated in the phase III program.

Methods

The population pharmacokinetic analysis included 570 subjects with opioid use disorder who received up to 12 monthly BUP-XR injections following induction with sublingual buprenorphine.

Results

In phase III studies, target therapeutic concentrations of buprenorphine were achieved from the first injection and maintained over the entire treatment duration. Buprenorphine plasma concentration–time profiles were well described by a two-compartment model, with first-order absorption for sublingual buprenorphine and a dual absorption submodel for BUP-XR. A covariate analysis evaluated the effects of subjects’ demographic characteristics, laboratory data, and genetic status regarding buprenorphine-metabolizing enzymes. Only two covariates, body mass index and body weight, were retained in the final model. Overall, their effects were not of sufficient magnitude to justify a dose adjustment. Finally, pharmacokinetic simulations showed that buprenorphine plasma concentrations decreased slowly after discontinuation of treatment and that a 2-week occasional delay in dosing would not impact efficacy, which translated into labeling claims.

Discussion

In conclusion, the present analysis led to the development of a robust population pharmacokinetic model and confirms the ability of BUP-XR to deliver and maintain therapeutic plasma concentrations over the entire treatment duration.

Electronic supplementary material

The online version of this article (10.1007/s40262-020-00957-0) contains supplementary material, which is available to authorized users.

Pain Management for the Otolaryngologist: Overview of Perioperative Analgesia and Introduction to Opioids

Nearly 50,000 US adults experience opioid-overdose deaths annually and 1.7 million experience a substance use disorder from prescription opioids. Hence, understanding analgesia strategies is of utmost importance. A pre-operative analgesic plan can consist of a brief conversation between the surgeon, patient, and anesthesiologist in an uncomplicated case or range all the way to an involved, multidisciplinary plan for a chronic pain patient. Over the past several decades, there have been myriad studies examining perioperative analgesic regimens for otolaryngologic procedures, many of which have demonstrated the efficacy of nonopioid analgesics.

Opioid and Polydrug Use Among Patients in Opioid Maintenance Treatment

Purpose

Opioid maintenance treatment reduces a person’s use of heroin. However, frequent substance use in treatment is a problem.

Aim

To examine the association between opioid maintenance treatment and opioid/polydrug use, and whether social factors, adverse experiences, social resources, and quality of life are associated with opioid/polydrug use during the first 12 months in treatment.

Patients and Methods

Forty-seven participants from treatment units in Bergen, Norway participated in five waves of data collection. Every third month, a structured face-to-face interview collected self-reported data on sociodemographic characteristics, opioid/polydrug use, participants’ social resources or adverse experiences, and quality of life. Data were collected as part of KVARUS, the National Quality Register for Substance Abuse Treatment. A multilevel binary logistic regression analysis was conducted to examine the association of opioid/polydrug use and time in current treatment. The analysis included regressions of opioid/polydrug use on time-invariant baseline adverse experiences and social resources, and time-varying reports of quality of life.

Results

There was a significant negative association between time in treatment and use of opioids, b =−0.89, SE = 0.19, p = <0.01. Furthermore, a negative association of age at substance use on polydrug use was found, b =−0.40, SE =0.19, p = 0.03. A higher overall quality of life was significantly associated with lower odds of opioid use during opioid maintenance treatment, b = −0.62, SE = 0.23, p = < 0.01. Social dimensions, participants’ adverse experiences, and social resources were not associated with polydrug or opioid use.

Conclusion

Opioid maintenance treatment is associated with lowered opioid use, but to a lesser degree with polydrug use. Our findings add quality of life as an important factor that should be given particular attention because it can offer insight to aspects that can affect the patients’ opioid use.

Developments in Drug Addiction During COVID-19-An Austrian Perspective Based on a Clinical Sample

Concerns about the negative consequences of the COVID-19 pandemic on people with substance use disorder (SUD) were raised by experts in the field around the world. Here we provide an Austrian perspective, discussing the impact of the pandemic on help-seeking patient with drug use disorder during the initial stage of the pandemic. Our perspectives are based on the situation as perceived at our clinical facility, and supported by original data collected from a small clinical sample of patients with drug use disorder (N = 32). The viewpoints and related descriptive data include the perceived individual impact of COVID-19, as well as various aspects of drug use behavior and the Austrian drug market before and after the onset of the pandemic. The consequences for a subgroup of patients in opioid substitution treatment (N = 24) are discussed. Surprisingly and in contrast to anticipated developments, we had the impression of a rather stable situation in Austria, at least at this early stage of the pandemic. The immediate impact of COVID-19 on these help-seeking patients with high levels of drug dependency seemed less severe than anticipated so far. Importantly, this observation might be a short-term effect for this already fragile group and careful monitoring of further developments as well as preparation of long-term strategies are advised. In general, problematic drug use is associated with many health risk factors and finding appropriate long-term health care strategies has to remain a top priority facing the pandemic. Our perspectives are restricted to observations from help-seeking patients at our clinic, and no conclusions for the general population can be directly drawn.

Comparative study between prison- and community-based treatment satisfaction for opioid use disorder in Lebanon

PURPOSE

Opioid substitution treatment (OST), such as Buprenorphine, has become a well-established evidence-based approach for the treatment of inmates with opioid use disorder (OUD) in most of the developed world. However, its application in Lebanon remains mainly as a community-based intervention. The purpose of this paper is to highlight the need of its implementation within the Lebanese correctional system.

DESIGN/METHODOLOGY/APPROACH

The work is a pilot cross-sectional study that compares two groups: 30 male adult prisoners with OUD convictions receiving symptomatic treatment and 30 male adult community patients with OUD receiving Buprenorphine. The objective was to measure the difference in the patients' general perception and satisfaction of the treatments available. OUD was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria and the level of satisfaction was measured by "Treatment Perceptions Questionnaire (TPQ)."

FINDINGS

The prison group reported significantly lower satisfaction when compared to the community group (total TPQ mean scores: M=34.73, SD =4.12 and M=16.67, SD =4.78, respectively, with t (56.76) =15.68, p=0.000). Furthermore, age, marital status, education level and elapsed time in treatment had no significant interactions with the total TPQ score.

ORIGINALITY/VALUE

The major principles of the ethics of care and evidence-based safe practices will be proposed for the introduction of Buprenorphine to Lebanese prisons. This work provides an opportunity for the expansion of the Lebanese OST program and consequently other countries in the region could benefit from this experience.

Non-prescribed use of methadone and buprenorphine prior to opioid substitution treatment: lifetime prevalence, motives, and drug sources among people with opioid dependence in five Swedish cities

Background

Opioid substitution treatment (OST) with methadone or buprenorphine is the most effective means of treating opioid dependence. If these substances are used by people who are not undergoing OST, they can however carry serious risks. This article examines the lifetime prevalence, motives, and drug sources for such use, as well as geographical differences in these variables.

Methods

Structured interviews were conducted with 411 patients from 11 OST clinics in five Swedish cities. The researchers carried out 280 interviews on-site, while 131 interviews were conducted by specially trained patients through privileged access interviewing. Data were analyzed by frequency and average calculations, cross-tabulations, and χ² tests.

Results

The lifetime prevalence of non-prescribed use was 87.8% for methadone, 80.5% for buprenorphine, and 50.6% for buprenorphine/naloxone. Pseudo-therapeutic motives—avoiding withdrawal symptoms, staying clean from heroin, detoxification, or taking care of one’s own OST—were commonly cited as driving the use, while using the drugs for euphoric purposes was a less common motive. Most respondents had bought or received the substances from patients in OST, but dealers were also a significant source of non-prescribed methadone and buprenorphine. Geographical differences of use, motives, and sources suggest that prescription practices in OST have a great impact on which substances are used outside of the treatment.

Conclusions

Experiences of non-prescribed use of methadone and buprenorphine are extremely common among those in OST in southern Sweden. As the use is typically driven by pseudo-therapeutic motives, increased access to OST might decrease the illicit demand for these substances. Buprenorphine/naloxone has a lower abuse potential than buprenorphine and should therefore be prioritized as the prescribed drug. Supervised dosage and other control measures are important provisions in the prevention of drug diversion and non-prescribed use among people not undergoing OST.

The complex relation between access to opioid agonist therapy and diversion of opioid medications: a case example of large-scale misuse of buprenorphine in the Czech Republic

Opioid agonist therapy (OAT) has been available in a standard regime in the Czech Republic since 2000. Buprenorphine is the leading medication, while methadone is available only in a few specialised centres. There is an important leakage of buprenorphine onto the illicit market, and the majority of Czech opioid users are characterised by the misuse (and injecting) of diverted buprenorphine medications. Most prescribed buprenorphine for OAT is not covered by current national health insurance schemes, and patients have to pay considerable prices to afford their treatment. This affordability barrier together with limited accessibility is likely the leading factor of limited coverage of OAT and of recent stagnation in the number of patients in the official treatment programmes in the Czech Republic. It also encourages doctor shopping and the re-selling of parts of their medication at a higher price, which represents the main factor that drives the Czech illicit market for buprenorphine, but at the same time co-finances the medication of clients in official OAT programmes. Improving access to OAT by making it financially affordable is essential to further increase OAT coverage and is one of the factors that can reduce the illicit market with OAT medications.

CYP2D6 genotype can help to predict effectiveness and safety during opioid treatment for chronic low back pain: results from a retrospective study in an Italian cohort

Background

Opioids are widely used for chronic low back pain (CLBP); however, it is still unclear how to predict their effectiveness and safety. Codeine, tramadol and oxycodone are metabolized by CYP/CYP450 2D6 (CYP2D6), a highly polymorphic enzyme linked to allele-specific related differences in metabolic activity.

Purpose

CYP2D6 genetic polymorphisms could potentially help to predict the effectiveness and safety of opioid-based drugs in clinical practice, especially in the treatment of CLBP.

Patients and methods

A cohort of 224 Italian patients with CLBP treated with codeine or oxycodone was retrospectively evaluated to determine whether adverse reactions and effectiveness were related to CYP2D6 single-nucleotide polymorphisms. CYP2D6 genotyping was performed using the xTAG^® CYP2D6 Kit v3 (Luminex) to determine CYP2D6 metabolizer phenotype (poor, intermediate, rapid and ultrarapid). Subjects from the cohort were categorized into two groups according to the occurrence of side effects (Case) or benefit (Control) after chronic analgesic treatment. The impact of CYP2D6 polymorphism on treatment outcome was tested at the metabolizer phenotype, diplotype and haplotype levels.

Results

CYP2D6 polymorphism was significantly associated with opioid treatment outcome (Omnibus P=0.018, for both global haplotype and diplotype distribution test). CYP2D6*6 and *9 carriers, alleles characterized by a reduced (*9) or absent (*6) enzymatic activity, were significantly (P<0.05) associated with therapeutic failure. CYP2D6 ultrarapid metabolizers (CYP2D6*2N patients) showed an increased risk of side effects, as would be predicted. Despite their low frequency, CYP2D6 *1/*11, *4/*6 and *41/* 2N diplotypes showed significant (P<0.05) associations of efficacy and side effects with chronic opioid treatment.

Conclusion

Our results showed that reduced CYP2D6 activity is correlated with lack of therapeutic effect. We found that the pharmacogenetic analysis of CYP2D6 could be helpful in foreseeing the safety and effectiveness of codeine or oxycodone treatment in CLBP.

Buprenorphine-based opioid substitution therapy in India: A few observations, thoughts, and opinions

The most evidence-based treatment for opioid dependence is opioid agonist maintenance treatment also known as opioid substitution therapy (OST). However, there are some critical, yet unaddressed issues of buprenorphine-based substitution therapy, especially in the Indian context. These comprise of generalizability of the evidence for OST, especially for natural and pharmaceutical opioids and for all age groups, optimum dose and duration of OST, and mode of treatment delivery including the frequency of dispensing. Notwithstanding the use of buprenorphine-naloxone combination, abuse and diversion are serious but often underreported problems. There is an urgent need for health services research in India on OST, focusing on these aspects. Rather than directly copying from Western models, it is important to try to understand the useful and safe program and policy options likely to be applicable in the Indian setting, with our own assets as well as vulnerabilities.

Challenges of Using Methadone in the Indian Pain and Palliative Care Practice

Palliative care providers across India lobbied to gain access to methadone for pain relief and this has finally been achieved. Palliative care activists will count on the numerous strengths for introducing methadone in India, including the various national and state government initiatives that have been introduced recognizing the importance of palliative care as a specialty in addition to improving opioid accessibility and training. Adding to the support are the Non-Governmental Organizations (NGOs), the medical fraternity and the international interactive and innovative programs such as the Project Extension for Community Health Outcome. As compelling as the need for methadone is, many challenges await. This article outlines the challenges of procuring methadone and also discusses the challenges specific to methadone. Balancing the availability and diversion in a setting of opioid phobia, implementing the amended laws to improve availability and accessibility in a country with diverse health-care practices are the major challenges in implementing methadone for relief of pain. The unique pharmacology of the drug requires meticulous patient selection, vigilant monitoring, and excellent communication and collaboration with a multidisciplinary team and caregivers. The psychological acceptance of the patient, the professional training of the team and the place where care is provided are also challenges which need to be overcome. These challenges could well be the catalyst for a more diligent and vigilant approach to opioid prescribing practices. Start low, go slow could well be the way forward with caregiver education to prescribe methadone safely in the Indian palliative care setting.

Chronic hepatitis C and individuals with a history of injecting drugs in Spain: population assessment, challenges for successful treatment

In Spain, there is a need to improve chronic hepatitis C care among people who inject drugs (PWID). Injecting drug use is an important risk behaviour for hepatitis C virus (HCV) infection. Review of 28 sources of the relevant published literature mapped the size of the addiction-HCV population in Spain. Experts in opioid use disorder (OUD) treatment in Spain completed a consensus to define the population size, HCV prevalence and access or barriers to hepatitis C treatment for PWID populations. In Spain, over 300 000 individuals have a lifetime history of injecting drugs. Currently, 150 000 individuals in Spain have OUD; many have injected drugs. Each year, 80 000 individuals engage with treatment services for OUD. A proportion of this group continues to inject drugs. There is a high HCV prevalence in PWID - estimates of 60-80% in Spain. Uptake of hepatitis C therapy in PWID in Spain is limited; barriers include awareness of treatment pathways, advocacy for regular screening and effective joint care. There is an urgent need to address barriers to effective hepatitis C care for PWID in Spain. Practical and specific strategies including peer-led solutions, patient buddy systems and joint working models at the local level can make important short-term differences.

Correlates of anti-hepatitis C positivity and use of harm reduction services among people who inject drugs in two cities in Croatia

BACKGROUND

We assessed correlates of anti-hepatitis C (anti-HCV) positivity and utilization of needle and syringe exchange programs (NSEP) and opioid agonist treatment (OAT) among people who inject drugs (PWID) in two Croatian cities.

METHODS

We conducted a cross-sectional study using respondent-driven (RDS) sampling among PWID in Rijeka (N=255) and Split (N=399). We used RDS-weighted population estimates and multivariable logistic regression to explore correlates of anti-HCV positivity and NSEP and OAT utilization.

RESULTS

Seventy-eight percent (78.0%) of PWID in Rijeka and 61.5% in Split had been tested previously for HCV, while 21.5% and 7.0%, respectively, were tested for HCV in the past 12 months. Among PWID who report being infected with HCV, 24.9% in Rijeka and 11.3% in Split received anti-HCV treatment. In Rijeka, PWID who utilized NSEP and, in Split, those who were ever imprisoned, had higher odds of anti-HCV positivity. In Rijeka, PWID on OAT were more likely to use non-sterile injecting equipment and to inject for longer than 10 years. PWID enrolled in NSEP were more likely to inject opioid agonist medication (OAM) and less likely to use non-sterile injecting equipment. More than half of PWID reported misuse of OAM in the past month, while out of PWID enrolled in OAT, 65.4% in Rijeka and 88.7% in Split injected OAM in the month prior to the survey.

CONCLUSIONS

Key findings of the paper point to the need to scale up HCV testing and treatment, improve access to NSEP and the quality of OAT provisions in order to prevent its misuse among PWID.