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Schmidt RA, Everett K, Perez-Brumer A, Strike C, Rush B, Gomes T. A population-based time-series analysis of opioid agonist treatment dispensed during pregnancy. Addiction 2024; 119:1111-1122. [PMID: 38476027 DOI: 10.1111/add.16459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/25/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND AND AIMS Identifying effective opioid treatment options during pregnancy is a high priority due to the growing prevalence of opioid use disorder across North America. We assessed the temporal impact of three population-level interventions on the use of opioid agonist treatment (OAT) during pregnancy in Ontario, Canada. DESIGN This was a population-based time-series analysis to identify trends in the monthly prevalence of pregnant people dispensed methadone and buprenorphine. The impact of adding buprenorphine/naloxone to the public drug formulary, the release of pregnancy-specific guidance and the start of the COVID-19 pandemic were assessed. SETTING AND PARTICIPANTS The study was conducted in Ontario, Canada between 1 July 2013 and 31 March 2022, comprising people who delivered a live or stillbirth in any Ontario hospital during the study period. MEASUREMENTS We identified any prescription for methadone or buprenorphine dispensed between the estimated conception date and delivery date and calculated the monthly prevalence of OAT-exposed pregnancies among all pregnant people in Ontario. FINDINGS Overall, rates of OAT during pregnancy have declined since mid-2018. Methadone-exposed pregnancies decreased from 0.46% of all pregnancies in Ontario in 2015 to a low of 0.16% in 2022. In the primary analysis, none of the interventions had a statistically significant impact on overall OAT rates; however, in the stratified analyses, there was a small increase in buprenorphine after the formulary change [0.006%, 95% confidence interval (CI) = 0.0032-0.0081, P < 0.0001] and a decrease in buprenorphine after the release of the 2017 guidelines (-0.005%, 95% CI = -0.0080 to -0.0020, P = 0.001) and the start of the COVID-19 pandemic (-0.003%, 95% CI = -0.0054 to -0.0006, P = 0.015). CONCLUSION Despite changes in guidance and funding, opioid agonist treatment during pregnancy has been declining in Ontario, Canada since 2018.
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Affiliation(s)
- Rose A Schmidt
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Centre for Addiction and Mental Health (CAMH), Institute for Mental Health Policy Research, Toronto, Canada
- ICES, Toronto, Canada
| | | | - Amaya Perez-Brumer
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Brian Rush
- Centre for Addiction and Mental Health (CAMH), Institute for Mental Health Policy Research, Toronto, Canada
| | - Tara Gomes
- ICES, Toronto, Canada
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Management and Evaluation at the University of Toronto, Institute of Health Policy, Toronto, Ontario, Canada
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Naji L, Dennis B, Rodrigues M, Bawor M, Hillmer A, Chawar C, Deck E, Worster A, Paul J, Thabane L, Samaan Z. Assessing fragility of statistically significant findings from randomized controlled trials assessing pharmacological therapies for opioid use disorders: a systematic review. Trials 2024; 25:286. [PMID: 38678289 PMCID: PMC11055220 DOI: 10.1186/s13063-024-08104-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 04/10/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND The fragility index is a statistical measure of the robustness or "stability" of a statistically significant result. It has been adapted to assess the robustness of statistically significant outcomes from randomized controlled trials. By hypothetically switching some non-responders to responders, for instance, this metric measures how many individuals would need to have responded for a statistically significant finding to become non-statistically significant. The purpose of this study is to assess the fragility index of randomized controlled trials evaluating opioid substitution and antagonist therapies for opioid use disorder. This will provide an indication as to the robustness of trials in the field and the confidence that should be placed in the trials' outcomes, potentially identifying ways to improve clinical research in the field. This is especially important as opioid use disorder has become a global epidemic, and the incidence of opioid related fatalities have climbed 500% in the past two decades. METHODS Six databases were searched from inception to September 25, 2021, for randomized controlled trials evaluating opioid substitution and antagonist therapies for opioid use disorder, and meeting the necessary requirements for fragility index calculation. Specifically, we included all parallel arm or two-by-two factorial design RCTs that assessed the effectiveness of any opioid substitution and antagonist therapies using a binary primary outcome and reported a statistically significant result. The fragility index of each study was calculated using methods described by Walsh and colleagues. The risk of bias of included studies was assessed using the Revised Cochrane Risk of Bias tool for randomized trials. RESULTS Ten studies with a median sample size of 82.5 (interquartile range (IQR) 58, 179, range 52-226) were eligible for inclusion. Overall risk of bias was deemed to be low in seven studies, have some concerns in two studies, and be high in one study. The median fragility index was 7.5 (IQR 4, 12, range 1-26). CONCLUSIONS Our results suggest that approximately eight participants are needed to overturn the conclusions of the majority of trials in opioid use disorder. Future work should focus on maximizing transparency in reporting of study results, by reporting confidence intervals, fragility indexes, and emphasizing the clinical relevance of findings. TRIAL REGISTRATION PROSPERO CRD42013006507. Registered on November 25, 2013.
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Affiliation(s)
- Leen Naji
- Department of Family Medicine, David Braley Health Sciences Centre, McMaster University, 100 Main St W, 3rdFloor, Hamilton, ON, L8P 1H6, Canada.
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
- Department of Medicine, Montefiore Medical Center, New York, NY, USA.
| | - Brittany Dennis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Myanca Rodrigues
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Monica Bawor
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Alannah Hillmer
- Department of Psychiatry and Behavaioral Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Caroul Chawar
- Physician Assistant Program, University of Toronto, Toronto, ON, Canada
| | - Eve Deck
- Department of Family Medicine, Western University, London, ON, Canada
| | - Andrew Worster
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - James Paul
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit, Research Institute at St Joseph's Healthcare, Hamilton, ON, Canada
| | - Zainab Samaan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
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Xu KY, Huang V, Williams AR, Martin CE, Bazazi AR, Grucza RA. Co-occurring psychiatric disorders and disparities in buprenorphine utilization in opioid use disorder: An analysis of insurance claims. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 9:100195. [PMID: 38023343 PMCID: PMC10630609 DOI: 10.1016/j.dadr.2023.100195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Background As the overdose crisis continues in the U.S. and Canada, opioid use disorder (OUD) treatment outcomes for people with co-occurring psychiatric disorders are not well characterized. Our objective was to examine the influence of co-occurring psychiatric disorders on buprenorphine initiation and discontinuation. Methods This retrospective cohort study used multi-state administrative claims data in the U.S. to evaluate rates of buprenorphine initiation (relative to psychosocial treatment without medication) in a cohort of 236,198 people with OUD entering treatment, both with and without co-occurring psychiatric disorders, grouping by psychiatric disorder subtype (mood, psychotic, and anxiety-and-related disorders). Among people initiating buprenorphine, we assessed the influence of co-occurring psychiatric disorders on buprenorphine retention. We used multivariable Poisson regression to estimate buprenorphine initiation and Cox regression to estimate time to discontinuation, adjusting for all 3 classes of co-occurring disorders simultaneously and adjusting for baseline demographic and clinical characteristics. Results Buprenorphine initiation occurred in 29.3 % of those with co-occurring anxiety-and-related disorders, compared to 25.9 % and 17.5 % in people with mood and psychotic disorders. Mood (adjusted-risk-ratio[aRR] = 0.82[95 % CI = 0.82-0.83]) and psychotic disorders (aRR = 0.95[0.94-0.96]) were associated with decreased initiation (versus psychosocial treatment), in contrast to greater initiation in the anxiety disorders cohort (aRR = 1.06[1.05-1.06]). We observed an increase in buprenorphine discontinuation associated with mood (adjusted-hazard-ratio[aHR] = 1.20[1.17-1.24]) and anxiety disorders (aHR = 1.12[1.09-1.14]), in contrast to no association between psychotic disorders and buprenorphine discontinuation. Conclusions We observed underutilization of buprenorphine among people with co-occurring mood and psychotic disorders, as well as high buprenorphine discontinuation across anxiety, mood, and psychotic disorders.
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Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Vivien Huang
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Arthur Robin Williams
- Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, New York, USA
- Division of Substance Use Disorders, New York State Psychiatric Institute, New York, New York, USA
| | - Caitlin E Martin
- Department of Obstetrics and Gynecology and the VCU Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Alexander R. Bazazi
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Richard A. Grucza
- Department of Family and Community Medicine, St. Louis University, St. Louis, Missouri, USA
- Department of Health and Clinical Outcomes Research, St. Louis University, St Louis, Missouri, USA
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López-Arteaga T, Moreno-Rubio C, Mohedano-Moriano A. Risk factors for opioid addiction in chronic non-cancer pain. Heliyon 2023; 9:e19707. [PMID: 37809400 PMCID: PMC10558926 DOI: 10.1016/j.heliyon.2023.e19707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 07/17/2023] [Accepted: 08/30/2023] [Indexed: 10/10/2023] Open
Abstract
Opioids are very effective pain medications, but they are not without complications. Its use in chronic cancer pain is clearly established, but not in chronic non-cancer pain. Opioid use has increased in recent years, but at the same time, it has been accompanied by an increase in side effects and related complications, including abuse, abuse and opioid addiction. If we look in the literature on the subject there is a global concern to make an adequate therapy with risk reduction, but the samples studied make it difficult to extrapolate results to the general population and even more so if we take into account factors such as psychiatric comorbidity. This leads us to consider the need to study our own population, its characteristics and see how it is being treated, to refine as much as possible on an appropriate prescription. The authors have carried out a cross-sectional study on patients with non-cancer chronic pain referred to psychiatry and the presence of opioid use disorder. We found risk factors related to the biopsychosocial characteristics of the patients and the characteristics of pain and its treatment. Knowing the risk factors, we can avoid yatrogeny, implement primary and secondary prevention and, ultimately, improve the quality of patient care.
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Affiliation(s)
- Teresa López-Arteaga
- Médico Psiquiatra. Directora Médica Área Integrada de Talavera. Hospital General Universitario Ntra. Sra. Del Prado. Talavera de la Reina, Spain
| | - Carlos Moreno-Rubio
- Jefe de Servicio de Psiquiatría. Hospital General Universitario Ntra. Sra. Del Prado. Talavera de la Reina, Spain
| | - Alicia Mohedano-Moriano
- Titular de la Facultad de Ciencias de la Salud Talavera de la Reina. Universidad de Castilla-La Mancha, Spain
- Académica del Vicerrectorado de Ciencias de la Salud de la Universidad de Castilla-La Mancha, Spain
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Sanger N, Panesar B, Dennis M, Rosic T, Rodrigues M, Lovell E, Yang S, Butt M, Thabane L, Samaan Z. The Inclusion of Patients' Reported Outcomes to Inform Treatment Effectiveness Measures in Opioid Use Disorder. A Systematic Review. Patient Relat Outcome Meas 2022; 13:113-130. [PMID: 35669100 PMCID: PMC9165704 DOI: 10.2147/prom.s297699] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 05/17/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Patient centred care is needed now more than ever in the treatment of opioid use disorder. Trials, policy makers, and service providers have most often used treatment retention and opioid urine screens as measures of treatment effectiveness. However, patients receiving medication for opioid use disorder treatment (MOUD) may prioritise the use of different ways to assess treatment success. Objective The aim of this review is to synthesize literature examining the self-reported goals patients would like to achieve in MOUD for opioid use disorder. Methods We searched MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane Library, Cochrane Clinical Trials Registry, the National Institutes for Health Clinical Trials Registry, and the WHO International Clinical Trials Registry Platform from inception until April 30th, 2021. No restrictions were placed on language, age, or type of MOUD. A qualitative synthesis is presented given that a meta-analysis was not possible. Results The search yielded a total of 21,082 records from which 8 met criteria for inclusion in the qualitative synthesis. We identified a total of 43 patient-reported treatment goals from the 8 studies. Twelve domains were created from the 43 goals reported. These domains cover a range of important areas for patients' goals related to living a normal life, physical health, mental health, treatment, and substance use specific areas. Conclusion This review highlights several patient goals that they would like to achieve during treatment for opioid use disorder that are not commonly considered as markers of treatment effectiveness. Goals related to health, living a normal life, and overall substance use concerns by patients should be taken into consideration by clinical trialists, researchers, policy makers, service providers, patients, and communities engaged in developing and tailoring treatment plans for opioid use disorder. Systematic Review Registration PROSPERO CRD42018095553.
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Affiliation(s)
- Nitika Sanger
- Medical Science Graduate Program, McMaster University, Hamilton, Ontario, Canada
| | - Balpreet Panesar
- Neuroscience Graduate Program, McMaster University, Hamilton, Ontario, Canada
| | - Michael Dennis
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tea Rosic
- Health Research Methodology Graduate Program, McMaster University, Hamilton, Ontario, Canada
| | - Myanca Rodrigues
- Health Research Methodology Graduate Program, McMaster University, Hamilton, Ontario, Canada
| | - Elizabeth Lovell
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Shuling Yang
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mehreen Butt
- Accelerated Nursing Program, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Health Research Methodology Graduate Program, McMaster University, Hamilton, Ontario, Canada
- Centre for Evaluation of Medicines, Programs for Assessment of Technology in Health (PATH) Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Zainab Samaan
- Health Research Methodology Graduate Program, McMaster University, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
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Cheng DK, Lai KSP, Pico-Espinosa OJ, Rice DB, Chung C, Modarresi G, Sud A. Interventions for Depressive Symptoms in People Living with Chronic Pain: A Systematic Review of Meta-Analyses. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:934-954. [PMID: 34373915 PMCID: PMC9071227 DOI: 10.1093/pm/pnab248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This review investigated the effectiveness of clinical interventions on depressive symptoms in people with all types of chronic pain. METHODS We searched seven electronic databases and reference lists on September 15, 2020, and included English-language, systematic reviews and meta-analyses of trials that examined the effects of clinical interventions on depressive outcomes in chronic pain. Two independent reviewers screened, extracted, and assessed the risk of bias. PROSPERO registration: CRD42019131871. RESULTS Eighty-three reviews were selected and included 182 meta-analyses. Data were summarized visually and narratively using standardized mean differences with 95% confidence intervals as the primary outcome of interest. A large proportion of meta-analyses investigated fibromyalgia or mixed chronic pain, and psychological interventions were most commonly evaluated. Acceptance and commitment therapy for general chronic pain, and fluoxetine and web-based psychotherapy for fibromyalgia showed the most robust effects and can be prioritized for implementation in clinical practice. Exercise for arthritis, pharmacotherapy for neuropathic pain, self-regulatory psychotherapy for axial pain, and music therapy for general chronic pain showed large, significant effects, but estimates were derived from low- or critically low-quality reviews. CONCLUSIONS No single intervention type demonstrated substantial superiority across multiple pain populations. Other dimensions beyond efficacy, such as accessibility, safety, cost, patient preference, and efficacy for non-depressive outcomes should also be weighed when considering treatment options. Further effectiveness research is required for common pain types such as arthritis and axial pain, and common interventions such as opioids, anti-inflammatories and acupuncture.
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Affiliation(s)
- Darren K Cheng
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Canada
| | | | | | | | | | - Golale Modarresi
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Canada
| | - Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Canada
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Silva TC, Andersson FB. The "black box" of treatment: Patients' perspective on what works in opioid maintenance treatment for opioid dependence. Subst Abuse Treat Prev Policy 2021; 16:41. [PMID: 33971909 PMCID: PMC8111936 DOI: 10.1186/s13011-021-00378-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND A lack of conceptual modeling of how the components of opioid maintenance treatment (OMT) for opioid dependence (OD) work causes it to occasionally be labeled the "black-box" of treatment. This study had a two-fold objective: First, to analyze which factors related to OMT for OD contribute to the abstinence of problematic use of non-prescribed opioids and sustain recovery, from the patients' perspective; second, to understand which changes OMT produced in the individuals' lives might significantly contribute to relapse prevention. METHODS We used qualitative methods of design, inquiry, and analysis from a convenience sample of 19 individuals in a Swedish treatment setting. RESULTS All the participants reported previous cycles of problematic use of non-prescribed opioids and other non-prescribed psychoactive substances, treatment, abstinence, recovery, and relapse before starting the current OMT program. During the pre-treatment stage, specific events, internal processes, and social environments enhanced motivation toward abstinence and seeking treatment. During the treatment stage, participants perceived the quality of the human relationships established with primary social groups as important as medication and the individual plan of care in sustaining recovery. From the participants' perspective, OMT was a turning point in their life course, allowing them a sense of self-fulfillment and the reconstruction of personal and social identity. However, they still struggled with the stigmatization produced by a society that values abstinence-oriented over medication-assisted treatments. CONCLUSION OMT is not an isolated event in individuals' lives but rather a process occurring within a specific social context. Structural factors and the sense of acceptance and belonging are essential in supporting the transformation. Treatment achievements and the risk for relapse vary over time, so the objectives of the treatment plan must account for characteristics of the pre-treatment stage and the availability and capacity of individuals to restructure their social network, besides the opioid maintenance treatment and institutional social care.
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Affiliation(s)
- Teresa C. Silva
- Department of Humanities and Social Sciences, Mid Sweden University, 10 – 85170 Holmgatan, Sundsvall, Sweden
- Risk and Crisis Research Center, Mid Sweden University, Kunskapens väg 1, Stapelmohrs väg, 831 40 Östersund, Sweden
| | - Fredrik B. Andersson
- Department of Humanities and Social Sciences, Mid Sweden University, 10 – 85170 Holmgatan, Sundsvall, Sweden
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Sanger N, Panesar B, Rosic T, Dennis B, D'Elia A, Hillmer A, Chawar C, Naji L, Hudson J, Samaan MC, de Souza RJ, Marsh DC, Thabane L, Samaan Z. The future of precision medicine in opioid use disorder: inclusion of patient-important outcomes in clinical trials. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2021; 43:138-146. [PMID: 32556002 PMCID: PMC8023161 DOI: 10.1590/1516-4446-2019-0734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 04/17/2020] [Indexed: 12/04/2022]
Abstract
Opioid use has reached an epidemic proportion in Canada and the United States that is mostly attributed to excess availability of prescribed opioids for pain. This excess in opioid use led to an increase in the prevalence of opioid use disorder (OUD) requiring treatment. The most common treatment recommendations include medication-assisted treatment (MAT) combined with psychosocial interventions. Clinical trials investigating the effectiveness of MAT, however, have a limited focus on effectiveness measures that overlook patient-important outcomes. Despite MAT, patients with OUD continue to suffer negative consequences of opioid use. Patient goals and personalized medicine are overlooked in clinical trials and guidelines, thus missing an opportunity to improve prognosis of OUD by considering precision medicine in addiction trials. In this mixed-methods study, patients with OUD receiving MAT (n=2,031, mean age 39.1 years [SD 10.7], 44% female) were interviewed to identify patient goals for MAT. The most frequently reported patient-important outcomes were to stop treatment (39%) and to avoid all drugs (25%). These results are inconsistent with treatment recommendations and trial outcome measures. We discuss theses inconsistencies and make recommendations to incorporate these outcomes to achieve patient-centered and personalized treatment strategies.
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Affiliation(s)
- Nitika Sanger
- Medical Science Graduate Program, McMaster University, Hamilton, ON, Canada
| | - Balpreet Panesar
- Neuroscience Graduate Program, McMaster University, Hamilton, ON, Canada
| | - Tea Rosic
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Brittany Dennis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Alessia D'Elia
- Neuroscience Graduate Program, McMaster University, Hamilton, ON, Canada
| | - Alannah Hillmer
- Neuroscience Graduate Program, McMaster University, Hamilton, ON, Canada
| | - Caroul Chawar
- Neuroscience Graduate Program, McMaster University, Hamilton, ON, Canada
| | - Leen Naji
- Department of Family Medicine, Halton Healthcare, Milton, ON, Canada
| | - Jacqueline Hudson
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - M. Constantine Samaan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Russell J. de Souza
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Genomics Program, Chanchlani Research Centre, McMaster University, Hamilton, ON, Canada
| | - David C. Marsh
- Northern Ontario School of Medicine, Laurentian University, Sudbury, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Genomics Program, Chanchlani Research Centre, McMaster University, Hamilton, ON, Canada
- Clinician Investigator Program, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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9
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Rice D, Corace K, Wolfe D, Esmaeilisaraji L, Michaud A, Grima A, Austin B, Douma R, Barbeau P, Butler C, Willows M, Poulin PA, Sproule BA, Porath A, Garber G, Taha S, Garner G, Skidmore B, Moher D, Thavorn K, Hutton B. Evaluating comparative effectiveness of psychosocial interventions adjunctive to opioid agonist therapy for opioid use disorder: A systematic review with network meta-analyses. PLoS One 2020; 15:e0244401. [PMID: 33370393 PMCID: PMC7769275 DOI: 10.1371/journal.pone.0244401] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/09/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Guidelines recommend that individuals with opioid use disorder (OUD) receive pharmacological and psychosocial interventions; however, the most appropriate psychosocial intervention is not known. In collaboration with people with lived experience, clinicians, and policy makers, we sought to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy (OAT) among persons with OUD. METHODS A review protocol was registered a priori (CRD42018090761), and a comprehensive search for randomized controlled trials (RCT) was conducted from database inception to June 2020 in MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Established methods for study selection and data extraction were used. Primary outcomes were treatment retention and opioid use (measured by urinalysis for opioid use and opioid abstinence outcomes). Odds ratios were estimated using network meta-analyses (NMA) as appropriate based on available evidence, and in remaining cases alternative approaches to synthesis were used. RESULTS Seventy-two RCTs met the inclusion criteria. Risk of bias evaluations commonly identified study limitations and poor reporting with regard to methods used for allocation concealment and selective outcome reporting. Due to inconsistency in reporting of outcome measures, only 48 RCTs (20 unique interventions, 5,404 participants) were included for NMA of treatment retention, where statistically significant differences were found when psychosocial interventions were used as an adjunct to OAT as compared to OAT-only. The addition of rewards-based interventions such as contingency management (alone or with community reinforcement approach) to OAT was superior to OAT-only. Few statistically significant differences between psychosocial interventions were identified among any other pairwise comparisons. Heterogeneity in reporting formats precluded an NMA for opioid use. A structured synthesis was undertaken for the remaining outcomes which included opioid use (n = 18 studies) and opioid abstinence (n = 35 studies), where the majority of studies found no significant difference between OAT plus psychosocial interventions as compared to OAT-only. CONCLUSIONS This systematic review offers a comprehensive synthesis of the available evidence and the limitations of current trials of psychosocial interventions applied as an adjunct to OAT for OUD. Clinicians and health services may wish to consider integrating contingency management in addition to OAT for OUD in their settings to improve treatment retention. Aside from treatment retention, few differences were consistently found between psychosocial interventions adjunctive to OAT and OAT-only. There is a need for high-quality RCTs to establish more definitive conclusions. TRIAL REGISTRATION PROSPERO registration CRD42018090761.
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Affiliation(s)
- Danielle Rice
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Psychology, McGill University, Montreal, Quebec, Canada
| | - Kimberly Corace
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Substance Use and Concurrent Disorders Program, The Royal Ottawa Mental Health Centre, Ottawa, Ontario Canada
- Department of Psychiatry, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institute of Mental Health Research, University of Ottawa, Ottawa, Ontario, Canada
| | - Dianna Wolfe
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Alan Michaud
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alicia Grima
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Bradley Austin
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Reuben Douma
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Claire Butler
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Melanie Willows
- Substance Use and Concurrent Disorders Program, The Royal Ottawa Mental Health Centre, Ottawa, Ontario Canada
- Department of Psychiatry, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institute of Mental Health Research, University of Ottawa, Ottawa, Ontario, Canada
- Faculty of Medicine, Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Patricia A. Poulin
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- Pain Clinic, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Beth A. Sproule
- Department of Pharmacy, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Amy Porath
- Canadian Center on Substance Use and Addiction, Ottawa, Ontario, Canada
| | - Gary Garber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
| | - Sheena Taha
- Canadian Center on Substance Use and Addiction, Ottawa, Ontario, Canada
| | - Gord Garner
- The Community Addictions Peer Support Association (CAPSA), Ottawa, Ontario, Canada
| | - Becky Skidmore
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - David Moher
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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10
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Reddon H, Kerr T, Milloy MJ. Ranking evidence in substance use and addiction. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 83:102840. [PMID: 32645584 PMCID: PMC7669593 DOI: 10.1016/j.drugpo.2020.102840] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 01/04/2023]
Abstract
Evidence-based medicine has consistently prized the epistemological value of randomized-controlled trials (RCTs) owing to their methodological advantages over alternative designs such as observational studies. However, there are limitations to RCTs that hinder their ability to study chronic and dynamic conditions such as substance use and addiction. For these conditions, observational studies may provide superior evidence based on methodological and practical strengths. Assuming epistemic superiority of RCTs has led to an inappropriate devaluation of other study designs and the findings they support, including support for harm reduction services, especially needle exchange programs and supervised injection facilities. The value offered by observational studies should be reflected in evidence-based medicine by allowing more flexibility in evidence hierarchies that presume methodological superiority of RCTs. Despite the popularity of evidence ranking systems and hierarchies, nothing should replace critical appraisal of study methodology and examining the suitability of applying a given study design to a specific research question.
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Affiliation(s)
- Hudson Reddon
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; CIHR Canadian HIV Trials Network, 588-1081 Burrard Street, Vancouver, BC V6B 3E6, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 1081 Burrard St, Vancouver, BC V6Z 1Y6, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 1081 Burrard St, Vancouver, BC V6Z 1Y6, Canada.
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11
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Das-Munshi J, Semrau M, Barbui C, Chowdhary N, Gronholm PC, Kolappa K, Krupchanka D, Dua T, Thornicroft G. Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness. BMC Psychiatry 2020; 20:237. [PMID: 32410598 PMCID: PMC7227317 DOI: 10.1186/s12888-020-02623-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/26/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND People with severe mental disorders (SMD) experience premature mortality mostly from preventable physical causes. The World Health Organization (WHO) have recently produced guidelines on the management of physical health conditions in SMD. This paper presents the evidence which led to the recommendations for tobacco cessation and management of substance use disorders in SMD. METHODS Scoping reviews informed 2 PICO (Population Intervention, Comparator, Outcome) questions relating to tobacco cessation and management of substance use disorders in SMD. Systematic searches led to the identification of systematic reviews with relevant evidence to address these questions. Retrieved evidence was assessed using GRADE methodology, informing the development of guidelines. RESULTS One thousand four hundred thirty-four records were identified through systematic searches for SMD and tobacco cessation, of which 4 reviews were included in GRADE tables and 18 reviews in narrative synthesis. For SMD and substance use disorders, 4268 records were identified, of which 4 studies from reviews were included in GRADE tables and 16 studies in narrative synthesis. People with SMD who use tobacco should be offered combined pharmacological (Varenicline, Bupropion or Nicotine Replacement Therapy) and non-pharmacological interventions such as tailored directive and supportive behavioural interventions. For people with SMD and substance use disorders (drug and/or alcohol), interventions should be considered in accordance with WHO mhGAP guidelines. Prescribers should note potential drug-drug interactions. Recommendation were conditional and based on low/very low certainty of evidence with a scarcity of evidence from low- and middle-income settings. CONCLUSIONS These guidelines mark an important step towards addressing premature mortality in people with SMD. The dearth of high-quality evidence and evidence from LMIC settings must inform the future research agenda. GUIDELINES https://www.who.int/mental_health/evidence/guidelines_physical_health_and_severe_mental_disorders/en https://www.who.int/publications-detail/mhgap-intervention-guide%2D%2D-version-2.0.
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Affiliation(s)
- Jayati Das-Munshi
- Department of Psychological Medicine, Institute of Psychiatry Psychology & Neurosciences, King's College London, South London & Maudsley NHS-Trust, De Crespigny Park, London, SE5 8AF, UK.
| | - Maya Semrau
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, UK
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Neerja Chowdhary
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Petra C Gronholm
- Centre for Global Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Kavitha Kolappa
- The Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, USA
| | - Dzmitry Krupchanka
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Tarun Dua
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Graham Thornicroft
- Centre for Global Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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12
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van Reekum EA, Rosic T, Hudson J, Sanger N, Marsh DC, Worster A, Thabane L, Samaan Z. Social functioning outcomes in men and women receiving medication-assisted treatment for opioid use disorder. Biol Sex Differ 2020; 11:20. [PMID: 32326982 PMCID: PMC7181574 DOI: 10.1186/s13293-020-00298-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 04/08/2020] [Indexed: 02/07/2023] Open
Abstract
Background Social functioning (SF), the ability to engage with life and fulfill roles may be a salient “patient important outcome” in addiction treatment. It is not known if medication-assisted treatment (MAT) impacts SF in opioid use disorder (OUD). There is a growing evidence to suggest that men and women are impacted differently by OUD. This study is the largest to date to study sex differences in OUD and explore associations between MAT and SF. Methods Data were collected from 2736 participants with OUD, enrolled in MAT for varying lengths of time, in outpatient clinics across Ontario. SF was defined according to the Maudsley Addiction Profile’s domains of (1) employment, (2) criminal activity, and (3) interpersonal conflict. Using logistic regression analysis, we examined sociodemographic and clinical factors associated with domains of SF. Results There were 1544 men (56%) and 1192 women (44%) in this study, and ages varied from 17 to 76 years for men and 18 to 69 years for women. At study entry, participants had been on MAT for a median of 2 years. Compared to men, women reported more psychological (mean MAP score 14/40, SD = 9.55, versus 11/40, SD = 8.64; p < 0.001) and physical symptoms (mean MAP score 17/40, SD = 7.70 versus 14/40, SD = 7.74; p < 0.001). More women reported unemployment(74% versus 58%; p < 0.0001) and interpersonal conflict (46% versus 35%; p < 0.0001). Men were more likely than women to report criminal activity (11%, versus 8%; p = 0.001). Psychological symptoms increased the risk of worse SF, across domains, for men and for women. Every year on MAT was associated with a 7% increase in the odds of women engaging with criminal activity (OR = 1.07, 95% CI 1.02, 1.12, p = 0.006). Conclusions Men and women had different SF profiles and psychological symptoms scores while on MAT. The length of time on MAT increased the risk of criminal activity in women, and overall, duration of MAT was not associated with improvement in SF. This may suggest that MAT alone may not support continual improvements in SF in OUD.
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Affiliation(s)
- Emma A van Reekum
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Tea Rosic
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Jacqueline Hudson
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Nitika Sanger
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - David C Marsh
- Northern Ontario School of Medicine, Sudbury, ON, Canada.,Canadian Addiction Treatment Centres, Markham, ON, Canada
| | - Andrew Worster
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Biostatistics Unit, Research Institute at St Joseph's Healthcare, Hamilton, ON, Canada.,Departments of Pediatrics/Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
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13
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Dennis BB, Akhtar D, Cholankeril G, Kim D, Sanger N, Hillmer A, Chawar C, D'Elia A, Panesar B, Worster A, Marsh DC, Thabane L, Samaan Z, Ahmed A. The impact of chronic liver disease in patients receiving active pharmacological therapy for opioid use disorder: One-year findings from a prospective cohort study. Drug Alcohol Depend 2020; 209:107917. [PMID: 32088589 DOI: 10.1016/j.drugalcdep.2020.107917] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/08/2020] [Accepted: 02/11/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Despite the demonstrated benefit of methadone, the incidence opioid-related overdose, and its associated mortality continues to rise at an alarming rate. The impact of high prevalence comorbid features such as chronic liver disease (CLD) on methadone treatment response remain unclear. AIM To determine whether CLD is associated with poor response to methadone treatment. METHODS Using a well-established multi-center cohort from the Genetics of Opioid Addiction Study (GENOA), we evaluated if presence of CLD among 1234 eligible patients with opioid use disorder receiving methadone treatment impacted health and behavioural responses to treatment. CLD was classified as any liver disorder/dysfunction present for a minimum period of six months. Serial urine toxicology assessments were used to determine treatment response. The effect of CLD was determined using a multi-variable logistic regression model. RESULTS CLD was present in 25 % (n = 314) of the population. On average, patients with CLD were found to be older (mean age 44 vs 36 years, p < 0.0001), unemployed (81.8 % vs 61 %, p < 0.0001), and receiving government disability benefits at significantly higher rates (21.9 % vs 11 %, p < 0.0001). Increased levels of physical craving, emotional stress, as well as health risk behaviors were noted in CLD patients. Findings from the multi-variable model demonstrate a 68 % increased risk for dangerous opioid consumption behaviors (Odds Ration [OR]: 1.68, 95 % Confidence Interval [CI] 1.22, 2.31, p = 0.001) among patients with CLD. Methadone dose (OR: 0.76, 95 % CI 0.70, 0.81, p < 0.0001) was shown to be protective with a significant risk reduction of 24 % per 20 mg increase in methadone. Duration in treatment was also found to be protective (OR: 0.99, 95 % CI 0.97, 0.99, p < 0.0001). CONCLUSION CLD poses a distinct risk for patients with opioid addiction. Closer drug monitoring, and substance use contingency management should be considered to reduce mortality risk in these patients.
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Affiliation(s)
- Brittany B Dennis
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton ON L8S4L8, Canada; Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Daud Akhtar
- Department of Medicine, University of British Columbia, Vancouver Costal Health, Vancouver Canada.
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Nitika Sanger
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton ON L8S4L8, Canada; McMaser Neuroscience Graduate Program, McMaster University, Hamilton ON, L8S4L8, Canada.
| | - Alannah Hillmer
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton ON L8S4L8, Canada; McMaser Neuroscience Graduate Program, McMaster University, Hamilton ON, L8S4L8, Canada.
| | - Caroul Chawar
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton ON L8S4L8, Canada; McMaser Neuroscience Graduate Program, McMaster University, Hamilton ON, L8S4L8, Canada.
| | - Alessia D'Elia
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton ON L8S4L8, Canada; McMaser Neuroscience Graduate Program, McMaster University, Hamilton ON, L8S4L8, Canada.
| | - Balpreet Panesar
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton ON L8S4L8, Canada; McMaser Neuroscience Graduate Program, McMaster University, Hamilton ON, L8S4L8, Canada.
| | - Andrew Worster
- Department of Health Research Evaluation and Impact (Formerly Department of Clinical Epidemiology and Biostatistics), McMaster University, Hamilton ON L8S4L8, Canada.
| | - David C Marsh
- Northern Ontario School of Medicine, Sudbury ON P3E2C6, Canada; Canadian Addiction Treatment Centres, Markham ON L3T 7P6, Canada.
| | - Lehana Thabane
- Department of Health Research Evaluation and Impact (Formerly Department of Clinical Epidemiology and Biostatistics), McMaster University, Hamilton ON L8S4L8, Canada; Centre for Evaluation of Medicine, Hamilton ON L8S4L8, Canada.
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton ON L8S4L8, Canada; McMaser Neuroscience Graduate Program, McMaster University, Hamilton ON, L8S4L8, Canada; Department of Health Research Evaluation and Impact (Formerly Department of Clinical Epidemiology and Biostatistics), McMaster University, Hamilton ON L8S4L8, Canada; Population Genomics Program, Chanchlani Research Centre, McMaster University, Hamilton ON L8S4L8, Canada.
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
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14
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Longo MSDC, Vilete LMP, Figueira I, Quintana MI, Mello MF, Bressan RA, Mari JDJ, Ribeiro WS, Andreoli SB, Coutinho ESF. Comorbidity in post-traumatic stress disorder: A population-based study from the two largest cities in Brazil. J Affect Disord 2020; 263:715-721. [PMID: 31780134 DOI: 10.1016/j.jad.2019.11.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 05/07/2019] [Accepted: 11/10/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND This study investigated the patterns of comorbidity between PTSD and depression, other anxiety disorders, alcohol-related disorders using the DSM-IV and ICD-10 criteria. The temporal sequence of the comorbid diagnoses was also investigated. METHODS We used data from a large population-based survey carried out between 2007 and 2008 in the two largest cities in Brazil: São Paulo and Rio de Janeiro. RESULTS Diagnoses of depression, other anxiety disorders, and alcohol-related disorder were more prevalent in the people with PTSD than in those without PTSD. Using the DSM-IV criteria, approximately 67% of cases presenting PTSD were also diagnosed with another mental disorder. The diagnosis category of other anxiety disorders presented the highest proportion of comorbidity (53%). Depression was found in 34% person with PTSD whilst alcohol-related disorders were observed in 7%. Considering the temporal relationship, the onset of comorbid depression was uniformly distributed through the periods before, within the same year and after PTSD's onset. When other anxiety disorders were comorbid with PTSD, in almost 90% of the cases the other anxiety disorders preceded PTSD. For comorbidity between of alcohol-related disorders and PTSD, in 50% of the cases alcohol-related disorders preceded the diagnosis of PTSD. LIMITATIONS The cross-sectional design imposes limitations on establishing a temporal relationship between the onset of psychiatric disorders due to memory bias. CONCLUSIONS Our findings indicate that among individuals presenting comorbid PTSD and other anxiety disorders, this diagnosis tend to precede PTSD. Comorbid cases are more frequent and more severe, and this should be taken into account in therapeutic research and clinical practice.
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Affiliation(s)
| | | | - Ivan Figueira
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Inês Quintana
- Departamento de Psiquiatria, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Marcelo Feijó Mello
- Departamento de Psiquiatria, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Rodrigo A Bressan
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience King's College London, UK
| | - Jair de Jesus Mari
- Departamento de Psiquiatria, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Wagner Silva Ribeiro
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | | | - Evandro Silva Freire Coutinho
- Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública, Rio de Janeiro, Brazil; Instituto de Medicina Social da Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
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15
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Rosic T, Worster A, Thabane L, Marsh DC, Samaan Z. Exploring psychological symptoms and associated factors in patients receiving medication-assisted treatment for opioid-use disorder. BJPsych Open 2020; 6:e8. [PMID: 31910933 PMCID: PMC7001483 DOI: 10.1192/bjo.2019.99] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/11/2019] [Accepted: 12/11/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients receiving treatment for opioid-use disorder (OUD) may experience psychological symptoms without meeting full criteria for psychiatric disorders. The impact of these symptoms on treatment outcomes is unclear. AIMS To determine the prevalence of psychological symptoms in a cohort of individuals receiving medication-assisted treatment for OUD and explore their association with patient characteristics and outcomes in treatment. METHOD Data were collected from 2788 participants receiving ongoing treatment for OUD recruited in two Canadian prospective cohort studies. The Maudsley Addiction Profile psychological symptoms subscale was administered to all participants via face-to-face interviews. A subset of participants (n = 666) also received assessment for psychiatric disorders with the Mini International Neuropsychiatric Interview. We used linear regression analysis to explore factors associated with psychological symptom score. RESULTS The mean psychological symptom score was 12.6/40 (s.d. = 9.2). Participants with psychiatric comorbidity had higher scores than those without (mean 16.8 v. 8.6, P<0.001) and 31% of those with psychiatric comorbidity reported suicidal ideation. Higher psychological symptom score was associated with female gender (B = 1.59, 95% CI 0.92-2.25, P<0.001), antidepressant prescription (B = 4.35, 95% CI 3.61-5.09, P<0.001), percentage of opioid-positive urine screens (B = 0.02, 95% CI 0.01-0.03, P<0.001), and use of non-opioid substances (B = 1.92, 95% CI 0.89-2.95, P<0.001). Marriage and employment were associated with lower psychological symptoms. CONCLUSIONS Psychological symptoms are associated with treatment outcomes in this population and the prevalence of suicidal ideation is an area of concern. Our findings highlight the ongoing need to optimise integrated mental health and addictions services for patients with OUD.
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Affiliation(s)
- Tea Rosic
- Department of Psychiatry and Behavioral Neurosciences, McMaster University; and Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Andrew Worster
- Department of Health Research Methods, Evidence, and Impact, McMaster University; and Department of Medicine, McMaster University, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University; Department of Medicine, McMaster University; Departments of Pediatrics/Anesthesia, McMaster University; and Biostatistics Unit, Research Institute at St Joseph's Healthcare, Canada
| | - David C. Marsh
- Northern Ontario School of Medicine; and Canadian Addiction Treatment Centres, Canada
| | - Zainab Samaan
- Department of Psychiatry and Behavioral Neurosciences, McMaster University; and Department of Medicine, McMaster University, Canada
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16
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Dennis BB, Sanger N, Bawor M, Naji L, Plater C, Worster A, Woo J, Bhalerao A, Baptist-Mohseni N, Hillmer A, Rice D, Corace K, Hutton B, Tugwell P, Thabane L, Samaan Z. A call for consensus in defining efficacy in clinical trials for opioid addiction: combined results from a systematic review and qualitative study in patients receiving pharmacological assisted therapy for opioid use disorder. Trials 2020; 21:30. [PMID: 31907000 PMCID: PMC6945391 DOI: 10.1186/s13063-019-3995-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 12/13/2019] [Indexed: 11/23/2022] Open
Abstract
Background Given the complex nature of opioid addiction treatment and the rising number of available opioid substitution and antagonist therapies (OSAT), there is no ‘gold standard’ measure of treatment effectiveness, and each successive trial measures a different set of outcomes which reflect success in arbitrary or opportune terms. We sought to describe the variation in current outcomes employed across clinical trials for opioid addiction, as well as determine whether a discrepancy exists between the treatment targets that patients consider important and how treatment effectiveness is measured in the literature. Methods We searched nine commonly used databases (e.g., EMBASE, MEDLINE) from inception to August 1, 2015. Outcomes used across trials were extracted and categorized according to previously established domains. To evaluate patient-reported goals of treatment, semi-structured interviews were conducted with 18 adults undergoing methadone treatment. Results We identified 60 trials eligible for inclusion. Once outcomes were categorized into eight broad domains (e.g., abstinence/substance abuse), we identified 21 specific outcomes with furthermore 53 subdomains and 118 measurements. Continued opioid use and treatment retention were the most commonly reported measures (46%, n = 28). The majority of patients agreed that abstinence from opioids was a primary goal in their treatment, although they also stressed goals under-reported in clinical trials. Conclusions There is inconsistency in the measures used to evaluate the effectiveness of OSATs. Individual and population level decision making is being guided by a standard of effect considered useful to researchers yet in direct conflict with what patients deem important. Trial registration PROSPERO, CRD42013006507.
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Affiliation(s)
- Brittany B Dennis
- McMaster University Internal Medicine Residency Program, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Nitika Sanger
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Monica Bawor
- McMaster University Internal Medicine Residency Program, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Leen Naji
- Department of Family Medicine Residency Program, Michael G. Degroote School of Medicine, McMaster University, Hamilton, Canada
| | - Carolyn Plater
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Andrew Worster
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, Hamilton General Hospital, Hamilton, Canada
| | - Julia Woo
- University of Toronto Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Anuja Bhalerao
- University of Toronto Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Natasha Baptist-Mohseni
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Alannah Hillmer
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Danielle Rice
- Faculty of Science, Department of Psychology, McGill University, Montreal, Canada.,Center for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kim Corace
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,University of Ottawa Institute of Mental Health Research, Ottawa, ON, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tugwell
- WHO Collaborating Centre for Knowledge Translation and Health Technology Assessment in Health Equity, Bruyère Research Institute, Ottawa, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Centre for Evaluation of Medicine, Hamilton, Canada.,System Linked Research Unit, Hamilton, Canada
| | - Zainab Samaan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada. .,Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada. .,Population Genomics Program, Chanchlani Research Center, McMaster University, Hamilton, Canada.
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17
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Lamont R, Rosic T, Sanger N, Samaan Z. Psychosis and Comorbid Opioid Use Disorder: Characteristics and Outcomes in Opioid Substitution Therapy. SCHIZOPHRENIA BULLETIN OPEN 2020; 1:sgaa007. [PMID: 32803158 PMCID: PMC7418864 DOI: 10.1093/schizbullopen/sgaa007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Substance use disorders are highly prevalent among individuals with psychotic disorders and are associated with negative outcomes. This study aims to explore differences in characteristics and treatment outcomes for individuals with psychotic disorders when compared with individuals with other nonpsychotic psychiatric disorders enrolled in treatment for opioid use disorder (OUD). METHODS Data were collected from a prospective cohort study of 415 individuals enrolled in outpatient methadone maintenance treatment (MMT). Psychiatric comorbidity was assessed using the Mini-International Neuropsychiatric Interview. Participants were followed for 12 months. Participant characteristics associated with having a psychotic disorder versus another nonpsychotic psychiatric disorder were explored by logistic regression analysis. RESULTS Altogether, 37 individuals (9%) with a psychotic disorder were identified. Having a psychotic disorder was associated with less opioid-positive urine drug screens (odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.95, 0.99, P = .046). Twelve-month retention in treatment was not associated with psychotic disorder group status (OR = 0.73, 95% CI = 0.3, 1.77, P = .485). Participants with psychotic disorders were more likely to be prescribed antidepressants (OR = 2.12, 95% CI = 1.06, 4.22, P = .033), antipsychotics (OR = 3.57, 95% CI = 1.74, 7.32, P = .001), mood stabilizers (OR = 6.61, 95% CI = 1.51, 28.97, P = .012), and benzodiazepines (OR = 2.22, 95% CI = 1.11, 4.43, P = .024). DISCUSSION AND CONCLUSIONS This study contributes to the sparse literature on outcomes of individuals with psychotic disorders and OUD-receiving MMT. Rates of retention in treatment and opioid use are encouraging and contrast to the widely held belief that these individuals do more poorly in treatment. Higher rates of coprescription of sedating and QTc-prolonging medications in this group may pose unique safety concerns.
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Affiliation(s)
- Rachel Lamont
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Tea Rosic
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nitika Sanger
- Medical Sciences Graduate Program, McMaster University, Hamilton, ON, Canada
| | - Zainab Samaan
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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18
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Luo C, Sanger N, Zielinski L, Bhatt M, Shahid H, Shams I, Mouravska N, Luetam S, Hudson J, Thabane L, Samaan Z. Sociodemographic characteristics of patients with children in a methadone maintenance program: a cross-sectional study. Harm Reduct J 2019; 16:13. [PMID: 30744638 PMCID: PMC6371427 DOI: 10.1186/s12954-019-0283-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/30/2019] [Indexed: 01/12/2023] Open
Abstract
Background Ever-increasing numbers of opioid use disorder (OUD) in Canada has created the recent opioid crisis. One common treatment for OUD is methadone maintenance treatment (MMT). Various factors, including being a parent which entails specific stressors, may increase susceptibility to negative treatment outcomes. This study aims to investigate differences between OUD patients with and without children in socio-demographic and clinical outcomes. Methods Data for this study are part of a larger program. All participants are 18+ years old with OUD, provided consent, and receiving MMT. We performed a multivariable logistic regression to examine the differences between participants’ parental status, sociodemographic variables, and clinical parameters including MMT outcomes. We performed subgroup analyses on individuals with children younger than 18. Results A total of 1099 participants were included, with 64% having children. Participants with children were older (OR 1.06, 95% CI 1.04, 1.08), more likely to be female (OR 2.39, 95% CI 1.75, 3.27), living with a partner (OR 1.75, 95% CI 1.27, 2.41), first exposed to opioids through a prescription (OR 1.517, 95% CI 1.13, 2.04) and had lower levels of education (OR 1.86, 95% CI 1.20, 2.87). There was no significant difference in illicit opioid use patterns between groups. Same results held true in the subgroup analyses based on the age of the children except for participant age. Conclusion Our results demonstrate social and demographic differences between parents and non-parents receiving MMT. These differences highlight the need to understand necessary additional support for parents such as child support and other necessary therapies.
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Affiliation(s)
- Candice Luo
- Bachelor of Health Sciences Program, McMaster University, 1280 Main St. W., Hamilton, Ontario, L8S 4L8, Canada
| | - Nitika Sanger
- Medical Sciences Graduate Program, McMaster University, 1280 Main St. W., Hamilton, Ontario, L8S 4L8, Canada
| | - Laura Zielinski
- MiNDS Graduate Program, McMaster University, 1280 Main St. W., Hamilton, Ontario, L8S 4L8, Canada
| | - Meha Bhatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. W., Hamilton, Ontario, L8S 4L8, Canada
| | - Hamnah Shahid
- Arts and Science Program, McMaster University, 1280 Main St. W., Hamilton, Ontario, L8S 4L8, Canada
| | - Ieta Shams
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main St. W., Hamilton, Ontario, L8S 4L8, Canada
| | - Natalia Mouravska
- Hamilton Health Sciences, 237 Barton St. E., Hamilton, Ontario, L8L 2X2, Canada
| | - Sabrina Luetam
- Michael G. DeGroote School of Medicine, McMaster University, 1280 Main St. W., Hamilton, Ontario, L8S 4L8, Canada
| | - Jackie Hudson
- Peter Boris Centre for Addictions Research, St Joseph's Healthcare Hamilton, 100th West 5th St., Hamilton, Ontario, L8N 3K7, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. W., Hamilton, Ontario, L8S 4L8, Canada
| | - Zainab Samaan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. W., Hamilton, Ontario, L8S 4L8, Canada. .,Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main St. W., Hamilton, Ontario, L8S 4L8, Canada. .,Peter Boris Centre for Addictions Research, St Joseph's Healthcare Hamilton, 100th West 5th St., Hamilton, Ontario, L8N 3K7, Canada. .,Populaton Genomics Program, Chanchlani Research Centre, McMaster University, 1280 Main St. W., Hamilton, Ontario, L8S 4L8, Canada. .,Mood Disorders Program, St. Joseph's Healthcare, 100 West 5th St., Hamilton, Ontario, L8N 3K7, Canada.
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Tomko RL, McClure EA, Squeglia LM, Treloar Padovano H, McRae-Clark AL, Baker NL, Carpenter MJ, Gray KM. Methods to reduce the incidence of false negative trial results in substance use treatment research. Curr Opin Psychol 2019; 30:35-41. [PMID: 30798020 DOI: 10.1016/j.copsyc.2019.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/10/2019] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
Abstract
Treatment development and evaluation for substance use disorders are hindered when randomized controlled trials fail to show a treatment effect when one exists. This manuscript provides an overview of addressable methodological factors that may contribute to incorrect trial results. The collection of remote, naturalistic, real-time adherence and substance use data through ambulatory assessment methods in everyday life is presented as a partial solution. Other recommendations related to participant recruitment and selection, ensuring adequate consistency/fidelity and dose of treatment, and rigorously assessing clinical outcomes are discussed. With implementation of eligibility criteria verification, treatment adherence monitoring, and remote assessment of substance use and biomarkers, ambulatory assessment may help improve clinical trial success rates by improving precision, increasing reproducibility, and reducing the impact of methodological issues that may lead to inaccurate trial results.
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Affiliation(s)
- Rachel L Tomko
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, United States.
| | - Erin A McClure
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, United States
| | - Lindsay M Squeglia
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, United States
| | | | - Aimee L McRae-Clark
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, United States
| | - Nathaniel L Baker
- Department of Public Health Sciences, Medical University of South Carolina, United States
| | - Matthew J Carpenter
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, United States
| | - Kevin M Gray
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, United States
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20
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Sanger N, Shahid H, Dennis BB, Hudson J, Marsh D, Sanger S, Worster A, Teed R, Rieb L, Tugwell P, Hutton B, Shea B, Beaton D, Corace K, Rice D, Maxwell L, Samaan MC, de Souza RJ, Thabane L, Samaan Z. Identifying patient-important outcomes in medication-assisted treatment for opioid use disorder patients: a systematic review protocol. BMJ Open 2018; 8:e025059. [PMID: 30518592 PMCID: PMC6286642 DOI: 10.1136/bmjopen-2018-025059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/22/2018] [Accepted: 11/05/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Illicit opioid use has become a national crisis in Canada, with over 65 000 people seeking treatment for opioid use disorder (OUD) in Ontario and British Columbia alone. Medication-assisted treatment (MAT) is a common treatment for OUD. There is substantial variability in treatment outcomes used to evaluate effectiveness of MAT, making it difficult to establish clinically and scientifically relevant treatment effect. Furthermore, patients are often excluded from the process of determining these outcomes. The primary objective of this review is to examine outcomes currently used to measure MAT effectiveness and to identify patient-relevant outcomes to enhance effectiveness of treatment options. This review refers to patient-important outcomes as those outcomes patients consider important to or markers of treatment success. METHODS AND ANALYSIS MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane Library, Cochrane Clinical Trials Registry, National Institutes for Health Clinical Trials Registry and WHO International Clinical Trials Registry Platform databases will be searched. We will search databases from inception to the date the search is ran. Studies of interest include those evaluating the effectiveness of MAT for patients with OUD, with or without consultation with patients regarding what they consider to be important as an indicator of treatment success. Results will be analysed using thematic analysis and qualitative analysis where possible. This will result in comprehensive synthesis of all outcomes and measures found related to OUD treatment effectiveness. ETHICS AND DISSEMINATION We are collaborating with Canadian Addiction Treatment Centres which provide MAT to patients with OUD who will participate in disseminating study results. Dissemination strategies will involve sharing study results through workshops, presentations, peer-reviewed publications, study reports, community presentations and resources in primary care settings. PROSPERO REGISTRATION NUMBER CRD42018095553.
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Affiliation(s)
- Nitika Sanger
- Medical Science Gradaute Program, McMaster University, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Hamnah Shahid
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Arts and Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Brittany B Dennis
- St. George’s Hospital Medical School, University of London, London, UK
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jackie Hudson
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - David Marsh
- Northern Ontario School of Medicine, Laurentian University, Sudbury, Ontario, Canada
- Canadian Addiction Treatment Centres, McMaster University, Markham, Ontario, Canada
| | - Stephanie Sanger
- Department of Health Sciences: Health Science Library, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Worster
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Rand Teed
- Rand Teed Consulting Services, Craven, Saskatchewan, Canada
| | - Launette Rieb
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Tugwell
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Brian Hutton
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ontario, Canada
| | - Beverley Shea
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dorcas Beaton
- Institute for Work and Health, St. Michael’s Hospital, Ottawa, Ontario, Canada
- Departments of Occupational Therapy and Medicine and the Clinical Epidemiology and Health Care Research Program, University of Toronto, Toronto, Ontario, Canada
| | - Kimberly Corace
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- University of Ottawa Institute of Mental Health Research, Ottawa, Ontario, Canada
| | - Danielle Rice
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
| | - Lara Maxwell
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
| | - M Constantine Samaan
- Division of Pediatric Endocrinology, McMaster University, Hamilton, Ontario, Canada
| | - Russell J de Souza
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ontario, Canada
- Centre for Evaluation of Medicines, Programs for Assessment of Technology in Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ontario, Canada
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Molero Y, Zetterqvist J, Binswanger IA, Hellner C, Larsson H, Fazel S. Medications for Alcohol and Opioid Use Disorders and Risk of Suicidal Behavior, Accidental Overdoses, and Crime. Am J Psychiatry 2018; 175:970-978. [PMID: 30068260 PMCID: PMC6169735 DOI: 10.1176/appi.ajp.2018.17101112] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined associations between medications for alcohol and opioid use disorders (acamprosate, naltrexone, methadone, and buprenorphine) and suicidal behavior, accidental overdoses, and crime. METHOD In this total population cohort study, 21,281 individuals who received treatment with at least one of the four medications between 2005 and 2013 were identified. Data on medication use and outcomes were collected from Swedish population-based registers. A within-individual design (using stratified Cox proportional hazards regression models) was used to compare rates of suicidal behavior, accidental overdoses, and crime for the same individuals during the period when they were receiving the medication compared with the period when they were not. RESULTS No significant associations with any of the primary outcomes were found for acamprosate. For naltrexone, there was a reduction in the hazard ratio for accidental overdoses during periods when individuals received treatment compared with periods when they did not (hazard ratio=0.82, 95% CI=0.70, 0.96). Buprenorphine was associated with reduced arrest rates for all crime categories (i.e., violent, nonviolent, and substance-related) as well as reduction in accidental overdoses (hazard ratio=0.75, 95% CI=0.60, 0.93). For methadone, there were significant reductions in the rate of suicidal behaviors (hazard ratio=0.60, 95% CI=0.40-0.88) as well as reductions in all crime categories. However, there was an increased risk for accidental overdoses among individuals taking methadone (hazard ratio=1.25, 95% CI=1.13, 1.38). CONCLUSIONS Medications currently used to treat alcohol and opioid use disorders also appear to reduce suicidality and crime during treatment.
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Affiliation(s)
- Yasmina Molero
- From the Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom; the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm; the Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm County Council, Norra Stationsgatan, Stockholm; the Institute for Health Research, Kaiser Permanente Colorado, Denver; the Division of General Internal Medicine, University of Colorado School of Medicine, Aurora; and the School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Johan Zetterqvist
- From the Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom; the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm; the Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm County Council, Norra Stationsgatan, Stockholm; the Institute for Health Research, Kaiser Permanente Colorado, Denver; the Division of General Internal Medicine, University of Colorado School of Medicine, Aurora; and the School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ingrid A Binswanger
- From the Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom; the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm; the Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm County Council, Norra Stationsgatan, Stockholm; the Institute for Health Research, Kaiser Permanente Colorado, Denver; the Division of General Internal Medicine, University of Colorado School of Medicine, Aurora; and the School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Clara Hellner
- From the Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom; the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm; the Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm County Council, Norra Stationsgatan, Stockholm; the Institute for Health Research, Kaiser Permanente Colorado, Denver; the Division of General Internal Medicine, University of Colorado School of Medicine, Aurora; and the School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Henrik Larsson
- From the Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom; the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm; the Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm County Council, Norra Stationsgatan, Stockholm; the Institute for Health Research, Kaiser Permanente Colorado, Denver; the Division of General Internal Medicine, University of Colorado School of Medicine, Aurora; and the School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Seena Fazel
- From the Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom; the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm; the Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm County Council, Norra Stationsgatan, Stockholm; the Institute for Health Research, Kaiser Permanente Colorado, Denver; the Division of General Internal Medicine, University of Colorado School of Medicine, Aurora; and the School of Medical Sciences, Örebro University, Örebro, Sweden
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Jarvis BP, Holtyn AF, Subramaniam S, Tompkins DA, Oga EA, Bigelow GE, Silverman K. Extended-release injectable naltrexone for opioid use disorder: a systematic review. Addiction 2018; 113:1188-1209. [PMID: 29396985 PMCID: PMC5993595 DOI: 10.1111/add.14180] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/18/2017] [Accepted: 01/26/2018] [Indexed: 12/14/2022]
Abstract
AIMS To review systematically the published literature on extended-release naltrexone (XR-NTX, Vivitrol® ), marketed as a once-per-month injection product to treat opioid use disorder. We addressed the following questions: (1) how successful is induction on XR-NTX; (2) what are adherence rates to XR-NTX; and (3) does XR-NTX decrease opioid use? Factors associated with these outcomes as well as overdose rates were examined. METHODS We searched PubMed and used Google Scholar for forward citation searches of peer-reviewed papers from January 2006 to June 2017. Studies that included individuals seeking treatment for opioid use disorder who were offered XR-NTX were included. RESULTS We identified and included 34 studies. Pooled estimates showed that XR-NTX induction success was lower in studies that included individuals that required opioid detoxification [62.6%, 95% confidence interval (CI) = 54.5-70.0%] compared with studies that included individuals already detoxified from opioids (85.0%, 95% CI = 78.0-90.1%); 44.2% (95% CI = 33.1-55.9%) of individuals took all scheduled injections of XR-NTX, which were usually six or fewer. Adherence was higher in prospective investigational studies (i.e. studies conducted in a research context according to a study protocol) compared to retrospective studies of medical records taken from routine care (6-month rates: 46.7%, 95% CI = 34.5-59.2% versus 10.5%, 95% CI = 4.6-22.4%, respectively). Compared with referral to treatment, XR-NTX reduced opioid use in adults under criminal justice supervision and when administered to inmates before release. XR-NTX reduced opioid use compared with placebo in Russian adults, but this effect was confounded by differential retention between study groups. XR-NTX showed similar efficacy to buprenorphine when randomization occurred after detoxification, but was inferior to buprenorphine when randomization occurred prior to detoxification. CONCLUSIONS Many individuals intending to start extended-release naltrexone (XR-NTX) do not and most who do start XR-NTX discontinue treatment prematurely, two factors that limit its clinical utility significantly. XR-NTX appears to decrease opioid use but there are few experimental demonstrations of this effect.
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Affiliation(s)
- Brantley P. Jarvis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine,Public Health Research and Translational Science, Battelle Memorial Institute
| | - August F. Holtyn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Shrinidhi Subramaniam
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - D. Andrew Tompkins
- Department of Psychiatry, University of California, San Francisco School of Medicine
| | - Emmanuel A. Oga
- Public Health Research and Translational Science, Battelle Memorial Institute
| | - George E. Bigelow
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Kenneth Silverman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
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Substance use disorders and medical comorbidities among high-need, high-risk patients with diabetes. Drug Alcohol Depend 2018; 186:86-93. [PMID: 29554592 PMCID: PMC5959045 DOI: 10.1016/j.drugalcdep.2018.01.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/01/2018] [Accepted: 01/04/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The majority of the U.S. healthcare resources are utilized by a small population characterized as high-risk, high-need persons with complex care needs (e.g., adults with multiple chronic conditions). Substance use disorders (SUDs) and mental health disorders (MHDs) are a driver of poor health and additional healthcare costs, but they are understudied among high-need patients. OBJECTIVE We examine the prevalence and correlates of SUDs and MHDs among adults with high-risk diabetes, who are patients at the top 10% risk score for developing poor outcomes (hospital admission or death). METHODS A risk algorithm developed from Duke University Health System electronic health records (EHRs) data was used to identify patients with high-risk diabetes for targeting home-based primary care. The EHR data of the 263 patients with high-risk diabetes were analyzed to understand patterns of SUDs and MHDs to inform care-coordinating efforts. RESULTS Both SUDs (any SUD 48.3%, alcohol 12.5%, tobacco 38.8%, drug 23.2%) and MHDs (any MHD 74.9%, mood 53.2%, sleep 37.3%, anxiety 32.7%, schizophrenia/psychotics/delusional 14.8%, dementia/delirium/amnestic/cognitive 14.4%, adjustment 9.1%) were prevalent. Overall, 81.7% of the sample had SUD or MHD. Elevated odds of SUD were noted among men (tobacco, alcohol) and those who were never-married (alcohol, cannabis). African-American race (vs. other race/ethnicity) was associated with lower odds of anxiety disorders. CONCLUSION While data are limited to one large academic health system, they provide clinical evidence revealing that 82% of patients with high-risk diabetes had SUD and/or MHD recorded in their EHRs, highlighting a need for developing service models to optimize high-risk care.
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Susukida R, Crum RM, Stuart EA, Mojtabai R. Generalizability of the findings from a randomized controlled trial of a web-based substance use disorder intervention. Am J Addict 2018; 27:231-237. [PMID: 29569403 PMCID: PMC6548718 DOI: 10.1111/ajad.12714] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 12/22/2017] [Accepted: 03/03/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is growing concern regarding the generalizability of findings from randomized controlled trials (RCTs) of interventions for substance use disorders (SUDs). This study used a selection model approach to assess and improve the generalizability of an evaluation for a web-based SUD intervention by making the trial sample resemble the target population. METHODS The sample of the web-based SUD intervention (Therapeutic Education System vs. Treatment-as-usual; n = 507) was compared with the target population of SUD treatment-seeking individuals from the Treatment Episodes Data Set-Admissions (TEDS-A). Using weights based on the probabilities of RCT participation, we computed weighted treatment effects on retention and abstinence. RESULTS Substantial differences between the RCT sample and the target population was demonstrated in significant difference in the mean propensity scores (1.62 standard deviations at p < .001). The population effect on abstinence (12 weeks and 6 months) was statistically insignificant after weighting the data with the generalizability weight. DISCUSSIONS AND CONCLUSIONS Generalizability of the findings from the RCT could be limited when the RCT sample does not well represent the target population. SCIENTIFIC SIGNIFICANCE Application of generalizability weights can be a potentially useful tool to improve generalizability of RCT findings. (Am J Addict 2018;27:231-237).
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Affiliation(s)
- Ryoko Susukida
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
- Department of Mental Health Policy and Evaluation, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan
| | - Rosa M. Crum
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe St. Baltimore, MD 21287
| | - Elizabeth A. Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, 615 N. Broadway, Baltimore, MD, 21205, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Ramin Mojtabai
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe St. Baltimore, MD 21287
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Ayaz-Shah AA, Hussain S, Knight SR. Do clinical trials reflect reality? A systematic review of inclusion/exclusion criteria in trials of renal transplant immunosuppression. Transpl Int 2018; 31:353-360. [PMID: 29274240 DOI: 10.1111/tri.13109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/24/2017] [Accepted: 12/15/2017] [Indexed: 02/01/2023]
Abstract
Renal transplant recipients and donors are becoming increasingly more marginal, with more expanded criteria (ECD) and donation after circulatory death (DCD) donors and older recipients. Despite this, high-risk donors and recipients are often excluded from clinical trials, leading to uncertainty about the generalizability of findings. We extracted data regarding inclusion/exclusion criteria from 174 trials of immunosuppression in renal transplant recipients published over a 5-year period and compared criteria with those specified in published trial registries. Frequently reported donor exclusion criteria were age (16.1%), donor type and cold ischaemic time (22.4%). Common recipient exclusion criteria included upper age limit (38.5%), high panel reactive antibody (PRA) (42.5%) and previous transplantation (39.7%). Inclusion/exclusion criteria recorded in trial registries matched those reported in the manuscript in only 6 (7.8%) trials. Of registered trials, 51 (66.2%) trials included additional criteria in the manuscript, 51 (66.2%) were missing criteria in the manuscript specified in the protocol, and in 19 (24.7%) key criteria changed from the protocol to the manuscript. Our findings suggest many recent immunosuppression trials have restrictive inclusion criteria which may not be reflective of current renal transplant populations. Discrepancies between trial protocols and published reports raise the possibility of selection bias.
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Affiliation(s)
- Anam A Ayaz-Shah
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Samia Hussain
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford Churchill Hospital, Oxford, UK
| | - Simon R Knight
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford Churchill Hospital, Oxford, UK
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Wiessing L, Ferri M, Darke S, Simon R, Griffiths P. Large variation in measures used to assess outcomes of opioid dependence treatment: A systematic review of longitudinal observational studies. Drug Alcohol Rev 2017; 37 Suppl 1:S323-S338. [PMID: 28971544 DOI: 10.1111/dar.12608] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 07/24/2017] [Accepted: 08/01/2017] [Indexed: 12/19/2022]
Abstract
ISSUES Treatment outcomes for drug users are critical for informing policy and therapeutic practice. The coherence of outcomes, changes and drug use measures from observational studies on opioid use treatment were reviewed. APPROACH Systematic review of the literature for longitudinal observational studies, from 1980 through November 2015, in all languages, with data on treated opioid users, using Pubmed, the Cochrane Library and additional strategies (e.g. Pubmed function 'related citations' and checking reference lists of eligible studies). KEY FINDINGS Twenty-seven studies were included (11 countries, 85 publications, recruitment 1962-2009). Baseline n was >65 686 and median follow-up 34.5 months (21 studies) or 51.4 person-months (10 studies). Eight outcome domains were identified: 'drug use' (21/27 studies), 'crime' (13), 'health' (13), 'treatment-related' outcomes (16), 'social functioning' (13), 'harms' (8), 'mortality' (13) and 'economic estimates' (2 studies). All studies using drug use outcomes included a binary (abstinence) category in at least one measure. Studies typically reported outcomes on less than half (on average 3.7 or 46%) of the eight outcome domains, while the average was 5.1 (64%) in seven studies initiated since 2000. IMPLICATIONS AND CONCLUSION Wide variation exists in outcome measures found in longitudinal observational studies of treatment of opioid users. This reduces replicability of studies and suggests a lack of common expectations on treatment success. Future studies should consider using all or most of eight outcome domains identified (excluding economic analyses if unfeasible), non-binary measures and amount/value of drugs used and consensus meetings with joint ownership of scientific, treatment and patient communities.
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Affiliation(s)
- Lucas Wiessing
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Marica Ferri
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Shane Darke
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Roland Simon
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Paul Griffiths
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
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Franchitto N, Jullian B, Salles J, Pelissier F, Rolland B. Management of precipitated opiate withdrawal syndrome induced by nalmefene mistakenly prescribed in opiate-dependent patients: a review for clinicians. Expert Opin Drug Metab Toxicol 2017; 13:669-677. [DOI: 10.1080/17425255.2017.1312340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Nicolas Franchitto
- Service d’Addictologie, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
- Centre Antipoison et de Toxicovigilance, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale (INSERM) UMR 1027, Université Paul Sabatier, Toulouse, France
| | - Benedicte Jullian
- Service d’Addictologie, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
| | - Juliette Salles
- Service d’Addictologie, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
| | - Fanny Pelissier
- Centre Antipoison et de Toxicovigilance, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
| | - Benjamin Rolland
- Département de Psychiatrie et d'Addictologie, Centre Hospitalo-Universitaire Lille, Lille, France
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Soyka M, Strehle J, Rehm J, Bühringer G, Wittchen HU. Six-Year Outcome of Opioid Maintenance Treatment in Heroin-Dependent Patients: Results from a Naturalistic Study in a Nationally Representative Sample. Eur Addict Res 2017; 23:97-105. [PMID: 28376505 DOI: 10.1159/000468518] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 03/01/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND In many countries, the opioid agonists, buprenorphine and methadone, are licensed for maintenance treatment of opioid dependence. Many short-term studies have been performed, but little is known about long-term effects. Therefore, this study described over 6 years (1) mortality, retention and abstinence rates and (2) changes in concomitant drug use and somatic and mental health. METHODS A prevalence sample of n = 2,694 maintenance patients, recruited from a nationally representative sample of n = 223 substitution doctors, was evaluated in a 6-year prospective-longitudinal naturalistic study. At 72 months, n = 1,624 patients were assessed for outcome; 1,147 had full outcome data, 346 primary outcome data and 131 had died; 660 individuals were lost to follow-up. RESULTS The 6-year retention rate was 76.6%; the average mortality rate was 1.1%. During follow-up, 9.4% of patients became "abstinent" and 1.9% were referred for drug-free addiction treatment. Concomitant drug use decreased and somatic health status and social parameters improved. CONCLUSIONS The study provides further evidence for the efficacy and safety of maintenance treatment with opioid agonists. In the long term, the number of opioid-free patients is low and most patients are more or less continuously under opioid maintenance therapy. Further implications are discussed.
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Bhatt M, Zielinski L, Baker-Beal L, Bhatnagar N, Mouravska N, Laplante P, Worster A, Thabane L, Samaan Z. Efficacy and safety of psychostimulants for amphetamine and methamphetamine use disorders: a systematic review and meta-analysis. Syst Rev 2016; 5:189. [PMID: 27842569 PMCID: PMC5109734 DOI: 10.1186/s13643-016-0370-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 10/28/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Amphetamine and methamphetamine use disorders are associated with severe health and social consequences. No pharmacological therapy has been approved for the treatment of these disorders. Psychostimulants can act as maintenance-like therapies for managing substance use among these patients. The aim of this study is to evaluate the literature examining the efficacy and safety of psychostimulant agents for increasing abstinence and treatment retention among patients with amphetamine and methamphetamine use disorders. METHODS We searched MEDLINE, EMBASE, PsycInfo, Cochrane Central, and CINAHL from inception to August 2016. Selection of studies, data extraction, and risk of bias assessment were conducted independently by two reviewers. We conducted meta-analyses to provide a pooled summary estimate for included trials and report the review according to PRISMA guidelines. RESULTS We identified and selected 17 studies with 1387 participants. Outcome reporting across trials was inconsistent, and the overall quality of evidence was very low due to high risk of bias and indirectness. A meta-analysis of five trials (642 participants) found no effect of psychostimulants for end-of-study abstinence (odds ratio = 0.97, 95% confidence interval 0.65 to 1.45). Additionally, the pooled estimate from 14 studies (1184 participants) showed no effect of psychostimulants for treatment retention (odds ratio = 1.20, 95% confidence interval = 0.91 to 1.58). The incidence of serious adverse events did not differ between intervention and placebo groups based on qualitative reports from trials. CONCLUSIONS Quantitative analyses showed no effect of psychostimulants for sustained abstinence or treatment retention. We also identified the need for more rigorous studies in this research area with clinician and patient important outcomes.
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Affiliation(s)
- Meha Bhatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street W., Hamilton, ON, L8S 4L8, Canada
| | - Laura Zielinski
- MiNDS Neuroscience Graduate Program, McMaster University, 1280 Main Street W., Hamilton, ON, L8S 4L8, Canada
| | - Lola Baker-Beal
- St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Neera Bhatnagar
- Health Sciences Library, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Natalia Mouravska
- Juravinski Hospital, Hamilton Health Sciences, 711 Concession Street, Hamilton, ON, L8V 1C3, Canada
| | - Phillip Laplante
- St. Joseph's Healthcare Hamilton, 100 West 5th Street, Hamilton, ON, L8N 3K7, Canada
| | - Andrew Worster
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Lehana Thabane
- Biostatistics Unit, Centre for Evaluation of Medicine, 25 Main Street West Suite 2000, Hamilton, ON, L8P 1H1, Canada.,System-Linked Research Unit on Health and Social Service Utilization, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Zainab Samaan
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street W., Hamilton, ON, L8S 4L8, Canada. .,St. Joseph's Healthcare Hamilton, 100 West 5th Street, Hamilton, ON, L8N 3K7, Canada. .,Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada. .,Peter Boris Centre for Addiction Research, St. Joseph's Healthcare Hamilton, 100 West 5th Street, Hamilton, ON, L8P 3R2, Canada. .,Population Genomics Program, Chanchlani Research Centre, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4L8, Canada.
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30
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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.
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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
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31
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Naji L, Dennis BB, Bawor M, Plater C, Pare G, Worster A, Varenbut M, Daiter J, Marsh DC, Desai D, Thabane L, Samaan Z. A Prospective Study to Investigate Predictors of Relapse among Patients with Opioid Use Disorder Treated with Methadone. SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2016; 10:9-18. [PMID: 27103815 PMCID: PMC4827793 DOI: 10.4137/sart.s37030] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 01/05/2016] [Accepted: 01/07/2016] [Indexed: 12/04/2022]
Abstract
INTRODUCTION Concomitant opioid abuse is a serious problem among patients receiving methadone maintenance treatment (MMT) for opioid use disorder. This is an exploratory study that aims to identify predictors of the length of time a patient receiving MMT for opioid use disorder remains abstinent (relapse-free). METHODS Data were collected from 250 MMT patients enrolled in addiction treatment clinics across Southern Ontario. The impact of certain clinical and socio-demographic factors on the outcome (time until opioid relapse) was determined using a Cox proportional hazard model. RESULTS History of injecting drug use behavior (hazard ratio (HR): 2.26, P = 0.042), illicit benzodiazepine consumption (HR: 1.07, P = 0.002), and the age of onset of opioid abuse (HR: 1.10, P < 0.0001) are important indicators of accelerated relapse among MMT patients. Conversely, current age is positively associated with duration of abstinence from illicit opioid use, serving as a protective factor against relapse (HR: 0.93, P = 0.003). CONCLUSION This study helps to identify patients at increased risk of relapse during MMT, allowing health care providers to target more aggressive adjunct therapies toward high-risk patients.
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Affiliation(s)
- Leen Naji
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Brittany B Dennis
- St. George's University of London, London, United Kingdom.; Department of Clinical Epidemiology and Biostatistics, McMaster University, ON, Hamilton, Canada
| | - Monica Bawor
- St. George's University of London, London, United Kingdom
| | - Carolyn Plater
- Canadian Addiction Treatment Centre, Richmond Hill, ON, Canada
| | - Guillaume Pare
- Department of Clinical Epidemiology and Biostatistics, McMaster University, ON, Hamilton, Canada
| | - Andrew Worster
- Canadian Addiction Treatment Centre, Richmond Hill, ON, Canada.; Department of Medicine, Hamilton General Hospital, Hamilton, ON, Canada
| | | | - Jeff Daiter
- Canadian Addiction Treatment Centre, Richmond Hill, ON, Canada
| | - David C Marsh
- Canadian Addiction Treatment Centre, Richmond Hill, ON, Canada.; Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Dipika Desai
- Population Genomics Program, Chanchlani Research Center, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, ON, Hamilton, Canada.; Centre for Evaluation of Medicine, Hamilton, ON, Canada.; System Linked Research Unit, Hamilton, ON, Canada
| | - Zainab Samaan
- Department of Clinical Epidemiology and Biostatistics, McMaster University, ON, Hamilton, Canada.; Population Genomics Program, Chanchlani Research Center, McMaster University, Hamilton, ON, Canada.; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada.; Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
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