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Dunn KE, Strain EC. Establishing a research agenda for the study and assessment of opioid withdrawal. Lancet Psychiatry 2024; 11:566-572. [PMID: 38521089 DOI: 10.1016/s2215-0366(24)00068-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/25/2024]
Abstract
The opioid crisis is an international public health concern. Treatments for opioid use disorder centre largely on the management of opioid withdrawal, an aversive collection of signs and symptoms that contribute to opioid use disorder. Whereas in the past 50 years more than 90 medications have been developed for depression, only five medications have been developed for opioid use disorder during this period. We posit that underinvestment has occurred in part due to an underdeveloped understanding of opioid withdrawal syndrome. This Personal View summarises substantial gaps in our understanding of opioid withdrawal that are likely to continue to limit major advancements in its treatment. There is no firm consensus in the field as to how withdrawal should be precisely defined; 10-550 symptoms of withdrawal can be measured on 18 scales. The imprecise understanding of withdrawal is likely to result in overestimating or underestimating the severity of an individual's withdrawal syndrome or potential therapeutic effects of different candidate medications. The severity of the opioid crisis is not remitting, and an international research agenda for the study and assessment of opioid withdrawal is necessary to support transformational changes in withdrawal management and treatment of opioid use disorder. Nine actionable targets are delineated here: develop a consensus definition of opioid withdrawal; understand withdrawal symptomatology after exposure to different opioids (particularly fentanyl); understand precipitated opioid withdrawal; understand how co-exposure of other drugs (eg, xylazine and stimulants) influences withdrawal expression; examine individual variation in withdrawal phenotypes; precisely characterise the protracted withdrawal syndrome; identify biomarkers of opioid withdrawal severity; identify predictors of opioid withdrawal severity; and understand which symptoms are most closely associated with treatment attrition or relapse. The US Food and Drug Administration recently established a formal indication for opioid withdrawal that has invigorated interest in drug development for opioid withdrawal management. Action is now needed to support these interests and help industry identify new classes of medications so that real change can be achieved for people with opioid use disorder.
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Affiliation(s)
- Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Akerstrom M, Severin J, Miech EJ, Wikström E, Roczniewska M. Reducing sickness absence among public-sector healthcare employees: the difference-making roles of managerial and employee participation. Int Arch Occup Environ Health 2024; 97:341-351. [PMID: 38409534 PMCID: PMC10944807 DOI: 10.1007/s00420-024-02048-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/16/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE Evaluations of organizational-level interventions to prevent work-related illness have identified enabling factors, but knowledge of necessary and sufficient conditions for intervention success is needed. The aim was to identify difference-making factors that distinguish intervention groups with and without a positive intervention effect on sickness absence. METHODS An organizational-level intervention designed to decrease sickness absence by providing support from process facilitators was implemented at eight healthcare workplaces in Sweden between 2017 and 2018. We applied coincidence analysis (CNA) to analyze 34 factors and determine which factors were necessary and sufficient for a successful implementation of tailored interventional measures on an organizational level (dichotomous) and reduced sickness absence (trichotomous). RESULTS Two factors perfectly explained both the presence and absence of a successful implementation: "a high sense of urgency" and "good anchoring and participation from the strategic management". The presence of either of these factors alone was sufficient for successful implementation, whereas the joint absence of both conditions was necessary and sufficient for the absence of successful implementation and an intervention effect. In addition, high employee participation was both necessary and sufficient for a high intervention effect. For organizations without high employee participation, successful implementation led to a medium-effect size. CONCLUSIONS This study identified participation as a difference-maker in the implementation process. Participation from different stakeholders turned out to be important in different phases. When implementing organizational-level interventions, high participation from both strategic management and employees appears to be crucial in terms of the intervention's effect on sickness absence.
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Affiliation(s)
- M Akerstrom
- Region Västra Götaland, Institute of Stress Medicine, Carl Skottbergs Gata 22B, 413 19, Gothenburg, Sweden.
- School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
| | - J Severin
- Region Västra Götaland, Institute of Stress Medicine, Carl Skottbergs Gata 22B, 413 19, Gothenburg, Sweden
- School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - E J Miech
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, USA
| | - E Wikström
- Department of Business Administration, School of Business, Economics and Law, University of Gothenburg, Gothenburg, Sweden
| | - M Roczniewska
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Institute of Psychology, SWPS University, Sopot, Poland
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Simpson KA, Bolshakova M, Kirkpatrick MG, Davis JP, Cho J, Barrington-Trimis J, Kral AH, Bluthenthal RN. Characterizing Opioid Withdrawal Experiences and Consequences Among a Community Sample of People Who Use Opioids. Subst Use Misuse 2024; 59:886-894. [PMID: 38287506 PMCID: PMC11062512 DOI: 10.1080/10826084.2024.2306221] [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] [Indexed: 01/31/2024]
Abstract
BACKGROUND Opioid withdrawal symptoms are a highly salient and consequential health condition experienced by people who use opioids (PWUO). This study utilized qualitative interviews to explore opioid withdrawal experiences and consequences among PWUO in Los Angeles County, USA. METHODS Semi-structured qualitative interviews were conducted with 22 PWUO (aged 27-63 years) between May 2021 and May 2022. Participants self-reported opioid and injection drug use in the last 30 days. We employed an inductive thematic approach to systematically code and synthesize textual interview data. RESULTS Participants experienced withdrawal symptoms frequently, with many going to great lengths to avoid them. Withdrawal pain was described as incapacitating and interfered with PWUO's ability to sustain regular employment and ensure stable housing. Avoiding withdrawal was described as influential in driving decisions to continue using opioids. Mechanisms for managing withdrawal included using other substances to the point of sedation. PWUO who transitioned from heroin to fentanyl use revealed more frequent, painful, and faster onset of withdrawal symptoms. Adverse withdrawal experiences and fear of precipitated withdrawal from buprenorphine were barriers to treatment initiation and continuation. CONCLUSION Withdrawal symptoms among PWUO increase health risk. Improved strategies to treat opioid withdrawal are urgently needed. Solutions such as safe supply and intentional opioid withdrawal interventions (educational trainings, withdrawal comfort kits) are needed to improve withdrawal management and reduce opioid-related harm.
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Affiliation(s)
- Kelsey A. Simpson
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, 9500, Gilman Drive, La Jolla, CA 92093
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, 1845 N. Soto St. Los Angeles, CA 90033
| | - Maria Bolshakova
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, 1845 N. Soto St. Los Angeles, CA 90033
| | - Matthew G. Kirkpatrick
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, 1845 N. Soto St. Los Angeles, CA 90033
| | - Jordan P. Davis
- University of Southern California Suzanne Dworak-Peck School of Social Work, 669 W 34th Street, Los Angeles, CA 90089
| | - Junhan Cho
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, 1845 N. Soto St. Los Angeles, CA 90033
| | - Jessica Barrington-Trimis
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, 1845 N. Soto St. Los Angeles, CA 90033
| | - Alex H. Kral
- Community Health Research Division, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, CA 94704
| | - Ricky N. Bluthenthal
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, 1845 N. Soto St. Los Angeles, CA 90033
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Knott CL, Miech EJ, Woodard N, Huq M. The role of organizational capacity in intervention efficacy in a church-based cancer education program: A configurational analysis. GLOBAL IMPLEMENTATION RESEARCH AND APPLICATIONS 2023; 3:284-294. [PMID: 38107832 PMCID: PMC10723821 DOI: 10.1007/s43477-023-00089-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/29/2023] [Indexed: 12/19/2023]
Abstract
It is well-established in the field of implementation science that the context in which an intervention is delivered can play a crucial role in how well it is implemented. However, less is known about how organizational context or capacity relates to efficacy outcomes, particularly with health promotion interventions delivered outside of healthcare settings. The present study examined whether organizational capacity indicators were linked to key efficacy outcomes in an evidence-based cancer control intervention delivered in 13 African American churches in Maryland. Outcomes included increases in colorectal cancer knowledge and self-report colonoscopy screening behavior from baseline to follow-up. We used Coincidence Analysis to identify features of organizational capacity that uniquely distinguished churches with varying levels of cancer knowledge and screening. Indicators of organizational capacity (e.g., congregation size, prior health promotion experience) were from an existing measure of church organizational capacity for health promotion. A single solution pathway accounted for greater increases in colorectal cancer knowledge over 12 months, a combination of two conditions: conducting 3 or more health promotion activities in the prior 2 years together with not receiving any technical assistance from outside partners in the prior 2 years. A single condition accounted for greater increases in colonoscopy screening over 24 months: churches that had conducted health promotion activities in 1-4 different topical areas in the prior 2 years. Findings highlight aspects of organizational capacity (e.g., prior experience in health promotion) that may facilitate intervention efficacy and can help practitioners identify organizational settings most promising for intervention impact.
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Affiliation(s)
- Cheryl L. Knott
- University of Maryland School of Public Health, Department of Behavioral and Community Health, 1234 School of Public Health Building, College Park, MD, 20742, USA
| | - Edward J. Miech
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, USA
| | - Nathaniel Woodard
- University of Maryland School of Public Health, Department of Behavioral and Community Health, 1234 School of Public Health Building, College Park, MD, 20742, USA
| | - Maisha Huq
- University of Maryland School of Public Health, Department of Behavioral and Community Health, 1234 School of Public Health Building, College Park, MD, 20742, USA
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Zimmerman C, Clark S, Guerra ME, Bratberg J, Adams KK. Low Dose Buprenorphine Initiation: A Guide for the Inpatient Clinician. Subst Abus 2023; 44:121-129. [PMID: 37728106 DOI: 10.1177/08897077231196417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Low dose buprenorphine initiation (LDBI) is a dosing strategy used to transition patients from full opioid agonists to buprenorphine. The purpose of LDBI is to circumvent obstacles associated with disruption in analgesia, precipitated withdrawal, and prerequisite opioid withdrawal prior to initiating buprenorphine, as not all patients are able to tolerate physical withdrawal symptoms recommended by national guidelines. No literature exists directly comparing traditional buprenorphine initiation to LDBI. Until information on long-term outcomes is available, these dosing strategies should be reserved for patients unable to tolerate traditional buprenorphine initiation. Available published research suggests LDBI strategies will allow some patients to successfully transition to buprenorphine with minimal or no symptoms of withdrawal. Ensuring access to pharmacotherapy during hospital admission is a crucial time for potential intervention and should be considered when appropriate. This narrative review discusses the background of LDBI strategies as well as practical clinical and operational considerations for the inpatient clinician.
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Affiliation(s)
- Cara Zimmerman
- Warren Alpert Medical School of Brown University, Addiction Medicine, Providence, RI, USA
| | - Seth Clark
- Warren Alpert Medical School of Brown University, Addiction Medicine, Providence, RI, USA
| | - Michael E Guerra
- Yale New Haven Hospital Department of Pharmacy, New Haven, CT, USA
| | - Jeffrey Bratberg
- University of Rhode Island College of Pharmacy, Kingston, RI, USA
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