Relative effectiveness of medications for opioid-related disorders: A systematic review and network meta-analysis of randomized controlled trials

The role of attachment and personality traits in choosing opiate addiction replacement therapy

Contemporary medical approaches for opioid addiction often include medication-assisted therapy, utilizing methadone and buprenorphine. However, factors influencing patient preferences for starting buprenorphine or methadone therapy are poorly understood. This study aims to explore whether variances in personality traits and attachment styles are related to treatment preferences among individuals undergoing buprenorphine and methadone maintenance therapies. 300 participants completed the Big Five Questionnaire for personality traits and sub-dimensions and the Experiences in Close Relationship Scale for assessing attachment styles. The results indicated that patients with higher levels of Dynamism, Conscientiousness, and Perseverance personality traits were more likely to choose buprenorphine over methadone for achieving and maintaining abstinence. Although attachment styles showed a greater ability to differentiate between groups compared to personality traits, the differences were not significant. However, Conscientiousness stood out for its high discriminant validity, suggesting that scores in this personality dimension could significantly distinguish between groups, with individuals in the buprenorphine group showing higher levels of Conscientiousness compared to the methadone group. The study suggests a partial association between individuals' preference for abstinence therapy and their personality traits. These findings could be considered useful indicators when choosing maintenance therapy to help opiate-addicted patients achieve and maintain abstinence.

Risk of drug-related death associated with co-prescribing of gabapentinoids and Z-drugs among people receiving opioid-agonist treatment: A national retrospective cohort study

BACKGROUND

Prescribing of gabapentinoids and Z-drug-hypnotics has increased in the population and among people receiving opioid-agonist treatment (OAT) for opioid dependence. Evidence is mixed on whether co-prescribing of sedatives such as gabapentinoids and Z-drugs during OAT increases risk of drug-related death (DRD).

METHODS

We conducted a retrospective cohort study of individuals prescribed OAT between 2011 and 2020 in Scotland. Prescribing records were linked to mortality data and other healthcare datasets (sociodemographic, comorbidity). We identified episodes of treatment with gabapentinoids/Z-drugs and used multivariable quasi-Poisson regression to model associations between co-prescription and DRD risk.

RESULTS

Among 46,602 individuals with 304,783 person-years of follow-up, we found that co-prescription was common, with 25 % and 34 % ever being co-prescribed gabapentinoids and Z-drugs, respectively. Gabapentinoid exposure was strongly associated (adjusted hazard ratio (aHR)=2·18, 95 % CI=1·92, 2·46) and Z-drug exposure moderately associated (aHR=1·39, 95 % CI=1·15, 1·66) with elevated risk of DRD. Gabapentinoid exposure was associated with DRD risk on and off OAT; Z-drug exposure was less strongly associated with DRD risk when on OAT.

CONCLUSIONS

Co-prescription of gabapentinoids and Z-drugs is common among OAT patients. However, co-prescription is associated with increased risk of DRD. Alternatives to prescribing sedative medications to OAT patients and/or greater monitoring - if prescribed - are needed.

Willingness to utilize a mobile treatment unit in five counties at the epicenter of the US rural opioid epidemic

INTRODUCTION

US federal policies are evolving to expand the provision of mobile treatment units (MTUs) offering medications for opioid use disorder (MOUD). Mobile MOUD services are critical for rural areas with poor geographic access to fixed-site treatment providers. This study explored willingness to utilize an MTU among a sample of people who use opioids in rural Eastern Kentucky counties at the epicenter of the US opioid epidemic.

METHODS

The study analyzed Cross-sectional survey data from the Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic (CARE2HOPE) study covering five rural counties in the state. Logistic regression models investigated the association between willingness to utilize an MTU providing buprenorphine and naltrexone and potential correlates of willingness, identified using the Behavioral Model for Vulnerable Populations.

RESULTS

The analytic sample comprised 174 people who used opioids within the past six months. Willingness to utilize an MTU was high; 76.5 % of participants endorsed being willing. Those who had recently received MOUD treatment, compared to those who had not received any form of treatment or recovery support services, had six-fold higher odds of willingness to use an MTU. However, odds of being willing to utilize an MTU were 73 % lower among those who were under community supervision (e.g., parole, probation) and 81 % lower among participants who experienced an overdose within the past six months.

CONCLUSIONS

There was high acceptability of MTUs offering buprenorphine and naltrexone within this sample, highlighting the potential for MTUs to alleviate opioid-related harms in underserved rural areas. However, the finding that people who were recently under community supervision or had overdosed were significantly less willing to seek mobile MOUD treatment suggest barriers (e.g., stigma) to mobile MOUD at individual and systemic levels, which may prevent improving opioid-related outcomes in these rural communities given their high rates of criminal-legal involvement and overdose.

Loss, liberation, and agency: Patient experiences of methadone treatment at opioid treatment programs during the COVID-19 pandemic

BACKGROUND

Despite its safety and effectiveness, methadone treatment for opioid use disorder (OUD) remains highly stigmatized, and stringent opioid treatment program (OTP) attendance requirements create barriers to retention for many patients. The COVID-19 pandemic prompted a shift in federal regulations governing methadone, including a blanket exemption permitting increased take-home doses of methadone. We studied the impact of these changes upon established patients' experiences of OTP care.

METHOD

We conducted semi-structured qualitative interviews with 18 OTP patients who met our criteria of having established OTP care (i.e., enrolled at the OTP for at least 12 weeks) and were administered methadone three to six days weekly prior to the March 2020 blanket exemption. Interviews centered on how COVID-19 had affected their experiences of receiving treatment at an OTP.

RESULTS

We identified three interconnected themes relevant to transformation of OTP care by the COVID-19 pandemic. Participants described mourning therapeutic OTP relationships and structure (1. loss), yet feeling more satisfaction with fewer in-person OTP visits (2. liberation), and appreciating more opportunities to self-direct their OUD care (3. agency).

DISCUSSION

Structural changes made to OTP care early in the COVID-19 pandemic resulted in loss of community and structure. Increasing the availability of take-home methadone also improved patient experience and sense of agency. Our findings join a diverse body of converging evidence in support of policy changes allowing for more flexible dosing and individualized OTP care.

Prescription psychostimulants for the treatment of amphetamine-type stimulant use disorder: A systematic review and meta-analysis of randomized placebo-controlled trials

BACKGROUND AND AIMS

There is currently no standard of care for pharmacological treatment of amphetamine-type stimulant (ATS) use disorder (ATSUD). This systematic review with meta-analysis (PROSPERO CRD42022354492) aimed to pool results from randomized placebo-controlled trials (RCTs) to evaluate efficacy and safety of prescription psychostimulants (PPs) for ATSUD.

METHODS

Major indexing sources and trial registries were searched to include records published before 29 August 2022. Eligible studies were RCTs evaluating efficacy and safety of PPs for ATSUD. Risk of bias (RoB) was assessed using the Cochrane RoB 2 tool. Risk ratio (RR) and risk difference were calculated for random-effect meta-analysis of dichotomous variables. Mean difference and standardized mean difference (SMD) were calculated for random-effect meta-analysis of continuous variables.

RESULTS

Ten RCTs (n = 561 participants) were included in the meta-analysis. Trials studied methylphenidate (n = 7), with daily doses of 54-180 mg, and dextroamphetamine (n = 3), with daily doses of 60-110 mg, for 2-24 weeks. PPs significantly decreased end-point craving [SMD  -0.29; 95% confidence interval (CI) = -0.55, -0.03], while such a decrease did not reach statistical significance for ATS use, as evaluated by urine analysis (UA) (RR = 0.93; 95% CI = 0.85-1.01). No effect was observed for self-reported ATS use, retention in treatment, dropout following adverse events, early-stage craving, withdrawal and depressive symptoms. In a sensitivity analysis, treatment was associated with a significant reduction in UA positive for ATS (RR = 0.89; 95% CI = 0.79-0.99) after removing studies with a high risk of bias. In subgroup analyses, methylphenidate and high doses of PPs were negatively associated with ATS use by UA, while higher doses of PPs and treatment duration (≥ 20 weeks) were positively associated with longer retention.

CONCLUSIONS

Among individuals with amphetamine-type stimulant use disorder, treatment with prescription psychostimulants may decrease ATS use and craving. While effect size is limited, it may increase with a higher dosage of medications.

Dental Disorders Reported to the FDA Adverse Event Reporting System in Association with Buprenorphine: An Analysis by Ingredient Composition and Route of Administration

BACKGROUND

Prior research has suggested buprenorphine-containing medications may be associated with an increased risk of dental disorders. However, published data describing adverse dental reactions in buprenorphine users by active ingredient composition and route of administration are limited.

OBJECTIVE

The purpose of this study was to evaluate the influence of formulation on spontaneous reporting of dental disorders among patients treated with buprenorphine.

METHODS

Adverse event reports submitted to the United States Food and Drug Administration Adverse Event Reporting System (FAERS) between 2015 and 2022 were analyzed. Reporting odds ratios (ROR) and 95% confidence intervals (CI) were calculated to measure disproportionality of dental disorder reporting as classified by 39 Medical Dictionary for Regulatory Activities preferred terms.

RESULTS

Compared to pooled reports for all other drugs across FAERS, both buprenorphine monotherapy (ROR 3.09; 95% CI 2.61-3.66) and combination buprenorphine/naloxone (ROR 14.61; 95% CI 13.34-16.01) were associated with positive disproportionality signals. Signals of disproportionate dental disorder reporting were also detected for buprenorphine medicines administered by sublingual (ROR 20.03; 95% CI 18.04-22.24), buccal (ROR 4.46; 95% CI 3.00-6.61) and oral (ROR 7.17; 95% CI 5.03-10.22) routes, but not for other modalities. In considering active ingredient and route together, sublingual buprenorphine monotherapies (ROR 23.55; 95% CI 17.84-31.11) and sublingual buprenorphine/naloxone (ROR 19.47; 95% CI 17.39-21.80) were each associated with disproportionate reporting of dental disorders.

CONCLUSION

Subject to the limitations of spontaneous adverse event data, this study identified significantly disproportionate reporting of dental disorders to FAERS among patients treated with buprenorphine- containing medications, including formulations administered by sublingual, buccal and oral routes. These findings are consistent with prior data and suggest that regular oral care and proper dental hygiene be emphasized for patients undergoing therapy with orally dissolving buprenorphine.

No obvious effect on mortality from a patient choice reform expanding access to opioid disorder treatment - results from a natural experiment of policy change in Sweden

BACKGROUND

Opioid-related overdose deaths remain a common cause of death in many settings, and opioid maintenance treatment is evidence-based for the treatment of opioid use disorders. However, access to such treatment varies and is limited in many settings.

METHODS

The present study examines the longitudinal effects of a regional patient choice reform which substantially increased availability to opioid maintenance treatment in one Swedish county, starting from 2014. A previous follow-up, limited in time, indicated a possible effect on mortality from this intervention, demonstrating a lower increase in overdose deaths than in counties without this reform. The present study follows overdose deaths through 2021, and compares the intervention county to the remaining parts in the country, using death certificate statistics from the national causes of death register.

RESULTS

The present study does not demonstrate any significant difference in the development of overdose mortality in the county where this reform substantially expanded treatment access, compared to other counties in the country.

CONCLUSIONS

The study underlines the importance to maintain extensive efforts against overdose deaths over and above the treatment of opioid use disorders, such as low-threshold provision of opioid antidotes or other interventions specifically addressing overdose risk behaviors.

Self-Adjuvanting TLR7/8 Agonist and Fentanyl Hapten Co-Conjugate Achieves Enhanced Protection against Fentanyl Challenge

Currently approved pharmacotherapies for opioid use disorders (OUDs) and overdose reversal agents are insufficient to slow the spread of OUDs due to the proliferation of fentanyl. This is evident in the 31% rise in drug overdose deaths from 2019 to 2022, with rates increasing from 21.6 to 28.3 overdoses per 100,000 deaths. Vaccines are a potential alternative or adjunct therapy for the treatment of several substance use disorders (nicotine, cocaine) but have shown limited clinical success due to suboptimal antibody titers. In this study, we demonstrate that coconjugation of a Toll-like receptor 7/8 (TLR7/8) agonist (UM-3006) alongside a fentanyl-based hapten (F1) on the surface of the carrier protein cross-reactive material 197 (CRM) significantly increased generation of high-affinity fentanyl-specific antibodies. This demonstrated enhanced protection against fentanyl challenges relative to an unconjugated (admix) adjuvant control in mice. Inclusion of aluminum hydroxide (alum) adjuvant further increased titers and enhanced protection, as determined by analysis of fentanyl concentration in serum and brain tissue. Collectively, our findings present a promising approach to enhance the efficacy of antiopioid vaccines, underscoring the need for extensive exploration of TLR7/8 agonist conjugates as a compelling strategy to combat opioid use disorders.

Stigma and level of familiarity with opioid maintenance treatment (OMT) among specialist physicians in Israel

CONTEXT

Opioid use disorder (OUD) poses significant public health problems that have increased dramatically, resulting in high rates of morbidity and mortality.

OBJECTIVES

To minimize the risk of an opioid epidemic in Israel and be prepared, we evaluated physicians' objective knowledge, level of stigma, and approach to prescribing opioids, risk factors, and identification of patients with substance use disorder (SUD), as well as their knowledge about opioid maintenance treatment (OMT) for OUD.

METHODS

Anonymous computerized questionnaires were distributed nationally to physicians by the Israel Medical Association. Knowledge, stigma, and approach were scored.

RESULTS

Of only 249 responders, 58.6% prescribe opioids, 32.1% prescribe cannabis, and 18.5% daily encounter patients with SUD. Logistic regression found the high knowledge group had daily encounters with SUD (Odds Ratio (OR) = 3.5, 95% CI 1.7-7.1) and were familiar with OMT (OR = 10.1, 95% CI 3.5-29.0). The high stigma group was characterized by physicians who prescribe opioids (OR = 1.7, 95% CI 1.0-2.9), but who self-reported having limited knowledge regarding OMT (OR = 2, 95% CI 1.1-3.7). The high approach group was characterized by those who prescribe opioids (OR = 11.7, 95% CI 4.9-28), prescribe cannabis (OR = 2.1, 95% CI 1.0-4.3), self-report having limited knowledge regarding OMT (OR = 11.2, 95% CI 1.4-89) and self-report identifying SUD (OR = 32.5, 95% CI 4.1-260).

CONCLUSION

High stigma was most evident among physicians who prescribe opioids but, importantly, who had limited knowledge specifically regarding OMT. Gaps in knowledge and approach were observed. An educational intervention is highly recommended to reduce stigma and increase referrals of patients for OMT, the most effective treatment for opioid use disorder.

Associations of methadone and buprenorphine-naloxone doses with unregulated opioid use, treatment retention, and adverse events in prescription-type opioid use disorders: Exploratory analyses of the OPTIMA study

BACKGROUND AND OBJECTIVES

Buprenorphine/naloxone (BUP-NX) and methadone are used to treat opioid use disorder (OUD), yet there is insufficient evidence on the impact of doses on interventions' effectiveness and safety when treating OUD attributable to other opioids than heroin.

METHODS

We explored associations between methadone and BUP-NX doses and treatment outcomes using data from OPTIMA, a 24-week, pragmatic, open-label, multicenter, pan-Canadian, randomized controlled, two-arm parallel trial with participants (N = 272) with OUD who primarily use opioids other than heroin. Participants were randomized to receive flexible take-home BUP-NX (n = 138) or standard supervised methadone treatment (n = 134). We examined associations between highest BUP-NX and methadone doses, and (1) percentage of opioid-positive urine drug screens (UDS); (2) retention in the assigned treatment; and (3) adverse events (AEs).

RESULTS

The mean (SD) highest BUP-NX and methadone dose were 17.31 mg/day (8.59) and 67.70 mg/day (34.70). BUP-NX and methadone doses were not associated with opioid-positive UDS percentages or AEs. Methadone dose was associated with higher retention in treatment (odds ratio [OR]: 1.025; 95% confidence interval [CI]: 1.010; 1.041), while BUP-NX dose was not (OR: 1.055; 95% CI: 0.990; 1.124). Higher methadone doses (70-110 mg/day) offered higher odds of treatment retention.

DISCUSSION AND CONCLUSION

Methadone dose was associated with higher retention, which may be related to its full µ-opioid receptor agonism. Future research should notably ascertain the effect of pace of titration on a wide range of outcomes.

SCIENTIFIC SIGNIFICANCE

Our results extend previous findings of high doses of methadone increasing retention to be applied in our population using opioids other than heroin, including highly potent opioids.

History of the discovery, development, and FDA-approval of buprenorphine medications for the treatment of opioid use disorder

Buprenorphine-based medications were first approved by the United States Food and Drug Administration in 2002 for the treatment of opioid dependence, or opioid use disorder (OUD) as the condition is presently known. This regulatory milestone was the outcome of 36 years of research and development, which also led to the development and approval of several other new buprenorphine-based medications. In this short review, we first describe the discovery and early development stages of buprenorphine. Second, we review key steps that led to the development of buprenorphine as a drug product. Third, we explain the regulatory approval of several buprenorphine-based medications for the treatment of OUD. We also discuss these developments in the context of the evolution of regulations and policies that have progressively improved OUD treatment availability and efficacy, although challenges remain in removing system-level, provider-level, and local-level barriers to quality treatment, to integrating OUD treatment into routine care and other settings, to reducing disparities in access to treatment, and to optimizing person-centered outcomes.

The effects of naltrexone on retention in treatment and being opioid-free in opioid-dependent people: A systematic review and meta-analysis

BACKGROUND

Opioid dependency is a chronic relapsing disorder for which different therapeutically interventions have been developed. Naltrexone is a non-selective opioid antagonist that can be utilized for maintenance therapy in opioid dependency. In this systematic review, we aimed to evaluate the effects of naltrexone on retention in treatment and being opioid-free.

METHODS

We systematically searched PubMed and EMBASE databases up to February 5, 2022, using the following keywords: "Naltrexone," "Substance abuse," "Drug abuse," "Opiate-related disorder," and "Opioid dependence." Studies that included opiate-dependent individuals who were treated with naltrexone and assessed retention in treatment or being opioid-free were included. Two authors independently used the Cochrane risk-of-bias tool for quality assessment. A random effect model in Comprehensive Meta-Analysis software was used for the conduction of the meta-analysis. We performed subgroup analysis to evaluate the effects of naltrexone types on outcomes.

RESULTS

Eighteen studies, including 2,280 participants met our inclusion criteria. The duration of treatment ranged from 21 days to 24 months. The retention in treatment with naltrexone was 63% higher than controls (odds ratio (OR): 1.64 [95% confidence interval (CI), 0.78-3.44]. The OR for being opioid-free was 1.63 (95% CI, 0.57-4.72). Injectable naltrexone was significantly effective on retention in treatment (OR 1.86; 95% CI, 1.17-2.98).

CONCLUSIONS

We found that naltrexone could be useful for retention in treatment and being opioid-free, however, the findings were not significant. Further high-quality and large-scale observational studies are recommended.