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Tarfa A, Lier AJ, Shenoi SV, Springer SA. Considerations when prescribing opioid agonist therapies for people living with HIV. Expert Rev Clin Pharmacol 2024; 17:549-564. [PMID: 38946101 PMCID: PMC11299801 DOI: 10.1080/17512433.2024.2375448] [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: 01/30/2024] [Accepted: 06/28/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION Medications for opioid use disorder (MOUD) include opioid agonist therapies (OAT) (buprenorphine and methadone), and opioid antagonists (extended-release naltrexone). All forms of MOUD improve opioid use disorder (OUD) and HIV outcomes. However, the integration of services for HIV and OUD remains inadequate. Persistent barriers to accessing MOUD underscore the immediate necessity of addressing pharmacoequity in the treatment of OUD in persons with HIV (PWH). AREAS COVERED In this review article, we specifically focus on OAT among PWH, as it is the most commonly utilized form of MOUD. Specifically, we delineate the intersection of HIV and OUD services, emphasizing their integration into the United States Ending the HIV Epidemic (EHE) plan by offering comprehensive screening, testing, and treatment for both HIV and OUD. We identify potential drug interactions of OAT with antiretroviral therapy (ART), address disparities in OAT access, and present the practical benefits of long-acting formulations of buprenorphine, ART, and pre-exposure prophylaxis for improving HIV prevention and treatment and OUD management. EXPERT OPINION Optimizing OUD outcomes in PWH necessitates careful attention to diagnosing OUD, initiating OUD treatment, and ensuring medication retention. Innovative approaches to healthcare delivery, such as mobile pharmacies, can integrate both OUD and HIV and reach underserved populations.
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Affiliation(s)
- Adati Tarfa
- Yale University School of Medicine; 135 College Street, Suite 280, New Haven, New Haven, CT 06510
| | - Audun J. Lier
- Renaissance School of Medicine at Stony Brook University; Northport VA Medical Center, 79 Middleville Road, Northport, NY 11768
| | - Sheela V. Shenoi
- Yale School of Medicine, VA Connecticut Health System, 950 Campbell Avenue, West Haven, CT 06516
| | - Sandra A. Springer
- Yale University School of Medicine; 135 College Street, Suite 280, New Haven, New Haven, CT 06510
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2
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Mocanu V, Bozinoff N, Wood E, Jutras-Aswad D, Le Foll B, Lim R, Cheol Choi J, Yin Mok W, Eugenia Socias M. Opioid agonist therapy switching among individuals with prescription-type opioid use disorder: Secondary analysis of a pragmatic randomized trial. Drug Alcohol Depend 2023; 248:109932. [PMID: 37224674 DOI: 10.1016/j.drugalcdep.2023.109932] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Engagement and retention in opioid agonist therapy (OAT) remains a challenge. This study evaluated the impact of initial randomized OAT allocation on subsequent switching among people with prescription-type opioid use disorder (POUD). METHODS Secondary analysis of a 24-week Canadian multicenter, pragmatic, randomized trial conducted between 2017 and 2020 comparing flexible take-home buprenorphine/naloxone versus supervised methadone models of care for POUD. We used Cox Proportional Hazards modeling to assess for impact of treatment assignment on time to OAT switching, adjusting for important confounders. For clinical correlates, we analyzed data from baseline questionnaires on demographic, substance use, and health factors as well as urine drug screen. RESULTS Of 272 randomized participants, 210 initiated OAT within 14 days per trial protocol, of whom 103 participants were randomized to buprenorphine/naloxone and 107 to methadone. Within 24-week follow-up, 41 (20.5%) of all participants switched OAT with 25 (24.3%, median 27 days, 88.4 per 100 person-years) and 16 participants (15.0%, median 53.5 days, 46.1 per 100 person-years) switching from buprenorphine/naloxone and methadone arms, respectively. In adjusted analysis, allocation to buprenorphine/naloxone was associated with significantly higher risk of switching (aHR = 2.31, 95% CI 1.22 - 4.38). CONCLUSIONS OAT switching was common in this sample of individuals with POUD, with individuals randomly allocated to buprenorphine/naloxone being more than twice as likely to switch versus methadone. This may reflect a stepped care approach in OUD management. More research is needed to evaluate overall retention and outcomes with the different observed risks of switching between methadone and buprenorphine/naloxone.
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Affiliation(s)
- Victor Mocanu
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Nikki Bozinoff
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Center for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, University of British Columbia, Vancouver, BC, Canada
| | - Didier Jutras-Aswad
- Research Centre, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Bernard Le Foll
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Center for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Department of Pharmacology and Toxicology, Faculty of Medicine, Medical Sciences Building, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Acute Care Program, CAMH, Toronto, ON, Canada
| | - Ron Lim
- Department of Family Medicine and Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jin Cheol Choi
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Wing Yin Mok
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - M Eugenia Socias
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, University of British Columbia, Vancouver, BC, Canada.
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3
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Azar P, Mathew N, Mahal D, Wong JSH, Westenberg JN, Schütz CG, Greenwald MK. Developing A Rapid Transfer from Opioid Full Agonist to Buprenorphine: "Ultrarapid Micro-Dosing" Proof of Concept. J Psychoactive Drugs 2023; 55:94-101. [PMID: 35152847 DOI: 10.1080/02791072.2022.2039814] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Buprenorphine/naloxone has been shown to be effective for treating opioid use disorder (OUD). However, the traditional method of induction requires a patient to be in moderate-to-severe withdrawal, which is challenging, time-consuming, and a common reason for leaving against medical advice. Induction strategies that minimize the severity and duration of patient discomfort while enabling patients to reach therapeutic doses during short hospital admissions can mitigate difficulties when inducing a patient on buprenorphine/naloxone. This case-series illustrates two patients with OUD using illicit fentanyl, who were successfully started on buprenorphine/naloxone using 24-hour and 6-hour micro-dosing induction protocol. During induction, the patients were up-titrated to a therapeutic dose through ultrarapid micro-dosing with ongoing use of short-acting opioids. Both patients reached therapeutic doses experiencing minimal levels of withdrawal. This case-series is a proof of concept for the use of a buprenorphine/naloxone ultrarapid micro-induction protocol for inpatients with OUD. By reducing the length of induction and precluding the need for withdrawal, this method offers several advantages over previously published inductions protocols and can improve the accessibility of buprenorphine/naloxone to patients with OUD.
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Affiliation(s)
- Pouya Azar
- Complex Pain and Addiction Services, Vancouver General Hospital, Vancouver, BC, Canada.,Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Nickie Mathew
- Complex Pain and Addiction Services, Vancouver General Hospital, Vancouver, BC, Canada.,Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,Department of the Provincial Health Services Authority, BC Mental Health & Substance Use Services, Provincial Health Services Authority, BC, Canada
| | - Daljeet Mahal
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - James S H Wong
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Jean N Westenberg
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Christian G Schütz
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,Department of the Provincial Health Services Authority, BC Mental Health & Substance Use Services, Provincial Health Services Authority, BC, Canada
| | - Mark K Greenwald
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, and Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
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4
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Preiss A, Baumgartner P, Edlund MJ, Bobashev GV. Using Named Entity Recognition to Identify Substances Used in the Self-medication of Opioid Withdrawal: Natural Language Processing Study of Reddit Data. JMIR Form Res 2022; 6:e33919. [PMID: 35353047 PMCID: PMC9008522 DOI: 10.2196/33919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/28/2021] [Accepted: 01/21/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The cessation of opioid use can cause withdrawal symptoms. People often continue opioid misuse to avoid these symptoms. Many people who use opioids self-treat withdrawal symptoms with a range of substances. Little is known about the substances that people use or their effects. OBJECTIVE The aim of this study is to validate a methodology for identifying the substances used to treat symptoms of opioid withdrawal by a community of people who use opioids on the social media site Reddit. METHODS We developed a named entity recognition model to extract substances and effects from nearly 4 million comments from the r/opiates and r/OpiatesRecovery subreddits. To identify effects that are symptoms of opioid withdrawal and substances that are potential remedies for these symptoms, we deduplicated substances and effects by using clustering and manual review, then built a network of substance and effect co-occurrence. For each of the 16 effects identified as symptoms of opioid withdrawal in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, we identified the 10 most strongly associated substances. We classified these pairs as follows: substance is a Food and Drug Administration-approved or commonly used treatment for the symptom, substance is not often used to treat the symptom but could be potentially useful given its pharmacological profile, substance is a home or natural remedy for the symptom, substance can cause the symptom, or other or unclear. We developed the Withdrawal Remedy Explorer application to facilitate the further exploration of the data. RESULTS Our named entity recognition model achieved F1 scores of 92.1 (substances) and 81.7 (effects) on hold-out data. We identified 458 unique substances and 235 unique effects. Of the 130 potential remedies strongly associated with withdrawal symptoms, 54 (41.5%) were Food and Drug Administration-approved or commonly used treatments for the symptom, 17 (13.1%) were not often used to treat the symptom but could be potentially useful given their pharmacological profile, 13 (10%) were natural or home remedies, 7 (5.4%) were causes of the symptom, and 39 (30%) were other or unclear. We identified both potentially promising remedies (eg, gabapentin for body aches) and potentially common but harmful remedies (eg, antihistamines for restless leg syndrome). CONCLUSIONS Many of the withdrawal remedies discussed by Reddit users are either clinically proven or potentially useful. These results suggest that this methodology is a valid way to study the self-treatment behavior of a web-based community of people who use opioids. Our Withdrawal Remedy Explorer application provides a platform for using these data for pharmacovigilance, the identification of new treatments, and the better understanding of the needs of people undergoing opioid withdrawal. Furthermore, this approach could be applied to many other disease states for which people self-manage their symptoms and discuss their experiences on the web.
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Affiliation(s)
- Alexander Preiss
- Center for Data Science, RTI International, Durham, NC, United States
| | - Peter Baumgartner
- Center for Data Science, RTI International, Durham, NC, United States
- ExplosionAI GmbH, Berlin, Germany
| | - Mark J Edlund
- Community Health Research Division, RTI International, Durham, NC, United States
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Lintzeris N, Mankabady B, Rojas-Fernandez C, Amick H. Strategies for Transfer From Methadone to Buprenorphine for Treatment of Opioid Use Disorders and Associated Outcomes: A Systematic Review. J Addict Med 2022; 16:143-151. [PMID: 33900228 PMCID: PMC8920020 DOI: 10.1097/adm.0000000000000855] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/06/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To review the currently available evidence on transfer strategies from methadone to sublingual buprenorphine used in clinical trials and observational studies of medication for opioid use disorder treatment, and to consider whether any strategies yield better clinical outcomes than others. METHODS Six medical and public health databases were searched for articles and conference abstracts. The Cochrane Central Register of Controlled Trials and the World Health Organization International Clinical Trials Registry Platform were used to identify unpublished trial results. Records were dually screened, and data were extracted and checked independently. Results were summarized qualitatively and, when possible, analyzed quantitatively. RESULTS Eighteen studies described transfer from methadone to buprenorphine. Transfer protocols were extremely varied. Most studies reported successful rates of transfer, even among studies involving transfer from high methadone doses, although lower pretransfer methadone dose was significantly associated with higher rate of successful transfer. Precipitated withdrawal was not reported frequently. A range of innovative approaches to transfer from methadone to buprenorphine remains untested. CONCLUSIONS Few studies have used designs that enable comparison of different approaches to transfer patients from methadone to buprenorphine. Most international clinical guidelines provide recommendations consistent with the available evidence. However, clinical guidelines should be perceived as providing "guidance" rather than "protocols," and clinicians and patients need to exercise judgment when attempting transfers.
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Affiliation(s)
- Nicholas Lintzeris
- Division Addiction Medicine, University Sydney; and South East Sydney Local Health District, NSW Health, New South Wales, Australia (NL); Indivior Inc., North Chesterfield, VA (BM); Venebio Group, LLC; Novartis Pharma Canada Inc., Cardiovascular, Renal and Metabolic Business Franchise, Dorval, Québec, Canada (CR-F); Venebio Group, LLC, Richmond, VA (HA)
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Rapid Transition to Buprenorphine in a Patient With Methadone-Related QTc Interval Prolongation. J Addict Med 2021; 16:488-491. [PMID: 34864786 DOI: 10.1097/adm.0000000000000935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with opioid use disorder (OUD) who are managed on methadone often require transition to buprenorphine therapy. Current recommendations require months to gradually taper off of methadone; however, in some cases, the need to transition is urgent. Only a few rapid methadone-to-buprenorphine transitions have been reported and there are no established protocols to guide clinicians in these cases. CASE PRESENTATION A 43-year-old man on 95 mg methadone for opioid use disorder experienced cardiac arrest attributable to ventricular fibrillation caused by QTc interval prolongation from methadone. In the hospital, a gradual taper of methadone was initiated but proved intolerable; the patient requested to restart his home dose of methadone and leave against medical advice. A rapid transition was initiated instead. Naltrexone (25 mg) was used to precipitate acute withdrawal followed 1 hour later by a "rescue" with buprenorphine/naloxone (16 mg/4 mg). The Clinical Opiate Withdrawal Score (COWS) peaked at 21 post-naltrexone and fell quickly to 15 within a half-hour of buprenorphine/naloxone administration. The patient was maintained on a total daily dose of 16 mg/4 mg buprenorphine/naloxone through the time of discharge. CONCLUSIONS A patient requiring an urgent taper off of methadone due to adverse cardiac effects successfully transitioned to buprenorphine/naloxone within 2 hours by using naltrexone to precipitate withdrawal followed by a "rescue" with buprenorphine/naloxone. A relatively high dose of 16 mg/4 mg buprenorphine/naloxone successfully arrested withdrawal symptoms. With further refinement, this protocol may be an important technique for urgent methadone-to-buprenorphine transitions in the inpatient setting.
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Case AA, Kullgren J, Anwar S, Pedraza S, Davis MP. Treating Chronic Pain with Buprenorphine-The Practical Guide. Curr Treat Options Oncol 2021; 22:116. [PMID: 34791564 DOI: 10.1007/s11864-021-00910-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 12/30/2022]
Abstract
OPINION STATEMENT Buprenorphine has unique and favorable pharmacological properties that make it useful in a variety of clinical scenarios. It has been recommended to consider buprenorphine first-line opioid for chronic pain, especially in the elderly as it may be associated with less cognitive impairment, falls, sexual dysfunction, and sarcopenia when compared with schedule II opioids. It may be useful in patients with comorbid substance use disorder or non-medical opioid use, as there is less risk of misuse, euphoria and it may improve mood. When used to treat opioid use disorder, the training and waiver was recently waived for licensed practitioners with a DEA and any provider may prescribe buprenorphine. For many reasons outlined in this article, the popularity of using buprenorphine for analgesia continues to grow and a practitioner should consider this as an excellent and safe option for chronic pain.
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Affiliation(s)
- Amy A Case
- Lee Foundation Endowed Chair Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.
| | - Justin Kullgren
- Palliative Medicine Clinical Pharmacy, Ohio State University Wexner Medical Center, James Cancer Hospital, Columbus, OH, USA
| | - Sidra Anwar
- Supportive Care, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Sandra Pedraza
- Palliative Care, Sibley Memorial Hospital Johns Hopkins Medicine, Washington, DC, USA
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8
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Fishbain DA. Opioid Tapering/Detoxification Protocols, A Compendium: Narrative Review. PAIN MEDICINE 2021; 22:1676-1697. [PMID: 33860319 DOI: 10.1093/pm/pnab019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The opioid epidemic has put pressure on clinicians to taper their chronic pain patients (CPPs) from opioids. This has resulted in rapid or forced tapers and opioid discontinuation. Partially responsible is lack of information on how to taper (tapering protocols).The objectives of this narrative review were then the following: compile all the published opioid tapering/detoxification protocols from the pain/drug rehabilitation/psychiatric literature whether for inpatient or outpatient use; organize these into general types; compare the types for advantages/disadvantages for use by a clinician in an outpatient setting; and answer some commonly asked questions relating to opioid tapering. METHODS Relevant references were identified by a search strategy utilizing the terms tapering, tapering protocols, detoxification, detoxification protocols, withdrawal, dependence, addiction, and drug rehabilitation. These were explored with the term opioids. Identified abstract were reviewed for any study relating to the objectives of this review. Those studies were then included in this review. As this is a narrative review, no quality ratings of these references were performed. RESULTS Of 1,922 abstracts identified by this search strategy, 301 were reviewed in detail for potential inclusion. Of these, 104 were utilized in this review. Nine types of opioid tapering protocols were identified and compared in tabular form. Twenty-two questions in reference to opioid tapering were addressed. CONCLUSIONS Based on this review, the protocol utilizing the opioid of current use is the simplest to use as it requires no rotation to another opioid and thereby avoids rotation errors. It also has behavior advantages.
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Affiliation(s)
- David A Fishbain
- Departments of Psychiatry, Miller School of Medicine at the University of Miami, Miami, Florida, USA.,Neurological Surgery, Miller School of Medicine at the University of Miami, Miami, Florida, USA.,Anesthesiology, Miller School of Medicine at the University of Miami, Miami, Florida, USA
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9
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The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med 2021; 14:1-91. [PMID: 32511106 DOI: 10.1097/adm.0000000000000633] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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10
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Oakley B, Wilson H, Hayes V, Lintzeris N. Managing opioid withdrawal precipitated by buprenorphine with buprenorphine. Drug Alcohol Rev 2021; 40:567-571. [PMID: 33480051 PMCID: PMC8248003 DOI: 10.1111/dar.13228] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 09/21/2020] [Accepted: 11/10/2020] [Indexed: 01/31/2023]
Abstract
Buprenorphine is a partial opioid agonist commonly used to treat opioid dependence. The pharmacology of buprenorphine increases the risk of a precipitated opioid withdrawal when commencing patients on buprenorphine treatment, particularly when transferring from long acting opioids (e.g. methadone). There is little documented experience regarding the management of precipitated withdrawal. In our case, a patient developed a significant precipitated opioid withdrawal following buprenorphine administration, and was able to be successfully treated in hospital with further buprenorphine. This demonstrates that rapid increases in buprenorphine dose can be used as an effective treatment for buprenorphine-induced precipitated opioid withdrawal. The use of buprenorphine to manage withdrawal then allows the individual to continue on this highly effective treatment.
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Affiliation(s)
- Bridget Oakley
- Drug and Alcohol ServicesSouth East Sydney Local Health DistrictSydneyAustralia
| | - Hester Wilson
- Drug and Alcohol ServicesSouth East Sydney Local Health DistrictSydneyAustralia,School of Public Health and Community MedicineUNSW SydneySydneyAustralia
| | - Victoria Hayes
- Drug and Alcohol ServicesSouth East Sydney Local Health DistrictSydneyAustralia,School of Public Health and Community MedicineUNSW SydneySydneyAustralia
| | - Nicholas Lintzeris
- Drug and Alcohol ServicesSouth East Sydney Local Health DistrictSydneyAustralia,Division Addiction MedicineUniversity of SydneySydneyAustralia
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11
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Srivastava AB, Mariani JJ, Levin FR. New directions in the treatment of opioid withdrawal. Lancet 2020; 395:1938-1948. [PMID: 32563380 PMCID: PMC7385662 DOI: 10.1016/s0140-6736(20)30852-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 03/10/2020] [Accepted: 04/06/2020] [Indexed: 12/16/2022]
Abstract
The treatment of opioid withdrawal is an important area of clinical concern when treating patients with chronic, non-cancer pain, patients with active opioid use disorder, and patients receiving medication for opioid use disorder. Current standards of care for medically supervised withdrawal include treatment with μ-opioid receptor agonists, (eg, methadone), partial agonists (eg, buprenorphine), and α2-adrenergic receptor agonists (eg, clonidine and lofexidine). Newer agents likewise exploit these pharmacological mechanisms, including tramadol (μ-opioid receptor agonism) and tizanidine (α2 agonism). Areas for future research include managing withdrawal in the context of stabilising patients with opioid use disorder to extended-release naltrexone, transitioning patients with opioid use disorder from methadone to buprenorphine, and tapering opioids in patients with chronic, non-cancer pain.
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Affiliation(s)
- A Benjamin Srivastava
- Division on Substance Use Disorders, Department of Psychiatry, Columbia University Irving Medical Center, New York State Psychiatric Institute, New York, NY, USA.
| | - John J Mariani
- Division on Substance Use Disorders, Department of Psychiatry, Columbia University Irving Medical Center, New York State Psychiatric Institute, New York, NY, USA
| | - Frances R Levin
- Division on Substance Use Disorders, Department of Psychiatry, Columbia University Irving Medical Center, New York State Psychiatric Institute, New York, NY, USA
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12
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Cook JE, Chandler C, Rüedi-Bettschen D, Taylor I, Patterson S, Platt DM. Changes in the elimination and resurgence of alcohol-maintained behavior in rats and the effects of naltrexone. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2020; 34:10-22. [PMID: 31750701 PMCID: PMC7007344 DOI: 10.1037/adb0000525] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Resurgence may be a mechanism of relapse in alcohol use disorder patients upon discharge from treatment as part of an abuse-treatment-relapse cycle. Adjunctive pharmacotherapies may be a means to facilitate behavioral treatments and block resurgence. Experiments were conducted using a model of alcohol self-administration to assess the repeatability of the elimination and resurgence of alcohol-maintained behavior and the effects of naltrexone. Experiments had three phases. In Phase 1, behavior was maintained by oral alcohol under a fixed-ratio schedule. In Phase 2, behavior was extinguished via condensed milk delivery under a differential-reinforcement-of-other-behavior (DRO) schedule. In Phase 3, the DRO schedule was eliminated. In Experiment 1, this 3-phase cycle was replicated 4 times. Across replications, response rates and dose of alcohol consumed did not differ in Phase 1, alcohol-maintained behavior was eliminated more rapidly in Phase 2, and the resurgence effect was generally stable in Phase 3. In Experiment 2, naltrexone was administered in Phase 2, Phase 3, or both Phases 2 and 3, to separate groups of rats. Naltrexone facilitated the elimination of alcohol-maintained behavior in Phase 2 and, the resurgence of alcohol-maintained behavior was reduced only for those rats that received naltrexone in both phases. Together, these experiments demonstrate that the resurgence of alcohol-maintained behavior is replicable within-subjects and, further, resurgence of alcohol-maintained behavior may be a useful model to evaluate pharmacological interventions to facilitate behavioral treatments and reduce the likelihood of relapse. Results with naltrexone support the use of medication-assisted therapy approaches to reduce relapse risk in patients. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | | | | | - Ian Taylor
- Department of Psychiatry and Human Behavior
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13
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A Review of Novel Methods To Support The Transition From Methadone and Other Full Agonist Opioids To Buprenorphine/Naloxone Sublingual In Both Community and Acute Care Settings. CANADIAN JOURNAL OF ADDICTION 2019. [DOI: 10.1097/cxa.0000000000000072] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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14
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Transferring Patients From Methadone to Buprenorphine: The Feasibility and Evaluation of Practice Guidelines. J Addict Med 2019; 12:234-240. [PMID: 29509558 PMCID: PMC5976217 DOI: 10.1097/adm.0000000000000396] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text Introduction and Aims: Transfer from methadone to buprenorphine is problematic for many opioid-dependent patients, with limited documented evidence or practical clinical guidance, particularly for the range of methadone doses routinely prescribed for most patients (>50 mg). This study aimed to implement and evaluate recent national Australian guidelines for transferring patients from methadone to buprenorphine. Design and Methods: A multisite prospective cohort study. Participants were patients who transferred from methadone to buprenorphine-naloxone at 1 of 4 specialist addiction centers in Australia and New Zealand. Clinicians were trained in the guidelines, and medical records were reviewed to examine process (eg, transfer setting, doses, and guideline adherence) and safety (precipitated withdrawal) measures. Participants completed research interviews before and after transfer—assessing changes in substance use, health outcomes, and side effects. Results: In all, 33 participants underwent transfer, 9 from low methadone doses (<30 mg), 9 from medium doses (30–50 mg), and 15 from high doses (>50 mg). The majority of high-dose transfers occurred in inpatient settings. There was reasonable guideline adherence, and no complications identified in the low and medium-dose transfers. Three high-dose transfers (20%) experienced precipitated withdrawal, and 7/33 participants (21%) returned to methadone within 1 week of attempted transfer. Discussions and Conclusions: Transfer is feasible in outpatient settings for those transferring from methadone doses below 50 mg; however, inpatient settings and specialist supervision is recommended for higher-dose transfers. The Australian clinical guidelines appear safe and feasible, although further research is required to optimize high-dose transfer procedures.
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Bruneau J, Ahamad K, Goyer MÈ, Poulin G, Selby P, Fischer B, Wild TC, Wood E. Management of opioid use disorders: a national clinical practice guideline. CMAJ 2019; 190:E247-E257. [PMID: 29507156 DOI: 10.1503/cmaj.170958] [Citation(s) in RCA: 265] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Julie Bruneau
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Keith Ahamad
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Marie-Ève Goyer
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Ginette Poulin
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Peter Selby
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Benedikt Fischer
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - T Cameron Wild
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Evan Wood
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
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16
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Exploring Slow Release Oral Morphine (SROM) As a Transition Bridge for Medium to High Doses of Methadone Conversion to Buprenorphine/Naloxone Sublingual: A Calgary Concept and Approach. CANADIAN JOURNAL OF ADDICTION 2019. [DOI: 10.1097/cxa.0000000000000050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Ward HB, Barnett BS, Suzuki J. Rapid transition from methadone to buprenorphine using naltrexone-induced withdrawal: A case report. Subst Abus 2019; 40:140-145. [PMID: 30888254 DOI: 10.1080/08897077.2019.1573776] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Patients taking methadone for opioid use disorder may desire transition to buprenorphine for a number of reasons. However, the current recommended approach for this transition generally takes weeks to months as an outpatient, causing considerable discomfort to the patient and a heightened risk of relapse during the transition period. Case: We describe the case of a patient on methadone maintenance who was rapidly transitioned to buprenorphine because of her desire to not return to her methadone clinic. In order to rapidly transition the patient from methadone to buprenorphine, naltrexone was administered to precipitate acute opioid withdrawal, which was followed soon after by buprenorphine induction. Discussion: Rapid transition from methadone maintenance to buprenorphine can be accomplished in inpatients by precipitating acute withdrawal with naltrexone, providing an effective alternative for patients who cannot tolerate the typical protracted methadone taper required prior to buprenorphine induction as an outpatient.
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Affiliation(s)
- Heather Burrell Ward
- Psychiatry Residency Program, Harvard Medical School, Brigham and Women's Hospital , Boston , Massachusetts , USA.,Harvard Medical School , Boston , Massachusetts , USA
| | - Brian S Barnett
- Harvard Medical School , Boston , Massachusetts , USA.,Addiction Psychiatry Fellowship Program, Partners Healthcare , Boston , Massachusetts , USA
| | - Joji Suzuki
- Harvard Medical School , Boston , Massachusetts , USA.,Department of Psychiatry, Brigham and Women's Hospital , Boston , Massachusetts , USA
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18
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Yu KC, Wei HT, Yeh YH, Hsu CH. Traditional Chinese medicine-facilitated treatments may relieve anxiety symptoms during drug switching from methadone to buprenorphine/naloxone for treating opioid dependence. BMJ Case Rep 2017; 2017:bcr-2017-220815. [PMID: 29127135 PMCID: PMC5695423 DOI: 10.1136/bcr-2017-220815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This study investigated a 51-year-old married man with a history of heroin dependence who underwent methadone maintenance treatment for 7 years. He received traditional Chinese medicine (TCM)-facilitated treatments and switched from methadone to buprenorphine/naloxone. Strong anxiety symptoms were observed during the initial stage; therefore, we prescribed a combination of Chaihu-Shugan-San, Zhi Bai Di Huang and Chin-Gin-Kuan-Ming decoction as the major herbal synergic regimen to relieve the symptoms of opioid withdrawal, anxiety and insomnia. During the treatment course, no precipitating withdrawal syndromes were noted, and the subject was gradually relieved of his anxiety symptoms through continual TCM treatments. In conclusion, TCM is effective in facilitating the switch from methadone to buprenorphine/naloxone and relieving anxiety symptoms. Therefore, focus on TCM-facilitated treatments for heroin dependence should be increased.
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Affiliation(s)
- Kai-Chiang Yu
- Department of Chinese Medicine, Taipei City Hospital, Linsen, Chinese Medicine, and Kunming Branch, Taipei, Taiwan.,Institute of Traditional Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Han-Ting Wei
- Department of Psychiatry, Taipei City Hospital, Linsen, Chinese Medicine, and Kunming Branch, Taipei, Taiwan
| | - Yuh-Hsiang Yeh
- Department of Chinese Medicine, Taipei City Hospital, Linsen, Chinese Medicine, and Kunming Branch, Taipei, Taiwan
| | - Chung-Hua Hsu
- Department of Chinese Medicine, Taipei City Hospital, Linsen, Chinese Medicine, and Kunming Branch, Taipei, Taiwan.,Institute of Traditional Medicine, National Yang-Ming University, Taipei, Taiwan
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19
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Rudolf G, Walsh J, Plawman A, Gianutsos P, Alto W, Mancl L, Rudolf V. A novel non-opioid protocol for medically supervised opioid withdrawal and transition to antagonist treatment. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2017; 44:302-309. [PMID: 28795846 DOI: 10.1080/00952990.2017.1334209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The clinical feasibility of a novel non-opioid and benzodiazepine-free protocol was assessed for the treatment of medically supervised opioid withdrawal and transition to subsequent relapse prevention strategies. METHODS A retrospective chart review of DSM-IV diagnosed opioid-dependent patients admitted for inpatient medically supervised withdrawal examined 84 subjects (52 males, 32 females) treated with a 4-day protocol of scheduled tizanidine, hydroxyzine, and gabapentin. Subjects also received ancillary medications as needed, and routine counseling. Primary outcomes were completion of medically supervised withdrawal, and initiation of injectable extended release (ER) naltrexone treatment. Secondary outcomes included the length of hospital stay, Clinical Opiate Withdrawal Scale (COWS) scores, and facilitation to substance use disorder treatment intervention. Ancillary medication use and adverse effects were also assessed. RESULTS A total of 79 (94%) of subjects completed medically supervised withdrawal. A total of 27 (32%) subjects chose to pursue transition to ER naltrexone, and 24 of the 27 (89%) successfully received the injection prior to hospital discharge. The protocol subjects had a mean length of hospital stay of 3.6 days, and the mean COWS scores was 3.3, 3.4, 2.8, and 2.4 on Day 1, 2, 3, and 4, respectively. Furthermore, 71 (85%) engaged in an inpatient or outpatient substance use disorder (SUD) treatment program following protocol completion. CONCLUSION This retrospective chart review suggests the feasibility of a novel protocol for medically supervised opioid withdrawal and transition to relapse prevention strategies, including injectable ER naltrexone. This withdrawal protocol does not utilize opioid agonists or other controlled substances..
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Affiliation(s)
- Gregory Rudolf
- a Department of Pain Services , Swedish Medical Center , Seattle , WA , USA
| | - Jim Walsh
- b Addiction Recovery Service, Swedish Medical Center , Seattle , WA , USA
| | - Abigail Plawman
- b Addiction Recovery Service, Swedish Medical Center , Seattle , WA , USA
| | - Paul Gianutsos
- c Department of Family Medicine , Swedish Medical Center Cherry Hill Campus , Seattle , WA , USA
| | - William Alto
- c Department of Family Medicine , Swedish Medical Center Cherry Hill Campus , Seattle , WA , USA
| | - Lloyd Mancl
- d Department of Biostatistics , University of Washington , Seattle , WA , USA
| | - Vania Rudolf
- b Addiction Recovery Service, Swedish Medical Center , Seattle , WA , USA
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Leone B, Di Nicola M, Moccia L, Pettorruso M, De Risio L, Nucara G, Zamboni L, Callea A, Janiri L, Cibin M, Lugoboni F. Gender-related psychopathology in opioid use disorder: Results from a representative sample of Italian addiction services. Addict Behav 2017; 71:107-110. [PMID: 28327378 DOI: 10.1016/j.addbeh.2017.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/19/2017] [Accepted: 03/08/2017] [Indexed: 12/15/2022]
Abstract
AIMS Gender and psychiatric comorbidity seem to influence patients' inter-individual response to Opioid Substitution Treatments (OST) in Opioid Use Disorder (OUD) management. The aim of the study was to assess psychopathological dimensions in an Italian sample of OUD individuals entering a methadone/buprenorphine maintenance program; secondary, we evaluated the possible gender-specific differences within the psychopathological profiles. METHODS In a cross-sectional study, we recruited 1052 (792 male; 260 female) OUD subjects receiving OST. All patients underwent a clinical and psychometric evaluation assessing demographics, psychiatric history, psychopathological features via the Symptom Checklist-90-Revised (SCL-90-R), and were prescribed psychopharmacological treatments. RESULTS Our results reveal gender-specific differences in a real-world sample of opioid-maintained OUD individuals attending public addiction services in Italy. Compared to men, women reported higher scores in both General Symptomatic Index (GSI) and in all the SCL-90-R sub-scales. No impact of pharmacological treatment was detected. Finally, regression analysis revealed that being in methadone-maintenance group was significantly associated with high GSI scores in the male, but not female, group. CONCLUSIONS Increasing the knowledge of psychopathological dimensions in patients with OST, with relevance to gender differences, is important for a better understanding of factors that influence the outcome and for further development in gender-tailored strategies.
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21
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Nutt DJ. Considerations on the role of buprenorphine in recovery from heroin addiction from a UK perspective. J Psychopharmacol 2015; 29:43-9. [PMID: 25389219 DOI: 10.1177/0269881114555248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The United Kingdom Drug Strategy emphasises recovery as a key focus in the treatment of drug dependence. A framework for recovery is defined in the Recovery-Orientated Drug Treatment report, written by an expert working group, and comprises four key phases: engagement and stabilisation, including the establishment of treatment goals; preparation for change, involving engagement in psychosocial and pharmacological interventions; active change, including detoxification and medical withdrawal; and completion, including interventions that strengthen community integration. A body of evidence supports the benefits of buprenorphine, a partial agonist at mu opioid receptors, in supporting individualised recovery based on this framework, specifically in relation to the potential for rapid stabilisation, flexibility to transition to other treatment options or achieve abstinence, effective blocking of on-top use of illicit drugs, the treatment of comorbidities through the minimisation of drug-drug interactions, and a good safety profile. In addition, the newer abuse-deterrent formulation of buprenorphine combined with the opioid antagonist naloxone is likely to strengthen recovery-orientated systems of care due to its potential to reduce misuse and diversion. Progress through the recovery journey and the ability to sustain recovery will depend on individual needs and goals and on the amount of recovery capital that individuals have developed.
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Mannelli P, Wu LT, Peindl KS, Swartz MS, Woody GE. Extended release naltrexone injection is performed in the majority of opioid dependent patients receiving outpatient induction: a very low dose naltrexone and buprenorphine open label trial. Drug Alcohol Depend 2014; 138:83-8. [PMID: 24602363 PMCID: PMC4017322 DOI: 10.1016/j.drugalcdep.2014.02.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 01/22/2014] [Accepted: 02/01/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The approval of extended release injectable naltrexone (XR-NTX; Vivitrol(®)) has introduced a new option for treating opioid addiction, but studies are needed to identify its place within the spectrum of available therapies. The absence of physiological opioid dependence is a necessary and challenging first step for starting XR-NTX. Outpatient detoxification gives poor results and inpatient detoxification is either unavailable or too brief for the physiological effects of opioids to resolve. Here we present findings from an open label study that tested whether the transition from opioid addiction to XR-NTX can be safely and effectively performed in an outpatient setting using very low dose naltrexone and buprenorphine. METHODS Twenty treatment seeking opioid addicted individuals were given increasing doses of naltrexone starting at 0.25mg with decreasing doses of buprenorphine starting at 4 mg during a 7-day outpatient XR-NTX induction procedure. Withdrawal discomfort, craving, drug use, and adverse events were assessed daily until the XR-NTX injection, then weekly over the next month. RESULTS Fourteen of the 20 participants received XR-NTX and 13 completed weekly assessments. Withdrawal, craving, and opioid or other drug use were significantly lower during induction and after XR-NTX administration compared with baseline, and no serious adverse events were recorded. CONCLUSIONS Outpatient transition to XR-NTX combining upward titration of very low dose naltrexone with downward titration of low dose buprenorphine was safe, well tolerated, and completed by most participants. Further studies with larger numbers of subjects are needed to see if this approach is useful for naltrexone induction.
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Affiliation(s)
- Paolo Mannelli
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, United States.
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, United States
| | - Kathleen S Peindl
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, United States
| | - Marvin S Swartz
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, United States
| | - George E Woody
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, United States
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Diaper AM, Law FD, Melichar JK. Pharmacological strategies for detoxification. Br J Clin Pharmacol 2014; 77:302-14. [PMID: 24118014 PMCID: PMC4014033 DOI: 10.1111/bcp.12245] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 09/24/2013] [Indexed: 02/06/2023] Open
Abstract
Detoxification refers to the safe discontinuation from a substance of dependence and is distinct from relapse prevention. Detoxification usually takes between a few days and a few weeks to complete, depending on the substance being misused, the severity of dependence and the support available to the user. Psychosocial therapies alongside pharmacological treatments are essential to improve outcome. The dependencies considered in this overview are detoxification from opioids (with methadone, buprenorphine, α2-adrenoceptor agonists and adjunct medications), alcohol (with benzodiazepines, anti-glutamatergics and γ-aminobutyric acid (GABA)-ergic drugs), stimulants and cannabis (with no clear recommended pharmacological treatments), benzodiazepines (with dose tapering) and nicotine (with nicotine replacement therapy, antidepressants and partial agonists). Evidence is limited by a lack of controlled trials robust enough for review bodies, and more research is required into optimal treatment doses and regimes, alone and in combination.
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24
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Mauger S, Fraser R, Gill K. Utilizing buprenorphine-naloxone to treat illicit and prescription-opioid dependence. Neuropsychiatr Dis Treat 2014; 10:587-98. [PMID: 24741316 PMCID: PMC3984058 DOI: 10.2147/ndt.s39692] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To review current evidence on buprenorphine-naloxone (bup/nx) for the treatment of opioid-use disorders, with a focus on strategies for clinical management and office-based patient care. QUALITY OF EVIDENCE Medline and the Cochrane Database of Systematic Reviews were searched. Consensus reports, guidelines published, and other authoritative sources were also included in this review. Apart from expert guidelines, data included in this review constitute level 1 evidence. FINDINGS Bup/nx is a partial μ-opioid agonist combined with the opioid antagonist naloxone in a 4:1 ratio. It has a lower abuse potential, carries less stigma, and allows for more flexibility than methadone. Bup/nx is indicated for both inpatient and ambulatory medically assisted withdrawal (acute detoxification) and long-term substitution treatment (maintenance) of patients who have a mild-to-moderate physical dependence. A stepwise long-term substitution treatment with regular monitoring and follow-up assessment is usually preferred, as it has better outcomes in reducing illicit opioid use, minimizing concomitant risks such as human immunodeficiency virus and hepatitis C transmission, retaining patients in treatment and improving global functioning. CONCLUSION Bup/nx is safe and effective for opioid detoxification and substitution treatment. Its unique pharmaceutical properties make it particularly suitable for office-based maintenance treatment of opioid-use disorder.
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Affiliation(s)
- Sofie Mauger
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Ronald Fraser
- Department of Psychiatry, McGill University, Montreal, QC, Canada ; Addictions Unit, McGill University Health Centre, Montreal, QC, Canada
| | - Kathryn Gill
- Department of Psychiatry, McGill University, Montreal, QC, Canada ; Addictions Unit, McGill University Health Centre, Montreal, QC, Canada
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