Autonomous Care Pathway to Patient Opioid Abstinence: Should All Programs Offer this Approach?

INTRODUCTION

The opioid epidemic resulted in vast increase in neonatal opioid withdrawal syndrome (NOWS). To mitigate NOWS and opioid dependency among women, staff established a gender specific, patient driven, autonomy based, outpatient therapeutic substitution program.

METHODS

Prospective observational study of obstetric patients receiving prenatal care 7/1/2016-12/31/2019. Patients underwent universal urine drug screens to identify illicit drug use with dependency and offered addiction counseling with voluntary outpatient therapeutic substitution in an obstetrical-addictions combined clinic to achieve abstinence with oral Buprenorphine tapering protocol. Urine substance screening and cord blood testing were obtained at delivery. Birth outcomes compared among groups who achieved abstinence at birth, were successful at tapering, or continued opioid use.

RESULTS

Of 783 births, 165 (20.9%) demonstrated opioid use with 91 (55.2%) participating at some point in pregnancy in therapeutic substitution program. At birth, 14/94 (14.9%) patients completed the program and achieved opioid abstinence, 22/94 (23.4%) still enrolled and actively tapering. 57/94 (34.5%) patients were lost to follow-up, relapsed, or terminated due to non-compliance. Seventy-four of 67 (44.3%) opioid positive mothers chose not to enroll. Of 14 women who completed the program, 0 babies born with NOWS, compared to 11/22 (50%) still enrolled in program and actively tapering, 29/57 (50.9%) lost to follow-up, relapsed, or terminated due to non-compliance, and 28/74 (37.8%) never enrolled in program.

CONCLUSION/IMPLICATIONS

Outpatient therapeutic substitution with oral Buprenorphine with abstinence is possible in pregnant patients and results zero NOWS. More data are needed to confirm findings and explore methods for enhanced success in obtaining abstinence.

SUPPORT

Appalachian Regional Commission and Prevention (ARC) 1^st through Charleston Area Medical Center in cooperation with Charleston Health Education and Research Institute (CHERI).

Effect of Therapeutic Interchange on Medication Changes Between Admission and Discharge

Background: Therapeutic interchange (TI) is the dispensing of an alternative medication within the same class as the original medication. TI often occurs in hospitals; however, failure to return patients to their original medications may increase the risk of adverse effects following hospital discharge. Objective: The purpose of this study was to evaluate the relationship between TI and discharge medication changes, hospital readmission rates, and emergency department visit rates following hospital discharge. Methods: Patient demographic and medication data were collected retrospectively for patients admitted to a nonprofit, acute care hospital. The primary outcome was the relationship between TI and the rate of discharge medication changes. Secondary outcomes included types of discharge medication changes and the relationship between TI and both hospital readmissions and emergency department visits following hospital discharge. Results: A total of 497 patients accounting for 1072 medications were included; 21.2% of home medications were interchanged following admission, and 21.8% of home medications were changed at discharge. TI increased the incidence of discharge medication changes by 70% (odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.22-2.37, P = .0021). Cardiovascular agents were most likely to be changed at discharge (26%), and gastrointestinal agents were most likely to be interchanged (65%). Psychotropic agents were least likely to be changed at discharge (12%) or interchanged (7%). Neither TI nor discharge medication changes were predictive of 30-, 60-, or 90-day hospital readmission or emergency department visits following discharge. Conclusion and Relevance: This study was the first to examine the effects of TI on post-discharge outcomes. Despite being associated with an increased rate of discharge medication changes, the presence of TI did not correlate with hospital readmission or emergency department visit rates. This study supports the safety of TI.

An Investigation of Topics and Trends of Tracheal Replacement Studies Using Co-Occurrence Analysis

This study evaluated tracheal regeneration studies using scientometric and co-occurrence analysis to identify the most important topics and assess their trends over time. To provide the adequate search options, PubMed, Scopus, and Web of Science (WOS) were used to cover various categories such as keywords, countries, organizations, and authors. Search results were obtained by employing Bibexcel. Co-occurrence analysis was applied to evaluate the publications. Finally, scientific maps, author's network, and country contributions were depicted using VOSviewer and NetDraw. Furthermore, the first 25 countries and 130 of the most productive authors were determined. Regarding the trend analysis, 10 co-occurrence terms out of highly frequent words were examined at 5-year intervals. Our findings indicated that the field of trachea regeneration has tested different approaches over the time. In total, 65 countries have contributed to scientific progress both in experimental and clinical fields. Special keywords such as tissue engineering and different types of stem cells have been increasingly used since 1995. Studies have addressed topics such as angiogenesis, decellularization methods, extracellular matrix, and mechanical properties since 2011. These findings will offer evidence-based information about the current status and trends of tracheal replacement research topics over time, as well as countries' contributions.

Impact of Cost Sharing on Therapeutic Substitution: The Story of Statins in 2006

BACKGROUND

Cost sharing is widely used to encourage therapeutic substitution. This study aimed to examine the impact of increases in patient cost-sharing differentials for brand name and generic drugs on statin utilization on entry into the Medicare Part D coverage gap.

METHOD AND RESULTS

Using 5% Medicare Chronic Condition Warehouse files from 2006, this quasi-experimental study examined patients with hyperlipidemia who filled prescriptions for atorvastatin or rosuvastatin between January and March 2006. Propensity score matching and difference-in-difference regressions were used to compare changes in statin utilization for the study group (patients who were not eligible for low-income subsidies [non-LIS] and had generic-only gap coverage) to those of a control group (LIS patients who faced the same cost sharing before and during the Part D coverage gap). In the final sample, 801 patients in the study group were matched to 801 patients in the control group. We found that, compared to the control group, the study group had a larger decline in any monthly brand-name statin use (-0.24 30-day fills, P<0.001). This was only partially offset by increased monthly generic statin use (+0.06 30-day fill, P<0.001), with an overall drop in any monthly statin use (-0.18 30-day fills, P<0.001). Overall adherence with statins declined (OR 0.81, P<0.001), and statin discontinuation increased (OR 1.62, P<0.001) in the study group as compared to the control group.

CONCLUSIONS

Increases in cost-sharing differentials for brand name and generic drugs on coverage gap entry were associated with discontinuation of statins in Medicare Part D patients with hyperlipidemia.

Next generation FIX muteins with FVIII-independent activity for alternative treatment of hemophilia A

BACKGROUND

FVIII neutralizing antibodies are the main complication of substitution therapy in hemophilia A (HA); auto-antibodies against FVIII causing acquired HA can also occur. Treatment of inhibitor patients remains challenging because prophylactic treatment with existing FVIII bypassing agents, all based on constitutively active coagulation factors, is difficult due to their short half-life.

OBJECTIVES

To generate zymogenic FIX variants with FVIII-independent activity for gene- and protein-based therapy for HA.

METHODS

Modifications were introduced into FIX based on current knowledge of FIX structure and FVIII-independent function followed by random screening. Activity, thrombin generation and FX activation by FIX mutants were characterized in the presence and absence of FVIII. Phenotype correction of promising candidates was assessed by the tail-clip assay in FVIII-knockout mice.

RESULTS

About 1600 clones were screened and three mutations (L6F, S102N and E185D) identified, which improved FVIII-independent activity in combination with our previously described variant FIX-ITV. By systematic combination of all mutations, six FIX mutants with the desired bypassing activity were designed. Candidate mutants FIX-IDAV and FIX-FIAV demonstrated the most efficient thrombin generation in FVIII-deficient plasma and had considerably increased activities towards FX in the absence of FVIII, in that they showed an up to 5-fold increase in catalytic efficiency. Expression of FIX-IDAV in FVIII knockout mice reduced blood loss after the tail-clip assay, even in the presence of neutralizing FVIII antibodies.

CONCLUSION

Activatable bioengineered FIX molecules (as opposed to pre-activated coagulation factors) with FVIII-independent activity might be a promising tool for improving HA treatment, especially for patients with inhibitors.

Effectiveness, safety and cost of drug substitution in hypertension

Cost-containment measures in healthcare provision include the implementation of therapeutic and generic drug substitution strategies in patients whose condition is already well controlled with pharmacotherapy. Treatment for hypertension is frequently targeted for such measures. However, drug acquisition costs are only part of the cost-effectiveness equation, and a variety of other factors need to be taken into account when assessing the impact of switching antihypertensives. From the clinical perspective, considerations include maintenance of an appropriate medication dose during the switching process; drug equivalence in terms of clinical effectiveness; and safety issues, including the diverse adverse-event profiles of available alternative drugs, differences in the 'inactive' components of drug formulations and the quality of generic formulations. Patients' adherence to and persistence with therapy may be negatively influenced by switching, which will also impact on treatment effectiveness. From the economic perspective, the costs that are likely to be incurred by switching antihypertensives include those for additional clinic visits and laboratory tests, and for hospitalization if required to address problems arising from adverse events or poorly controlled hypertension. Indirect costs and the impact on patients' quality of life also require assessment. Substitution strategies for antihypertensives have not been tested in large outcome trials and there is little available clinical or economic evidence on which to base decisions to switch drugs. Although the cost of treatment should always be considered, careful assessment of the human and economic costs and benefits of antihypertensive drug substitution is required before this practice is recommended.