1
|
O'Conor C, Farhi S, Cowan E, Fitzgerald R. Inpatient initiation of long-acting injectable buprenorphine at a community hospital: A retrospective case series. J Addict Dis 2024:1-7. [PMID: 39219151 DOI: 10.1080/10550887.2024.2391145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
OBJECTIVES Determine if long-acting injectable buprenorphine (LAIB) can be successfully and safely administered in the hospital with minimal sublingual buprenorphine lead-in and potentially improve follow-up engagement in care. METHODS We performed a retrospective case series of 46 patients who received LAIB while hospitalized at a safety-net community hospital. We abstracted demographic information, details about substance use disorder treatment history, in-hospital buprenorphine initiation methods and follow-up data from inpatient and outpatient electronic medical records. RESULTS In total, 46 hospitalized patients received LAIB during the study period. The majority of our patients were older Black adults with Medicaid who self-reported intranasal heroin use. A low-dose buprenorphine initiation protocol was used most commonly, either in sublingual or intravenous form, with only two cases of precipitated withdrawal occurring during the buprenorphine initiation process and no cases of precipitated withdrawal after the administration of LAIB. 87% (40) of the patients received LAIB after receiving either sublingual or IV buprenorphine for fewer than the recommended seven days. Of the 46 hospitalized patients who received LAIB, 23 (50%) attended a follow-up addiction medicine appointment within 30 days of discharge. CONCLUSIONS Hospital administration of LAIB could play an important role in retention in care after hospital discharge.
Collapse
Affiliation(s)
| | - Shai Farhi
- Rush University Medical College, Chicago, IL, USA
| | - Ethan Cowan
- Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | |
Collapse
|
2
|
Brandt L, Odom GJ, Hu MC, Castro C, Balise RR. Empirically contrasting urine drug screening-based opioid use disorder treatment outcome definitions. Addiction 2024; 119:1289-1300. [PMID: 38616571 DOI: 10.1111/add.16494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 02/21/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND AND AIMS A lack of consensus on the optimal outcome measures to assess opioid use disorder (OUD) treatment efficacy and their precise definition and computation has hampered the pooling of research data for evidence synthesis and meta-analyses. This study aimed to empirically contrast multiple clinical trial definitions of treatment success by applying them to the same dataset. METHODS Data analysis used a suite of functions, developed as a software package for the R language, to operationalize 61 treatment outcome definitions based on urine drug screening (UDS) results. Outcome definitions were derived from clinical trials that are among the most influential in the OUD treatment field. Outcome functions were applied to a harmonized dataset from three large-scale National Drug Abuse Treatment Clinical Trials Network (CTN) studies, which tested various medication for OUD (MOUD) options (n = 2492). Hierarchical clustering was employed to empirically contrast outcome definitions. RESULTS The optimal number of clusters identified was three. Cluster 1, comprising eight definitions focused on detecting opioid-positive UDS, did not include missing UDS in outcome calculations, potentially resulting in inflated rates of treatment success. Cluster 2, with the highest variability, included 10 definitions characterized by strict criteria for treatment success, relying heavily on UDS results from either a brief period or a single study visit. The 43 definitions in Cluster 3 represented a diverse range of outcomes, conceptualized as measuring abstinence, use reduction and relapse. These definitions potentially offer more balanced measures of treatment success or failure, as they avoid the extreme methodologies characteristic of Clusters 1 and 2. CONCLUSIONS Clinical trials using urine drug screening (UDS) for objective substance use assessment in outcome definitions should consider (1) incorporating missing UDS data in outcome computation and (2) avoiding over-reliance on UDS data confined to a short time frame or the occurrence of a single positive urine test following a period of abstinence.
Collapse
Affiliation(s)
- Laura Brandt
- Department of Psychology, The City College of New York, New York, New York, USA
| | - Gabriel J Odom
- Department of Biostatistics, Florida International University, Miami, Florida, USA
| | - Mei-Chen Hu
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Clinton Castro
- The Information School, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Raymond R Balise
- Division of Biostatistics, Department of Public Health Sciences, The University of Miami, Miami, Florida, USA
| |
Collapse
|
3
|
Calihan JB, Bagley SM. Injectable Buprenorphine: An Opportunity to Improve Treatment Access for Youth With Opioid Use Disorder. J Adolesc Health 2024; 75:13-14. [PMID: 38880557 DOI: 10.1016/j.jadohealth.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/03/2024] [Accepted: 04/09/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Jessica B Calihan
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Sarah M Bagley
- Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| |
Collapse
|
4
|
D'Onofrio G, Herring AA, Perrone J, Hawk K, Samuels EA, Cowan E, Anderson E, McCormack R, Huntley K, Owens P, Martel S, Schactman M, Lofwall MR, Walsh SL, Dziura J, Fiellin DA. Extended-Release 7-Day Injectable Buprenorphine for Patients With Minimal to Mild Opioid Withdrawal. JAMA Netw Open 2024; 7:e2420702. [PMID: 38976265 PMCID: PMC11231806 DOI: 10.1001/jamanetworkopen.2024.20702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/05/2024] [Indexed: 07/09/2024] Open
Abstract
Importance Buprenorphine is an effective yet underused treatment for opioid use disorder (OUD). Objective To evaluate the feasibility (acceptability, tolerability, and safety) of 7-day injectable extended-release buprenorphine in patients with minimal to mild opioid withdrawal. Design, Setting, and Participants This nonrandomized trial comprising 4 emergency departments in the Northeast, mid-Atlantic, and Pacific geographic areas of the US included adults aged 18 years or older with moderate to severe OUD and Clinical Opiate Withdrawal Scale (COWS) scores less than 8 (minimal to mild), in which scores range from 0 to 7, with higher scores indicating increasing withdrawal. Exclusion criteria included methadone-positive urine, pregnancy, overdose, or required admission. Outcomes were assessed at baseline, daily for 7 days by telephone surveys, and in person at 7 days. Patient recruitment occurred between July 13, 2020, and May 25, 2023. Intervention Injection of a 24-mg dose of a weekly extended-release formulation of buprenorphine (CAM2038) and referral for ongoing OUD care. Main Outcomes and Measures Primary feasibility outcomes included the number of patients who (1) experienced a 5-point or greater increase in the COWS score or (2) transitioned to moderate or greater withdrawal (COWS score ≥13) within 4 hours of extended-release buprenorphine or (3) experienced precipitated withdrawal within 1 hour of extended-release buprenorphine. Secondary outcomes included injection pain, satisfaction, craving, use of nonprescribed opioids, adverse events, and engagement in OUD treatment. Results A total of 100 adult patients were enrolled (mean [SD] age, 36.5 [8.7] years; 72% male). Among the patients, 10 (10.0% [95% CI, 4.9%-17.6%]) experienced a 5-point or greater increase in COWS and 7 (7.0% [95% CI, 2.9%-13.9%]) transitioned to moderate or greater withdrawal within 4 hours, and 2 (2.0% [95% CI, 0.2%-7.0%]) experienced precipitated withdrawal within 1 hour of extended-release buprenorphine. A total of 7 patients (7.0% [95% CI, 2.9%-13.9%]) experienced precipitated withdrawal within 4 hours of extended-release buprenorphine, which included 2 of 63 (3.2%) with a COWS score of 4 to 7 and 5 of 37 (13.5%) with a COWS score of 0 to 3. Site pain scores (based on a total pain score of 10, in which 0 indicated no pain and 10 was the worst possible pain) after injection were low immediately (median, 2.0; range, 0-10.0) and after 4 hours (median, 0; range, 0-10.0). On any given day among those who responded, between 29 (33%) and 31 (43%) patients reported no cravings and between 59 (78%) and 75 (85%) reported no use of opioids; 57 patients (60%) reported no days of opioid use. Improving privacy (62%) and not requiring daily medication (67%) were deemed extremely important. Seventy-three patients (73%) were engaged in OUD treatment on day 7. Five serious adverse events occurred that required hospitalization, of which 2 were associated with medication. Conclusions and Relevance This nonrandomized trial of the feasibility of a 7-day buprenorphine injectable in patients with minimal to mild opioid withdrawal (COWS scores, 0-7) found the formulation to be acceptable, well tolerated, and safe in those with COWS scores of 4 to 7. This new medication formulation could substantially increase the number of patients with OUD receiving buprenorphine. Trial Registration ClinicalTrials.gov Identifier: NCT04225598.
Collapse
Affiliation(s)
- Gail D'Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, Connecticut
| | - Andrew A Herring
- Department of Emergency Medicine, Highland General Hospital-Alameda Health System, Oakland, California
- Department of Addiction Medicine, Highland General Hospital-Alameda Health System, Oakland, California
- Department of Emergency Medicine, University of California, San Francisco
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Kathryn Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, Connecticut
| | - Elizabeth A Samuels
- Department of Emergency Medicine, David Geffen School of Medicine at the University of California, Los Angeles
- Department of Emergency Medicine, the Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Ethan Cowan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erik Anderson
- Department of Emergency Medicine, Highland General Hospital-Alameda Health System, Oakland, California
- Department of Addiction Medicine, Highland General Hospital-Alameda Health System, Oakland, California
| | - Ryan McCormack
- Ronald O. Perelman Department of Emergency Medicine at New York University Langone Health, New York
| | - Kristen Huntley
- Center for Clinical Trials, Clinical Trials Network, National Institute on Drug Abuse, Rockville, Maryland
| | - Patricia Owens
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Shara Martel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Michele R Lofwall
- Department of Behavioral Science, University of Kentucky College of Medicine, Lexington
- Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington
| | - Sharon L Walsh
- Department of Behavioral Science, University of Kentucky College of Medicine, Lexington
- Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington
| | - James Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David A Fiellin
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Daglish MRC, Hayllar JS, McDonough M. An Australian retrospective observational cohort comparison of the use of long-acting injectable buprenorphine products. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 162:209348. [PMID: 38494054 DOI: 10.1016/j.josat.2024.209348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/16/2024] [Accepted: 02/21/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION In early 2019, Australia became the first jurisdiction to have two brands of long-acting injectable buprenorphine (LAI-B) products available. Previously published studies have mostly followed pre-planned dosing schedules and seldom compared use of both products. This study presents a retrospective analysis of the "real-world" dosing requirements of patients on LAI-B. METHOD Five clinics provided data for patients commenced on LAI-B between 1 February 2019 and 30 June 2021 for buprenorphine doses and intervals between dosing. The study recorded basic demographic data including age, gender, and previous dose of transmucosal buprenorphine. The Local Institutional Ethics Committee provided approval. RESULTS Over 3600 individual doses (59 % Buvidal® & 41 % Sublocade®) were administered to 340 individual patients (median age 40 years, 63 % male), with the longest duration in treatment of 856 days. Median estimated duration of a treatment episode was 16.5 months (95%CI: 14.3-19.1). Approximately 94 % transferred from transmucosal buprenorphine (median daily dose 16 mg, range 2-32 mg). Most common LAI-B doses were Sublocade® 100 mg (22.4 %) and Buvidal® Monthly 128 mg (21.5 %); Buvidal® Weekly 24 mg (0.8 %) was least used. 13 % transitioned between LAI-B products. Weekly dose intervals were a median 7 days and monthly doses were given a median of 28 days apart. Overall, 36 % discontinued LAI-B before the census date. DISCUSSIONS AND CONCLUSIONS Most patients who started LAI-B remained in treatment, with similar rates in both products. A small, but appreciable number of people switched brands, suggesting that it remains important to have treatment options available.
Collapse
Affiliation(s)
- Mark R C Daglish
- Hospital Alcohol & Drug Service, Royal Brisbane & Women's Hospital, Metro North Heath, Brisbane, Australia; Alcohol & Drug Service, The Prince Charles Hospital, Metro North Health, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia.
| | - Jeremy S Hayllar
- Alcohol & Drug Service, The Prince Charles Hospital, Metro North Health, Brisbane, Australia
| | | |
Collapse
|
7
|
Nunes EV, Comer SD, Lofwall MR, Walsh SL, Peterson S, Tiberg F, Hjelmstrom P, Budilovsky-Kelley NR. Extended-Release Injection vs Sublingual Buprenorphine for Opioid Use Disorder With Fentanyl Use: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2417377. [PMID: 38916892 PMCID: PMC11200143 DOI: 10.1001/jamanetworkopen.2024.17377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 04/17/2024] [Indexed: 06/26/2024] Open
Abstract
Importance Fentanyl has exacerbated the opioid use disorder (OUD) and opioid overdose epidemic. Data on the effectiveness of medications for OUD among patients using fentanyl are limited. Objective To assess the effectiveness of sublingual or extended-release injection formulations of buprenorphine for the treatment of OUD among patients with and without fentanyl use. Design, Setting, and Participants Post hoc analysis of a 24-week, randomized, double-blind clinical trial conducted at 35 outpatient sites in the US from December 2015 to November 2016 of sublingual buprenorphine-naloxone vs extended-release subcutaneous injection buprenorphine (CAM2038) for patients with OUD subgrouped by presence vs absence of fentanyl or norfentanyl in urine at baseline. Study visits with urine testing occurred weekly for 12 weeks, then 6 times between weeks 13 and 24. Data were analyzed on an intention-to-treat basis from March 2022 to August 2023. Intervention Weekly and monthly subcutaneous buprenorphine vs daily sublingual buprenorphine-naloxone. Main Outcomes and Measures Retention in treatment, percentage of urine samples negative for any opioids (missing values imputed as positive), percentage of urine samples negative for fentanyl or norfentanyl (missing values not imputed), and scores on opiate withdrawal scales and visual analog craving scales. Results Of 428 participants, 123 (subcutaneous buprenorphine, n = 64; sublingual buprenorphine-naloxone, n = 59; mean [SD] age, 39.1 [10.8] years; 75 men [61.0%]) had evidence of baseline fentanyl use and 305 (subcutaneous buprenorphine, n = 149; buprenorphine-naloxone, n = 156; mean [SD] age, 38.1 [11.1] years; 188 men [61.6%]) did not have evidence of baseline fentanyl use. Study completion was similar between the fentanyl-positive (60.2% [74 of 123]) and fentanyl-negative (56.7% [173 of 305]) subgroups. The mean percentage of urine samples negative for any opioid were 28.5% among those receiving subcutaneous buprenorphine and 18.8% among those receiving buprenorphine-naloxone in the fentanyl-positive subgroup (difference, 9.6%; 95% CI, -3.0% to 22.3%) and 36.7% among those receiving subcutaneous buprenorphine and 30.6% among those receiving buprenorphine-naloxone in the fentanyl-negative subgroup (difference, 6.1%; 95% CI, -1.9% to 14.1%), with significant main associations of baseline fentanyl status and treatment group. In the fentanyl-positive subgroup, the mean percentage of urine samples negative for fentanyl during the study was 74.6% among those receiving subcutaneous buprenorphine vs 61.9% among those receiving sublingual buprenorphine-naloxone (difference, 12.7%; 95% CI, 9.6%-15.9%). Opioid withdrawal and craving scores decreased rapidly after treatment initiation across all groups. Conclusions and Relevance In this post hoc analysis of a randomized clinical trial of sublingual vs extended-release injection buprenorphine for OUD, buprenorphine appeared to be effective among patients with baseline fentanyl use. Patients with fentanyl use had fewer opioid-negative urine samples during the trial compared with the fentanyl-negative subgroup. These findings suggest that the subcutaneous buprenorphine formulation may be more effective at reducing fentanyl use. Trial Registration ClinicalTrials.gov Identifier: NCT02651584.
Collapse
Affiliation(s)
- Edward V. Nunes
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York
- Columbia University Irving Medical Center Department of Psychiatry, New York, New York
| | - Sandra D. Comer
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York
- Columbia University Irving Medical Center Department of Psychiatry, New York, New York
| | - Michelle R. Lofwall
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington
| | - Sharon L. Walsh
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington
| | | | | | | | | |
Collapse
|
8
|
Reddy IA, Audet CM, Reese TJ, Peek G, Marcovitz D. Provider Perceptions toward Extended-Release Buprenorphine for Treatment of Opioid Use Disorder. J Addict Med 2024:01271255-990000000-00322. [PMID: 38829032 DOI: 10.1097/adm.0000000000001320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVES The persistence of the opioid crisis and the proliferation of synthetic fentanyl have heightened the demand for the implementation of novel delivery mechanisms of pharmacotherapy for the treatment of opioid use disorder, including injectable extended-release buprenorphine (buprenorphine-ER). The purpose of this study was to understand provider-level barriers to prescribing buprenorphine in order to facilitate targeted strategies to improve implementation for patients who would benefit from this novel formulation. METHODS Using an interview template adapted from the Consolidated Framework for Implementation Research (CFIR), we conducted structured focus group interviews with 20 providers in an outpatient addiction clinic across 4 sessions to assess providers' perceptions of buprenorphine-ER. Ninety-four unique comments were identified and deductively coded using standardized CFIR constructs. RESULTS Providers expressed mixed receptivity and confidence in using buprenorphine-ER. Although providers could identify a number of theoretical advantages to the injectable formulation over sublingual buprenorphine, many expressed reservations about using it due to inexperience, negative patient experiences, uncertainties about patient candidacy, cost, and logistical constraints. CONCLUSIONS Provider concerns about buprenorphine-ER may limit utilization. Some concerns may be mitigated through improved education, research, and logistical support. Given the putative benefits of buprenorphine-ER, future research should target barriers to implementation, in part based on hypotheses generated by these findings.
Collapse
Affiliation(s)
- India A Reddy
- From the Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN (IAR, DM); Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN (CMA); Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN (TJR); and Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN (GP)
| | | | | | | | | |
Collapse
|
9
|
Yarborough BJH, Stumbo SP, Janoff SL, Keast EM, Leo MC, Leitz SJ. Reduced emergency department use among insured individuals receiving extended-release buprenorphine in a health system setting. DRUG AND ALCOHOL DEPENDENCE REPORTS 2024; 11:100233. [PMID: 38699647 PMCID: PMC11063592 DOI: 10.1016/j.dadr.2024.100233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 05/05/2024]
Abstract
Introduction Extended-release buprenorphine (XR-Bup) is associated with reduced opioid use and opioid negative urine drug screens. Little is known about its use in outpatient addiction care provided within health systems. Methods Individuals prescribed XR-Bup were identified from electronic health records; chart abstraction was conducted. Primary outcome was all-cause emergency department (ED) use. Secondary outcomes included ED use or inpatient stays for mental health or substance use, ED use for any other cause, discontinuation reasons, and drug substitution. Statistical comparisons used nonparametric tests from related samples (McNemar's test and Wilcoxon matched pair tests) to test outcomes six months prior and 6 months following XR-Bup initiation. Results 152 individuals had an XR-Bup order, 126 received >1 injection. Among those consistently insured 6 months prior to and following XR-Bup initiation (n=99), the mean number of injections following initiation was 3.95; one-third received 6 doses in the 6 months. The proportion of individuals using ED services for all causes declined (41% prior vs. 28% following XR-Bup initiation, p<.05); similar results were found for secondary ED use outcomes. The proportion of individuals requiring inpatient treatment for mental health or substance use also declined (46% vs. 16%, p<.01). Common reasons for discontinuing XR-Bup included losing insurance (21%) or cost (11%). The most common non-prescribed substances used during treatment were opioids (n=31) and THC (n=20). Conclusions In this non-randomized retrospective observational study, use of XR-Bup was associated with reduced ED use 6 months following initiation. XR-Bup may help health systems reduce use of costly ED services.
Collapse
Affiliation(s)
- Bobbi Jo H. Yarborough
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, United States
- Kaiser Permanente School of Medicine, Pasadena, CA, United States
| | - Scott P. Stumbo
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, United States
| | - Shannon L. Janoff
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, United States
| | - Erin M. Keast
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, United States
| | - Michael C. Leo
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, United States
| | | |
Collapse
|
10
|
Naren T, Cook J, MacCartney P. Direct induction onto high-dose long-acting injectable buprenorphine: A case series. Australas Psychiatry 2024; 32:238-241. [PMID: 38444394 DOI: 10.1177/10398562241237655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
INTRODUCTION This case series reports on five patients with opioid use disorder (OUD) who were commenced directly onto high-dose long-acting injectable buprenorphine (LAIB). METHOD A retrospective audit and manual review of the electronic medical record at cohealth Innerspace was conducted for patients who had been directly inducted onto high-dose LAIB. RESULTS Five cases were identified on retrospective manual file review. All patients identified were males aged between 33 and 60 years old and were treated with either high-dose Buvidal Weekly and Monthly preparations. No immediate significant adverse effects were noticed and 4 out of 5 remain engaged with treatment. CONCLUSION This case series shows it is possible to directly induct patients with OUD onto high-dose LAIB preparations without significant side effects or harm to the patient and could be considered a viable option in the treatment of patients with OUD.
Collapse
Affiliation(s)
- Thileepan Naren
- Drug Health Services, Western Health, Footscray, AU-VIC, Australia; and
- Monash University, Clayton, VIC, Australia
| | - Jon Cook
- Drug Health Services, Western Health, Footscray, AU-VIC, Australia; and
- Monash University, Clayton, VIC, Australia
| | | |
Collapse
|
11
|
Wai JM, Blevins D, Hunt T, Gilbert L, Campbell ANC, Levin FR, El-Bassel N, Nunes E. An Approach to Enhancing Medication Treatment for Opioid Use Disorder in the HEALing Communities Study. Psychiatr Serv 2024; 75:580-588. [PMID: 38347814 DOI: 10.1176/appi.ps.20230159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
The HEALing (Helping to End Addiction Long-term) Communities Study (HCS) aims to test the effectiveness of the Communities That HEAL intervention in decreasing opioid overdose deaths in 67 communities across four U.S. states. This intervention enlists a collaborative team of researchers, academic experts, and community coalitions to select and implement interventions from a menu of evidence-based practices, including medications for opioid use disorder (MOUD). The HCS's New York team developed an integrated network systems (INS) approach with a mapping tool to coach coalitions in the selection of strategies to enhance medication treatment. With the INS approach, community coalitions develop a map of service delivery venues in their local county to better engage people with medication treatment wherever this need arises. The map is structured around core services that can provide maintenance MOUD and satellite services, which include all settings where people with opioid use disorder are encountered and can be identified, possibly given medication, and referred to core programs for ongoing MOUD care. This article describes the rationale for the INS mapping tool, with a discussion framed by the consolidated framework for implementation research, and provides a case example of its application.
Collapse
Affiliation(s)
- Jonathan M Wai
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, and Division on Substance Use Disorders, New York State Psychiatric Institute, New York City (Wai, Blevins, Campbell, Levin, Nunes); School of Social Work, Columbia University, New York City (Hunt, Gilbert, El-Bassel)
| | - Derek Blevins
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, and Division on Substance Use Disorders, New York State Psychiatric Institute, New York City (Wai, Blevins, Campbell, Levin, Nunes); School of Social Work, Columbia University, New York City (Hunt, Gilbert, El-Bassel)
| | - Tim Hunt
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, and Division on Substance Use Disorders, New York State Psychiatric Institute, New York City (Wai, Blevins, Campbell, Levin, Nunes); School of Social Work, Columbia University, New York City (Hunt, Gilbert, El-Bassel)
| | - Louisa Gilbert
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, and Division on Substance Use Disorders, New York State Psychiatric Institute, New York City (Wai, Blevins, Campbell, Levin, Nunes); School of Social Work, Columbia University, New York City (Hunt, Gilbert, El-Bassel)
| | - Aimee N C Campbell
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, and Division on Substance Use Disorders, New York State Psychiatric Institute, New York City (Wai, Blevins, Campbell, Levin, Nunes); School of Social Work, Columbia University, New York City (Hunt, Gilbert, El-Bassel)
| | - Frances R Levin
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, and Division on Substance Use Disorders, New York State Psychiatric Institute, New York City (Wai, Blevins, Campbell, Levin, Nunes); School of Social Work, Columbia University, New York City (Hunt, Gilbert, El-Bassel)
| | - Nabila El-Bassel
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, and Division on Substance Use Disorders, New York State Psychiatric Institute, New York City (Wai, Blevins, Campbell, Levin, Nunes); School of Social Work, Columbia University, New York City (Hunt, Gilbert, El-Bassel)
| | - Edward Nunes
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, and Division on Substance Use Disorders, New York State Psychiatric Institute, New York City (Wai, Blevins, Campbell, Levin, Nunes); School of Social Work, Columbia University, New York City (Hunt, Gilbert, El-Bassel)
| |
Collapse
|
12
|
Urban K, Gkeka A, Chandra M, Greiner D, Pollich S, Ruf S, Kelemen Y, Sundermann T, Pravetoni M, Baehr C, Stebbins CE, Papavasiliou FN, Verdi JP. The fentanyl-specific antibody FenAb024 can shield against carfentanil effects. Toxicol Lett 2024; 396:1-10. [PMID: 38588756 DOI: 10.1016/j.toxlet.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/10/2024]
Abstract
The surge in opioid-related deaths, driven predominantly by fentanyl and its synthetic derivatives, has become a critical public health concern, which is particularly evident in the United States. While the situation is less severe in Europe, the European Monitoring Centre for Drugs and Drug Addiction reports a rise in drug overdose deaths, with emerging concerns about the impact of fentanyl-related molecules. Synthetic opioids, initially designed for medical use, have infiltrated illicit markets due to their low production costs and high potency, with carfentanil posing additional threats, including potential chemical weaponization. Existing overdose mitigation heavily relies on naloxone, requiring timely intervention and caregiver presence, while therapeutic prevention strategies face many access challenges. To provide an additional treatment option, we propose the use of a fentanyl-specific monoclonal antibody (mAb), as a non-opioid method of prophylaxis against fentanyl and carfentanil. This mAb shows protection from opioid effects in a pre-clinical murine model. mAbs could emerge as a versatile countermeasure in civilian and biodefense settings, offering a novel approach to combat opioid-associated mortality.
Collapse
Affiliation(s)
| | | | | | | | | | - Sandra Ruf
- Panosome GmbH, Heidelberg 69123, Germany; Division of Immune Diversity, German Cancer Research Center, Heidelberg 69120, Germany
| | | | - Tom Sundermann
- Department of Forensic Toxicology, Institute for Forensic Medicine and Traffic Medicine, Heidelberg University Clinic, Heidelberg 69115, Germany
| | - Marco Pravetoni
- Department of Pharmacology, University of Minnesota Medical School, Minneapolis, MN 55455, USA; Department of Psychiatry and Behavioral Sciences, Department of Pharmacology, University of Washington School of Medicine, Center for Medication Development for Substance Use Disorders, Seattle, WA 98195, USA
| | - Carly Baehr
- Department of Pharmacology, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - C Erec Stebbins
- Division of Structural Biology of Infection and Immunity, German Cancer Research Center, Heidelberg 69120, Germany
| | - F Nina Papavasiliou
- Division of Immune Diversity, German Cancer Research Center, Heidelberg 69120, Germany
| | - Joseph P Verdi
- Panosome GmbH, Heidelberg 69123, Germany; Division of Immune Diversity, German Cancer Research Center, Heidelberg 69120, Germany; Hepione Therapeutics, Inc., New York, NY 10014, USA.
| |
Collapse
|
13
|
Walsh SL, Comer SD, Zdovc JA, Sarr C, Björnsson M, Strandgården K, Hjelmström P, Tiberg F. Pharmacokinetic-pharmacodynamic analysis of drug liking blockade by buprenorphine subcutaneous depot (CAM2038) in participants with opioid use disorder. Neuropsychopharmacology 2024; 49:1050-1057. [PMID: 38200140 PMCID: PMC11039630 DOI: 10.1038/s41386-023-01793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024]
Abstract
Buprenorphine is used to treat opioid use disorder (OUD). Weekly and monthly subcutaneous long-acting buprenorphine injections (CAM2038) provide more stable buprenorphine plasma levels and reduce the treatment burden, misuse, and diversion associated with sublingual transmucosal buprenorphine formulations. To characterize the pharmacokinetic/pharmacodynamic (PK/PD) relationship, a maximum inhibition (Imax) model was developed relating CAM2038 buprenorphine plasma concentration to drug liking maximum effect (Emax) visual analog scale (VAS; bipolar) score after intramuscular hydromorphone administration. Data included time-matched observations of buprenorphine plasma concentration and drug liking Emax VAS score after hydromorphone 18 mg administration in 47 non-treatment-seeking adults with moderate to severe OUD in a phase 2 study. Analysis used non-linear mixed-effects modeling (NONMEM®). The final Imax model adequately described the PK/PD relationship between buprenorphine plasma concentration and drug liking Emax VAS score. Simulations showed drug liking was effectively blocked at low buprenorphine plasma concentrations (0.4 ng/mL) where the upper 95% confidence interval of the drug liking Emax VAS score was below the pre-defined 11-point complete blockade threshold. The buprenorphine plasma concentration required to achieve 90% of the maximal effect (IC90) of drug liking was 0.675 ng/mL. Interindividual variability in responses to buprenorphine was observed; some participants experienced fluctuating responses, and a few did not achieve drug liking blockade even with higher buprenorphine plasma concentrations. This affirms the need to individualize treatment and titrate doses for optimal treatment outcomes. PK/PD models were also developed for desire to use VAS and Clinical Opiate Withdrawal Scale (COWS) scores, with results aligned to those for drug liking.
Collapse
Affiliation(s)
- Sharon L Walsh
- Behavioral Science, Pharmacology, Psychiatry and Pharmaceutical Sciences Departments, University of Kentucky College of Medicine and Pharmacy, Kentucky, KY, USA
| | - Sandra D Comer
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | | | | | | | - Peter Hjelmström
- Camurus AB, Lund, Sweden
- Uppsala Monitoring Centre, Uppsala, Sweden
| | | |
Collapse
|
14
|
Barnett A, Pienaar K, Lubman DI, Arunogiri S, Phan V, Hayes V, Lintzeris N, Savic M. The dynamics of more-than-human care in depot buprenorphine treatment: A new materialist analysis of Australian patients' experiences. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 127:104399. [PMID: 38636315 DOI: 10.1016/j.drugpo.2024.104399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 03/05/2024] [Accepted: 03/21/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Long-acting injectable depot buprenorphine has become an important treatment option for the management of opioid dependence. However, little is known about patients' experiences of depot buprenorphine and its embodied effects. This qualitative study aims to explore patients' experiences of depot buprenorphine treatment, including how it feels within the body, experiences of dosing cycles across time, and how this form of treatment relies on wider ecologies of care beyond the clinical encounter. METHODS Participants were recruited from sites in Sydney, regional New South Wales, and Melbourne, Victoria, Australia. Thirty participants (16 men, 14 women) participated in semi-structured interviews. Participants had histories of both heroin and prescription opioid consumption, and opioid agonist therapy including daily dosing of buprenorphine and methadone. RESULTS Our analysis illuminates: (1) how patients' expectations and concerns about treatment are linked to past embodied experiences of withdrawal and uncertainty about the effectiveness of depot buprenorphine; (2) the diverse meanings patients attribute to the depot buprenorphine substrate 'under the skin'; and, (3) how depot buprenorphine is embedded within wider ecologies of care, such as counselling and social supports. CONCLUSION Our analysis destabilises commonplace assumptions about a linear, causal relationship between the pharmacological action of depot buprenorphine and experiences of treatment. Instead, it highlights patients' variable experiences of depot buprenorphine, tracing the everyday practices, embodied feelings, expectations and wider networks of care that shape patient experiences. We conclude with some reflections on the implications of our analysis for alcohol and other drug treatment, specifically how they might inform the design of client education materials and care.
Collapse
Affiliation(s)
- Anthony Barnett
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, VIC and Turning Point, Eastern Health, Richmond, VIC, Australia.
| | - Kiran Pienaar
- Sociology, School of Humanities and Social Science, Faculty of Arts and Education, Deakin University, Australian Research Centre in Sex, Health & Society (ARCSHS), La Trobe University, Bundoora, VIC, Australia
| | - Dan I Lubman
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, VIC and Turning Point, Eastern Health, Richmond, VIC, Australia
| | - Shalini Arunogiri
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, VIC and Turning Point, Eastern Health, Richmond, VIC, Australia
| | - Vicky Phan
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, VIC and Turning Point, Eastern Health, Richmond, VIC, Australia
| | - Vicky Hayes
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, NSW, Australia
| | - Nicholas Lintzeris
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, NSW, Australia
| | - Michael Savic
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, VIC and Turning Point, Eastern Health, Richmond, VIC, Australia.
| |
Collapse
|
15
|
Farrell M, Shahbazi J, Chambers M, Byrne M, Gholami J, Zahra E, Grebely J, Lintzeris N, Larance B, Ali R, Nielsen S, Dunlop A, Dore GJ, McDonough M, Montebello M, Weiss R, Rodgers C, Cook J, Degenhardt L. 96-week retention in treatment with extended-release subcutaneous buprenorphine depot injections among people with opioid dependence: Extended follow-up after a single-arm trial. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 127:104390. [PMID: 38522175 DOI: 10.1016/j.drugpo.2024.104390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 03/07/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The most recent formulation of buprenorphine treatment is extended-release depot injections (BUP-XR) that are administered subcutaneously by health care professionals. This study aimed to observe treatment outcomes of BUP-XR delivered in standard practice during a 96-week follow-up period in a community setting. METHODS This study is an extension of the CoLAB study, a prospective single-arm, multicentre, open label trial (N=100, 7 sites in Australia) among people with opioid dependence who received monthly injections of BUP-XR to evaluate the retention in treatment. Participants were followed for 96 weeks, comprising 48 weeks of the CoLAB study followed by a 48-week extension. RESULTS Of 100 participants at baseline, 47 were retained on BUP-XR at 96 weeks. The median time retained on monthly depot was 90 weeks. Heroin use (adjusted OR=0.19, P=0.012) in the month prior to baseline was associated with lower odds of retention on BUP-XR. Older age at first opioid use (adjusted OR= 1.08, P=0.009) and longer duration in OAT at baseline (adjusted OR= 1.12, P=0.001) were associated with increased retention. Prevalence of past four-weeks opioid use was estimated at 4% at 96 weeks of treatment (prevalence 0.04, 95%CI: 0.00-0.11) compared to 15% at baseline. Quality of life and medication treatment satisfaction improved over time for those retained in treatment. CONCLUSION This is one of the few studies to describe long term (96 week) retention in treatment with BUP-XR in a community setting. It displayed retention rates with 47% of participants completing 96 weeks of treatment with BUP-XR. Patient reported outcomes suggest improvements in client wellbeing. FUNDING Indivior.
Collapse
Affiliation(s)
| | | | - Mark Chambers
- National Drug and Alcohol Research Centre, UNSW, Australia
| | - Marianne Byrne
- National Drug and Alcohol Research Centre, UNSW, Australia; The Kirby Institute, UNSW, Australia
| | - Jaleh Gholami
- National Drug and Alcohol Research Centre, UNSW, Australia
| | - Emma Zahra
- National Drug and Alcohol Research Centre, UNSW, Australia
| | | | - Nicholas Lintzeris
- Discipline of Addiction Medicine, University of Sydney, NSW, Australia; Drug and Alcohol Services, South East Sydney Local Health District, Surry Hills, NSW, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW, Australia; School of Psychology, University of Wollongong, Wollongong, NSW, Australia
| | - Robert Ali
- National Drug and Alcohol Research Centre, UNSW, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW, Australia; Monash Addiction Research Centre, Eastern Health Clinical School, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | - Adrian Dunlop
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | | | - Michael McDonough
- Drug and Alcohol Services South Australia, Adelaide, South Australia, Australia
| | - Mark Montebello
- National Drug and Alcohol Research Centre, UNSW, Australia; Discipline of Addiction Medicine, University of Sydney, NSW, Australia; Drug and Alcohol Services, North Sydney Local Health District, St Leonards, NSW, Australia
| | - Rob Weiss
- Frankston Healthcare, Frankston, Victoria, Australia
| | - Craig Rodgers
- Alcohol and Drug Service, St Vincent's Hospital, Darlinghurst NSW Australia
| | - Jon Cook
- Drug and Alcohol Clinical Advisory Service, Western Health, Victoria, Australia
| | | |
Collapse
|
16
|
Nordgren J, Monwell B, Johnson B, Gunnarsson NV, Capusan AJ. Healthcare staff's perspectives on long-acting injectable buprenorphine treatment: a qualitative interview study. Addict Sci Clin Pract 2024; 19:25. [PMID: 38581022 PMCID: PMC10996245 DOI: 10.1186/s13722-024-00458-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/25/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Long-acting injectable buprenorphine (LAIB) formulations are a novel treatment approach in opioid agonist treatment (OAT), which provide patients with a steady dose administered weekly or monthly and thus reduce the need for frequent clinic visits. Several studies have analyzed patient experiences of LAIB but the perspective of OAT staff is unknown. This study aimed to explore how healthcare staff working in OAT clinics in Sweden perceive and manage treatment with LAIB. METHODS Individual qualitative interviews were conducted with OAT physicians (n = 10) in tandem with nine focus group sessions with OAT nurses and other staff categories (n = 41). The data was analyzed with thematic text analysis. RESULTS Five central themes were identified in the data: (1) advantages and disadvantages of LAIB, (2) patient categories that may or may not need LAIB, (3) patients' degrees of medication choice, (4) keeping tabs, control and treatment alliance, and (5) LAIB's impact on risk and enabling environments in OAT. Overall staff found more advantages than disadvantages with LAIB and considered that patients with ongoing substance use and low adherence were most likely to benefit from LAIB. However, less frequent visits were viewed as problematic in terms of developing a treatment alliance and being able to keep tabs on patients' clinical status. Clinics differed regarding patients' degrees of choice in medication, which varied from limited to extensive. LAIB affected both risk and enabling environments in OAT. CONCLUSIONS LAIB may strengthen the enabling environment in OAT for some patients by reducing clinic visits, exposure to risk environments, and the pressure to divert medication. A continued discussion about the prerequisites and rationale for LAIB implementation is needed in policy and practice.
Collapse
Affiliation(s)
- Johan Nordgren
- Department of Social Work, Malmö University, Nordenskiöldsgatan 1, 211 19, Malmö, Sweden.
| | - Bodil Monwell
- Department of Social Work, Jönköping University, Jönköping, Sweden
- Psychiatric clinic, County Hospital Ryhov, Jönköping, Sweden
| | - Björn Johnson
- School of Social Work, Lund University, Lund, Sweden
| | | | - Andrea Johansson Capusan
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
17
|
Langlois J, Nolan S, Dickhout P, Cui Z, Paterson J, Fairbairn N, Socías ME. The FASTER-BUP Study, Extended-Release Injectable Buprenorphine for the Treatment of Opioid Use Disorder Among Individuals at High Risk of Overdose: Protocol for an Observational Prospective Study. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:176-180. [PMID: 38254287 DOI: 10.1177/29767342231222103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
North America is facing an unprecedented public health emergency of opioid-related morbidity and mortality. The mortality benefits of oral medication treatment for opioid use disorder (MOUD), such as methadone or buprenorphine, are well documented. However, barriers to access and long-term engagement have prevented maximizing their benefits. Long-acting injectable buprenorphine formulations were developed to address some of the challenges associated with oral MOUD. The "Pilot study to assess the feasibility, efficacy, and safety of extended-release injectable buprenorphine for the treatment of opioid use disorder among individuals at high risk of overdose" (FASTER-BUP) was developed to explore this treatment option in populations at high risk of overdose in a real-world Canadian setting. FASTER-BUP is a 24-week observational prospective study evaluating the feasibility and clinical utility of extended-release injectable buprenorphine (XR-BUP) for the treatment of opioid use disorder (OUD) among 40 adults at high risk of overdose (ie, lifetime history of overdose or a positive urine drug test (UDT) for fentanyl within 30 days prior to screening) in Vancouver, BC. The primary outcome is retention in treatment and secondary outcomes include: use of unregulated opioids, safety, overdose events, treatment satisfaction, changes in drug-related problems, changes in quality of life, opioid cravings, health service utilization, and criminal activity. FASTER-BUP is the first study to explore XR-BUP among individuals at high risk of overdose in a real-world Canadian setting. This commentary provides a brief narrative about the study thus far and presents insights on key adaptations to the study protocol, including those adopted to mitigate recruitment challenges.
Collapse
Affiliation(s)
- Jenna Langlois
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Faculty of Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Seonaid Nolan
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Faculty of Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Piper Dickhout
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Zishan Cui
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Josh Paterson
- Faculty of Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nadia Fairbairn
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Faculty of Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - M Eugenia Socías
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Faculty of Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
18
|
Lancaster K, Gendera S, Treloar C, Rhodes T, Shahbazi J, Byrne M, Nielsen S, Degenhardt L, Farrell M. Tinkering with care: Implementing extended-release buprenorphine depot treatment for opioid dependence. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 126:104359. [PMID: 38382354 DOI: 10.1016/j.drugpo.2024.104359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
We examine how extended-release buprenorphine depot (BUP-XR) is put to use and made to work in implementation practices, attending to how care practices are challenged and adapted as a long-acting technology is introduced into service in opioid agonist treatment (OAT) in Australia. Our approach is informed by ideas in science and technology studies (STS) emphasising the irreducible entanglement of care practices and technology, and in particular the concept of 'tinkering' as a practice of adaptation. To make our analysis, we draw on qualitative interview accounts (n = 19) of service providers involved in BUP-XR implementation across five sites. Our analysis considers the disruptive novelty of BUP-XR. Tinkering to make a novel technology work in practice slows down the expectation of implementation in relation to transformative innovation, despite the promise of dramatic or rapid change. Tinkering allowed for more open relations, for new care practices that departed from the routine and familiar, opening potential for how BUP-XR could be put to use and made to work in its new situation, and as its situation evolved along-with its implementation. Flexibility and openness of altering relations was, however, at times, held in tension with inflexibility and closure. This analysis identifies a concern for what is made present and what is made absent in the altered care network affected by BUP-XR, with the multiple effects of supervised daily dosing practices thrown into relief as they become absented. Tinkering to implement BUP-XR locally connects with a broader assemblage of trial and movement in the constitution of treatment. The introduction of long-acting technologies prompts new questions about embedded implementation practices, including supervised dosing, urinalysis, the time and place of psychosocial support, and how other social aspects of care might be recalibrated in drug treatment.
Collapse
Affiliation(s)
- K Lancaster
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia; Goldsmiths, University of London, UK.
| | - S Gendera
- Social Policy Research Centre, University of New South Wales, Sydney, Australia
| | - C Treloar
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - T Rhodes
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia; London School of Hygiene and Tropical Medicine, UK
| | - J Shahbazi
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - M Byrne
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - S Nielsen
- Monash Addiction Research Centre, Monash University, Melbourne, Australia
| | - L Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - M Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| |
Collapse
|
19
|
Fine DR, Critchley N, Hart K, Joyce A, Sporn N, Gaeta J, Wright J, Baggett TP, Kruse G. "I'm on the Right Path": Exploring 1-Month Retention in a Homeless-Tailored Outpatient-Based Opioid Treatment Program. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:268-277. [PMID: 38258838 PMCID: PMC11369761 DOI: 10.1177/29767342231218529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Homeless-tailored office-based opioid treatment (OBOT) programs have been developed to address the ongoing opioid overdose crisis, which disproportionately affects people experiencing homelessness. The objective of this study was to evaluate the facilitators of and barriers to retention in a homeless-tailored OBOT program. METHODS We performed in-depth qualitative interviews with 24 homeless-experienced adults who newly enrolled in Boston Health Care for the Homeless Program's OBOT program from January 6, 2022 through January 5, 2023. We purposively sampled participants based on whether they were retained at 1 month (n = 12) or not (n = 12). We used an abductive analytic process, applying codes to the interview transcripts from an a priori analytic framework based on the Behavioral Model for Vulnerable Populations and supplementing with emergent codes as needed. We compared themes by participants' 1-month retention status to explore facilitators of and barriers to retention in OBOT care. RESULTS The average age was 41.9 years, 29.2% were female, 20.8% were Black, 58.3% were White, and 33.0% were Hispanic. Facilitators of retention common to many participants included the clinic experience, low-threshold model, clinic staff, and provision of comprehensive care. Among participants who were retained at 1-month, personal motivation, use of extended-release buprenorphine, and adequate buprenorphine efficacy were additional facilitators. Barriers to retention common to many participants included the clinic's surrounding environment, competing subsistence difficulties, and transportation difficulty. Among participants who were not retained at 1-month, opioid use severity, drug use in social networks, and inadequate buprenorphine efficacy represented additional barriers. CONCLUSIONS We identified several common determinants of OBOT retention among our homeless-experienced participants as well as some facilitators and barriers that differed by 1-month retention status. These divergent factors represent potential points of intervention to promote retention in homeless-tailored OBOT programs.
Collapse
Affiliation(s)
- Danielle R. Fine
- Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA, 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Natalia Critchley
- Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA, 02114, USA
| | - Katherine Hart
- Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA, 02114, USA
| | - Andrea Joyce
- Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA, 02114, USA
| | - Nora Sporn
- Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA, 02114, USA
| | - Jessie Gaeta
- Boston Health Care for the Homeless Program, 780 Albany Street, Boston, MA, 02118, USA
- Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA
| | - Joe Wright
- Boston Health Care for the Homeless Program, 780 Albany Street, Boston, MA, 02118, USA
| | - Travis P. Baggett
- Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA, 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
- Boston Health Care for the Homeless Program, 780 Albany Street, Boston, MA, 02118, USA
| | - Gina Kruse
- University of Colorado School of Medicine, 12631 E 17 Avenue, Aurora, CO 80045, USA
| |
Collapse
|
20
|
Johnson B, Monwell B, Capusan AJ. Long-acting injectable depot buprenorphine from a harm reduction perspective in patients with ongoing substance use and multiple psychiatric comorbidities: a qualitative interview study. Harm Reduct J 2024; 21:68. [PMID: 38528531 PMCID: PMC10964574 DOI: 10.1186/s12954-024-00984-1] [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: 12/06/2023] [Accepted: 03/07/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Long-acting injectable depot buprenorphine may increase access to opioid agonist treatment (OAT) for patients with opioid use disorder in different treatment phases. The aim of this study was to explore the experiences of depot buprenorphine among Swedish patients with ongoing substance use and multiple psychiatric comorbidities. METHOD Semi-structured qualitative interviews were conducted with OAT patients with experience of depot buprenorphine. Recruitment took place at two OAT clinics with a harm reduction focus, specializing in the treatment of patients with ongoing substance use and multiple comorbidities. Nineteen participants were included, 12 men and seven women, with a mean age of 41 years (range 24-56 years), and a mean of 21 years (5-35 years) of experience with illicit substance use. All participants had ongoing substance use and psychiatric comorbidities such as ADHD, anxiety, mood, psychotic and eating disorders. Interviews were transcribed verbatim. Thematic content analysis was conducted both manually and using qualitative data analysis software. RESULTS Participants reported social benefits and positive changes in self-perception and identity. In particular, depot buprenorphine contributed to a realization that it was possible to make life changes and engage in activities not related to substance use. Another positive aspect that emerged from the interviews was a noticeable relief from perceived pressure to divert OAT medication, while some expressed the lack of income from diverted oral/sublingual OAT medication as a negative, but still acceptable, consequence of the depot buprenorphine. Many participants considered that the information provided prior to starting depot buprenorphine was insufficient. Also, not all patients found depot buprenorphine suitable, and those who experienced coercion exhibited particularly negative attitudes towards the medication. CONCLUSIONS OAT patients with ongoing substance use and multiple psychiatric comorbidities reported clear benefits of depot buprenorphine, including changes in self-perception which has been theorized to play an important role in recovery. Clinicians should consider the specific information needs of this population and the extensive diversion of traditional OAT medications in this population to improve the treatment experience and outcomes. Overall, depot buprenorphine is a valuable treatment option for a population in need of harm reduction and may also contribute to psychological changes that may facilitate recovery in those with the greatest need.
Collapse
Affiliation(s)
- Björn Johnson
- School of Social Work, Lund University, Lund, Sweden.
| | - Bodil Monwell
- Department of Psychiatry, County Hospital Jönköping, Jönköping, Sweden
- Department of Social Work, Jönköping University, Jönköping, Sweden
| | - Andrea Johansson Capusan
- Department of Psychiatry in Linköping, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
21
|
Gorham JW, Ansari F, Sethi R. The Effectiveness of Buprenorphine Transdermal Patch and Low Dose Sublingual Buprenorphine Induction to Transition to Long-Acting Subcutaneous Buprenorphine Injection in Opioid Use Disorder in Inpatient Setting. Kans J Med 2024; 17:20-21. [PMID: 38694173 PMCID: PMC11060775 DOI: 10.17161/kjm.vol17.21229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 02/21/2024] [Indexed: 05/04/2024] Open
Affiliation(s)
- Jack W Gorham
- University of Kansas School of Medicine-Kansas City, Kansas City, KS
| | - Faisal Ansari
- University of Kansas School of Medicine-Kansas City, Kansas City, KS
- Department of Psychiatry and Behavioral Sciences
| | - Roopa Sethi
- University of Kansas School of Medicine-Kansas City, Kansas City, KS
- Department of Psychiatry and Behavioral Sciences
| |
Collapse
|
22
|
Thakarar K, Appa A, Abdul Mutakabbir JC, Goff A, Brown J, Tuell C, Fairfield K, Wurcel A. Frame Shift: Focusing on Harm Reduction and Shared Decision Making for People Who Use Drugs Hospitalized With Infections. Clin Infect Dis 2024; 78:e12-e26. [PMID: 38018174 DOI: 10.1093/cid/ciad664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Indexed: 11/30/2023] Open
Affiliation(s)
- Kinna Thakarar
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Center for Interdisciplinary Population & Health Research, MaineHealth Institute for Research, Portland, Maine, USA
- Department of Medicine, Maine Medical Center, Portland, Maine, USA
| | - Ayesha Appa
- Division of HIV, Infectious Diseases, and Global Medicine at San Francisco General Hospital, University of California-San Francisco, San Francisco, California, USA
| | - Jacinda C Abdul Mutakabbir
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California-San Diego, La Jolla, California, USA
- Division of the Black Diaspora and African American Studies, University of California-San Diego, La Jolla, California, USA
| | - Amelia Goff
- Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Jessica Brown
- Department of Care Management, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Kathleen Fairfield
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Center for Interdisciplinary Population & Health Research, MaineHealth Institute for Research, Portland, Maine, USA
- Department of Medicine, Maine Medical Center, Portland, Maine, USA
| | - Alysse Wurcel
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Division of Geographic Medicine and Infectious Diseases, Tufts Medicine, Boston, Massachusetts, USA
| |
Collapse
|
23
|
Roberts E, Humphreys K. Does the advent of depot therapy represent a step change in our understanding of opioid use disorder and its treatment? Drug Alcohol Rev 2024; 43:261-264. [PMID: 37525510 PMCID: PMC10828099 DOI: 10.1111/dar.13732] [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: 03/20/2023] [Revised: 07/06/2023] [Accepted: 07/18/2023] [Indexed: 08/02/2023]
Abstract
After years of minimal innovation in pharmacotherapeutics, impressive outcomes in the treatment of opioid use disorder are being obtained from a new way of delivering an old medication; long-acting injectable formulations of buprenorphine appear to produce compelling reductions in relapse to illicit opioid use not only during use but also following depot discontinuation. This commentary discusses potential mechanisms behind this observation, asks if the removal of the need for daily oral opioid agonist dosing furthers our understanding of addiction treatment and whether we should therefore consider expanding access to depot formulations.
Collapse
Affiliation(s)
- Emmert Roberts
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, USA
| | - Keith Humphreys
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, USA
- Veterans Affairs Palo Alto Health Care System, Menlo Park, USA
| |
Collapse
|
24
|
South AM, Oller D, Lofwall M, Fanucchi LC. Pain Management in Patients With Opioid Use Disorder on Extended-release Buprenorphine: A Case Report. J Addict Med 2024; 18:86-89. [PMID: 38039082 DOI: 10.1097/adm.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
ABSTRACT Persons with opioid use disorder (OUD) are receiving extended-release buprenorphine (ER-buprenorphine) for treatment of OUD. There are no clinical guidelines for management of patients with OUD on ER-buprenorphine experiencing acute or chronic pain. This case report describes 3 patient-involved, multidisciplinary approaches for pain management in various clinical scenarios, including a scheduled knee replacement, emergent surgery for an ischemic limb, and management of chronic pain from metastatic malignancy. These cases illustrate that adequate analgesia for patients who have received ER-buprenorphine is possible, and approaches can be individualized, with shared decision making between providers and patients addressing all barriers to optimize treatment outcomes. Options for acute pain management that can be considered include supplemental sublingual buprenorphine, nonopioid adjuncts, and short courses of full opioid agonists. Potential barriers that impact OUD and acute/chronic pain are provider bias, limited access to palliative care clinicians with addiction medicine training, and payor restrictions to adding sublingual buprenorphine for patients that are on ER-buprenorphine. Additional training for clinicians and other members of the health care team is recommended to improve patient-involved care of persons with OUD experiencing pain.
Collapse
Affiliation(s)
- Anna-Maria South
- From the Department of Internal Medicine, Division of Hospital Medicine, Addiction Consult and Education Service, University of Kentucky College of Medicine, Lexington, KY (A-MS); Department of Internal Medicine, Division of General Internal Medicine, Addiction Consult and Education Service, University of Kentucky, College of Medicine, Lexington, KY (DO); Departments of Behavioral Science and Psychiatry, First Bridge and Straus Clinics, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY (ML); Department of Internal Medicine, Division of Infectious Diseases, Addiction Consult and Education Service, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY (LCF)
| | | | | | | |
Collapse
|
25
|
Heil J, Salzman M, Hunter K, Baston KE, Milburn C, Schmidt R, Haroz R, Ganetsky VS. Evaluation of an injectable monthly extended-release buprenorphine program in a low-barrier specialty addiction medicine clinic. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 156:209183. [PMID: 37879433 DOI: 10.1016/j.josat.2023.209183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 10/05/2023] [Accepted: 10/10/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Monthly injectable extended-release buprenorphine (XR-BUP) can address several systemic and individual barriers to consistent sublingual buprenorphine treatment for patients with opioid use disorder (OUD). Real-world evaluations of XR-BUP in the outpatient addiction treatment setting are limited. The purpose of this study was to compare 6-month treatment retention and urine drug tests between patients who initiated XR-BUP compared to those who were prescribed but did not initiate XR-BUP in a low-barrier addiction medicine specialty clinic. METHODS We conducted a retrospective cohort study of adults with OUD prescribed XR-BUP between 12/1/2018 and 12/31/2020 in a low-barrier addiction medicine specialty clinic to compare 6-month treatment retention between patients who initiated XR-BUP and those who were prescribed but did not initiate XR-BUP (comparison group). Secondary outcomes included percent of urine toxicology tests negative for non-prescribed opioids. Multivariable logistic regression models evaluated factors associated with 6-month treatment retention and XR-BUP initiation. RESULTS Of the 233 patients prescribed XR-BUP, 148 (63.8 %) identified as non-Hispanic white, 218 (93.6 %) were insured by public insurance (Medicare/Medicaid), and nearly two-thirds were prescribed XR-BUP due to unstable OUD. Approximately 50 % of patients initiated XR-BUP treatment (mean number of injections = 3.7). About 60 % of XR-BUP-treated patients received supplemental sublingual buprenorphine and nearly two-thirds received a 300 mg maintenance dose. Six-month treatment retention was greater in the XR-BUP treatment versus comparison group (70.3 % vs. 36.5 %, p < 0.001). The XR-BUP treatment group had a higher percentage of opioid-negative urine toxicology tests versus the comparison group (67.2 % vs. 36.3 %, p < 0.001). Receipt of XR-BUP was an independent predictor of 6-month treatment retention (OR 5.40, 95 % CI 2.18-13.38). Those prescribed XR-BUP due to unstable OUD had lower odds of treatment retention (OR 0.41, 95 % CI 0.24-0.98) after controlling for receipt of XR-BUP and other variables known to impact retention. CONCLUSIONS XR-BUP improved 6-month treatment retention and resulted in a greater proportion of opioid-negative urine toxicology tests compared to a comparison group of patients who were prescribed but did not initiate XR-BUP. Patients with unstable OUD had lower odds of XR-BUP initiation, suggesting the need for targeted interventions to increase XR-BUP uptake in this high-risk population.
Collapse
Affiliation(s)
- Jessica Heil
- Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, NJ, United States
| | - Matthew Salzman
- Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, NJ, United States; Cooper University Health Care, Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology, Camden, NJ, United States
| | - Krystal Hunter
- Cooper University Health Care, Cooper Research Institute, Camden, NJ, United States
| | - Kaitlan E Baston
- Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, NJ, United States
| | - Christopher Milburn
- Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, NJ, United States
| | - Ryan Schmidt
- Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, NJ, United States
| | - Rachel Haroz
- Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, NJ, United States; Cooper University Health Care, Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology, Camden, NJ, United States
| | - Valerie S Ganetsky
- Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, NJ, United States.
| |
Collapse
|
26
|
Woods RH. Dental Disorders Reported to the FDA Adverse Event Reporting System in Association with Buprenorphine: An Analysis by Ingredient Composition and Route of Administration. Curr Drug Saf 2024; 19:261-267. [PMID: 37526182 DOI: 10.2174/1574886318666230731151447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 08/02/2023]
Abstract
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.
Collapse
Affiliation(s)
- Richard H Woods
- Levin, Papantonio, Rafferty, Proctor, Buchanan, O'Brien, Barr & Mougey, P.A., Pensacola, FL 32502, United States
| |
Collapse
|
27
|
Mariani JJ, Dobbins RL, Heath A, Gray F, Hassman H. Open-label investigation of rapid initiation of extended-release buprenorphine in patients using fentanyl and fentanyl analogs. Am J Addict 2024; 33:8-14. [PMID: 37936553 DOI: 10.1111/ajad.13484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 09/22/2023] [Accepted: 09/24/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Synthetic opioids, including fentanyl and fentanyl analogs, account for over 70,000 annual overdose deaths in the United States, but there is limited information examining methods of induction and maintenance outcomes for buprenorphine treatment of patients with opioid use disorder (OUD) using these opioids. METHODS A secondary analysis of results grouped by fentanyl use status was completed for an open-label study with rapid induction of extended-release buprenorphine in the inpatient research unit. Eligible participants received a single 4 mg dose of transmucosal buprenorphine (BUP-TM) followed by an extended-release buprenorphine 300 mg injection ([BUP-XR]) after approximately 1 h. An extension study continued follow-up up to 6 months (6 monthly injections). RESULTS Among participants with fentanyl-positive urine samples (FEN+; n = 19), all received BUP-TM, 17 received BUP-XR, 13 elected to receive a second BUP-XR injection, and 10 received all six scheduled injections. Among participants with fentanyl-negative samples (FEN-; n = 7), all received BUP-TM and BUP-XR, four elected to receive a second injection, and two participants received all six scheduled injections. Induction day clinical opioid withdrawal scale (COWS) scores were similar for FEN+ and FEN- groups. In the FEN+ group, mean COWS scores fell to below 5 within 24 h of BUP-XR injection. DISCUSSION AND CONCLUSIONS The treatment of individuals with OUD using fentanyl with a rapid 1-day induction to BUP-XR 300 mg injection is feasible and well-tolerated. SCIENTIFIC SIGNIFICANCE A prospective trial of participants grouped by fentanyl use status at induction demonstrates comparable patient retention and clinical response following single-day induction of BUP-XR in participants who are FEN+ and FEN-.
Collapse
Affiliation(s)
- John J Mariani
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York, New York, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Robert L Dobbins
- Global Medicines Development, Indivior Inc., Richmond, Virginia, USA
| | - Amy Heath
- Global Medicines Development, Indivior Inc., Richmond, Virginia, USA
| | - Frank Gray
- Global Medicines Development, Indivior Inc., Richmond, Virginia, USA
| | - Howard Hassman
- Hassman Research Institute, CenExel, Berlin, New Jersey, USA
| |
Collapse
|
28
|
Kurtz T, Charles JE, Schwartz M, Smid MC. Postpartum Extended-Release Buprenorphine Tissue Necrosis. Obstet Gynecol 2023; 142:1504-1508. [PMID: 37917935 DOI: 10.1097/aog.0000000000005425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 09/14/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Extended-release buprenorphine (XRB) may improve medication for opioid use disorder continuation among postpartum individuals. However, obstetric clinicians have relatively little experience with XRB. We describe two cases of XRB-related tissue necrosis in postpartum individuals to highlight recommended injection technique and management strategies for this rare complication. CASES One patient developed tissue necrosis after her initial injection. Her wound was expectantly managed. Another patient on long-term XRB developed tissue necrosis within 1 day of injection. General surgery excised the depot. Both instances were attributed to injection of XRB intradermally rather than subcutaneously. Both patients continued monthly XRB without recurrence, suggesting that this complication is not an allergy. CONCLUSION Clinicians should be able to prevent, recognize, and manage tissue necrosis, a rare complication of XRB injection.
Collapse
Affiliation(s)
- Theresa Kurtz
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, and Family Medicine, Exodus Healthcare Network, Magna, Utah
| | | | | | | |
Collapse
|
29
|
Lofwall MR, Young JL, Hansen Z, Wachman EM, Wilder C, Guille C, Charles JE, Leeman L, Gray JR, Winhusen TJ. What to Expect With Pregnant or Postpartum Prescribing of Extended-Release Buprenorphine (CAM2038). JOURNAL OF CLINICAL GYNECOLOGY AND OBSTETRICS 2023; 12:110-116. [PMID: 38435674 PMCID: PMC10906993 DOI: 10.14740/jcgo919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Weekly and monthly CAM2038 (Brixadi®) extended-release subcutaneous buprenorphine (XR bup) has been available in Europe and Australia for several years and was approved by the Food and Drug Administration in May 2023. Little is known about the clinical experience of patients and providers using this new medication during prenatal care. Two cases of pregnant persons with opioid use disorder receiving weekly XR bup in an ongoing randomized multi-site outpatient clinical trial are presented along with a brief review of the pharmacology and literature on XR bup formulations. The cases in pregnancy illustrate how treatment with the weekly formulation is initiated including how to make dose adjustments, which may be necessary given the longer half-life; it takes 1 month to achieve steady state. Injection site pain with medication administration was time limited and managed readily. Other injection site reactions experienced included subcutaneous erythema and induration that was delayed in onset and typically mild, resolving with minimal intervention. Delivery management and breastfeeding recommendations while on weekly XR bup were not different compared to sublingual buprenorphine (SL bup). Weekly XR bup is a new treatment for opioid use disorder that may be used in the obstetric population. Obstetric and addiction medicine clinicians should be aware of this new formulation as its use is expected to increase.
Collapse
Affiliation(s)
- Michelle R. Lofwall
- Departments of Behavioral Science and Psychiatry, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Jessica L. Young
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Zachary Hansen
- Department of Family Medicine, Division of Addiction Science, Marshall University, Huntington, WV, USA
| | | | - Christine Wilder
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Constance Guille
- Department of Psychiatry and Behavioral Science, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Jasmin E. Charles
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, UT, USA
- Department of Internal Medicine, Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lawrence Leeman
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Jessica R. Gray
- Substance Use Disorder Initiative, Department of Psychiatry, and Departments of Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - T. John Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
30
|
Marsden J, Kelleher M, Gilvarry E, Mitcheson L, Bisla J, Cape A, Cowden F, Day E, Dewhurst J, Evans R, Hardy W, Hearn A, Kelly J, Lowry N, McCusker M, Murphy C, Murray R, Myton T, Quarshie S, Vanderwaal R, Wareham A, Hughes D, Hoare Z. Superiority and cost-effectiveness of monthly extended-release buprenorphine versus daily standard of care medication: a pragmatic, parallel-group, open-label, multicentre, randomised, controlled, phase 3 trial. EClinicalMedicine 2023; 66:102311. [PMID: 38045803 PMCID: PMC10692661 DOI: 10.1016/j.eclinm.2023.102311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 12/05/2023] Open
Abstract
Background Daily methadone maintenance or buprenorphine treatment is the standard-of-care (SoC) medication for opioid use disorder (OUD). Subcutaneously injected, extended-release buprenorphine (BUP-XR) may be more effective-but there has been no superiority evaluation. Methods This pragmatic, parallel-group, open-label, multi-centre, effectiveness superiority randomised, controlled, phase 3 trial was conducted at five National Health Service community-based treatment clinics in England and Scotland. Participants (adults aged ≥ 18 years; all meeting DSM-5 diagnostic criteria for moderate or severe OUD at admission to their current maintenance treatment episode) were randomly assigned (1:1) to receive continued daily SoC (liquid methadone (usual dose range: 60-120 mg) or sublingual/transmucosal buprenorphine (usual dose range: 8-24 mg) for 24 weeks; or monthly BUP-XR (Sublocade;® two injections of 300 mg, then four maintenance injections of 100 mg or 300 mg, with maintenance dose selected by response and preference) for 24 weeks. In the intent-to-treat population (senior statistician blinded to blinded to treatment group allocation), and with a seven-day grace period after randomisation, the primary endpoint was the count of days abstinent from non-medical opioids between days 8-168 (i.e., weeks 2-24; range: 0-161 days). Safety was reported for the intention-to- treat population. Adopting a broad societal perspective inclusive of criminal justice, NHS and personal social service costs, a trial-based cost-utility analysis estimated the Incremental Cost-effectiveness Ratio (ICER) per quality-adjusted life year (QALY) of BUP-XR versus SoC at the National Institute for Health and Care Excellence threshold. The study was registered EudraCT (2018-004460-63) and ClinicalTrials.gov (NCT05164549), and is completed. Findings Between Aug 9, 2019 and Nov 2, 2021, 314 participants were randomly allocated to receive SoC (n = 156) or BUP-XR (n = 158). Participants were abstinent from opioids for an adjusted mean of 104.37 days (standard error [SE] 9.89; range: 0-161 days) in the SoC group and an adjusted mean of 123.43 days (SE 4.76; range: 24-161 days) in the BUP-XR group (adjusted incident rate ratio [IRR] 1.18, 95% confidence interval [CI] 1.05-1.33; p-value 0.004). The incidence of any adverse event was higher in the BUP-XR group than the SoC group (128 [81.0%] of 158 participants versus 67 [42.9%] of 156 participants, respectively-most commonly rapidly-resolving (mild-moderate range) pain from drug administration in the BUP-XR group (121 [26.9%] of 450 adverse events). There were 11 serious adverse events (7.0%) in the 158 participants in the BUP-XR group, and 18 serious adverse events (11.5%) in the 156 participants in the SoC group-none judged to be related to study treatment. The BUP-XR treatment group had a mean incremental cost of £1033 (95% central range [CR] -1189 to 3225) and was associated with a mean incremental QALY of 0.02 (95% CR 0.00-0.05), and an ICER of £47,540 (0.37 probability of being cost-effective at the £30,000/QALY gained willingness-to-pay threshold). However, BUP-XR dominated the SoC among participants who were rated more severe at study baseline, and among participants in maintenance treatment for more that 28 days at study enrolment. Interpretation Evaluated against the daily oral SoC, monthly BUP-XR is clinically superior, delivering greater abstinence from opioids, and with a comparable safety profile. BUP-XR was not cost-effective in a base case cost-utility analysis using the societal perspective, but it was more effective and less costly (dominant) among participants with more severe OUD, or those whose current treatment episode was longer than 28 days. Further trials are needed to evaluate if BUP-XR is associated with better clinical and health economic outcomes over the longer term. Funding Indivior.
Collapse
Affiliation(s)
- John Marsden
- Addictions Department, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Mike Kelleher
- Addictions Department, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Eilish Gilvarry
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, United Kingdom
| | - Luke Mitcheson
- Addictions Department, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Jatinder Bisla
- King’s Clinical Trials Unit, Research Management and Innovation Directorate, King’s College London, United Kingdom
| | - Angela Cape
- King’s Clinical Trials Unit, Research Management and Innovation Directorate, King’s College London, United Kingdom
| | - Fiona Cowden
- NHS Tayside and Dundee Health and Social Care Partnership, Scotland, United Kingdom
| | - Edward Day
- Birmingham and Solihull Mental Health, NHS Foundation Trust, Birmingham, United Kingdom
| | - Jonathan Dewhurst
- Addictions Division, Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Rachel Evans
- School of Health Sciences, Bangor University, Wales, United Kingdom
| | - Will Hardy
- Clinic for Health Economics and Medicines Evaluation, Bangor University, Wales, United Kingdom
| | - Andrea Hearn
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, United Kingdom
| | - Joanna Kelly
- King’s Clinical Trials Unit, Research Management and Innovation Directorate, King’s College London, United Kingdom
| | - Natalie Lowry
- Addictions Department, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Martin McCusker
- Lambeth Service User Council, South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Caroline Murphy
- King’s Clinical Trials Unit, Research Management and Innovation Directorate, King’s College London, United Kingdom
| | - Robert Murray
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, United Kingdom
| | - Tracey Myton
- Addictions Division, Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Sophie Quarshie
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, United Kingdom
| | - Rob Vanderwaal
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - April Wareham
- Patient and Public Involvement and Engagement Representative, United Kingdom
| | - Dyfrig Hughes
- Clinic for Health Economics and Medicines Evaluation, Bangor University, Wales, United Kingdom
| | - Zoë Hoare
- School of Health Sciences, Bangor University, Wales, United Kingdom
| |
Collapse
|
31
|
D’Onofrio G, Perrone J, Hawk KF, Cowan E, McCormack R, Coupet E, Owens PH, Martel SH, Huntley K, Walsh SL, Lofwall MR, Herring A. Early emergency department experience with 7-day extended-release injectable buprenorphine for opioid use disorder. Acad Emerg Med 2023; 30:1264-1271. [PMID: 37501652 PMCID: PMC10822018 DOI: 10.1111/acem.14782] [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: 06/05/2023] [Revised: 07/17/2023] [Accepted: 07/25/2023] [Indexed: 07/29/2023]
Abstract
As the opioid overdose epidemic escalates, there is an urgent need for treatment innovations to address both patient and clinician barriers when initiating buprenorphine in the emergency department (ED). These include insurance status, logistical challenges such as the ability to fill a prescription and transportation, concerns regarding diversion, and availability of urgent referral sites. Extended-release buprenorphine (XR-BUP) preparations such as a new 7-day injectable could potentially solve some of these issues. We describe the pharmacokinetics of a new 7-day XR-BUP formulation and the feasibility of its use in the ED setting. We report our early experiences with this medication (investigational drug CAM2038), in the context of an ongoing clinical trial entitled Emergency Department-Initiated BUP VAlidaTION (ED INNOVATION), to inform emergency clinicians as they consider incorporating this medication into their practice. The medication was approved by the European Medicines Agency in 2018 and the U.S. Food and Drug Administration in 2023 for those 18 years or older for the treatment of moderate to severe opioid use disorder (OUD). We report our experience with approximately 800 ED patients with OUD who received the 7-day XR-BUP preparation in the ED between June 2020 and July 2023.
Collapse
Affiliation(s)
- Gail D’Onofrio
- Department of Emergency Medicine, Yale School of Medicine,
New Haven, Connecticut
- Yale School of Public Health New Haven, Connecticut
| | - Jeanmarie Perrone
- Department of Emergency Medicine Perelman School of
Medicine at the University of Pennsylvania. Philadelphia, Pennsylvania
| | - Kathryn F. Hawk
- Department of Emergency Medicine, Yale School of Medicine,
New Haven, Connecticut
- Yale School of Public Health New Haven, Connecticut
| | - Ethan Cowan
- Department of Emergency Medicine, Yale School of Medicine,
New Haven, Connecticut
- Department of Emergency Medicine Icahn School of Medicine
at Mount Sinai New York, New York
| | - Ryan McCormack
- Department of Emergency Medicine NYU Langone Medical Center
New York, New York
| | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine,
New Haven, Connecticut
| | - Patricia H. Owens
- Department of Emergency Medicine, Yale School of Medicine,
New Haven, Connecticut
| | - Shara H. Martel
- Department of Emergency Medicine, Yale School of Medicine,
New Haven, Connecticut
| | | | - Sharon L. Walsh
- University of Kentucky College of Medicine Center on Drug
and Alcohol Research, Lexington, Kentucky
| | - Michelle R. Lofwall
- University of Kentucky College of Medicine Center on Drug
and Alcohol Research, Lexington, Kentucky
| | - Andrew Herring
- Department of Emergency Medicine Highland Hospital Oakland,
California
| | | |
Collapse
|
32
|
Parkin S, Neale J, Strang J. Conceptualising retention in treatment with long-acting injectable buprenorphine (for opioid use disorder) as a journey: Findings from a longitudinal qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 122:104221. [PMID: 37865052 DOI: 10.1016/j.drugpo.2023.104221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Conceptualisations of the 'patient journey' are popular within health service research. Patient journeys provide a person-centred approach to health care that typically prioritise subjective patient experience with the aim of improving relevant forms of intervention. This article explores the conceptualisation of retention in treatment for opioid use disorder (OUD) using long-acting injectable buprenorphine (LAIB) as a journey. METHODS Data derive from a longitudinal qualitative study, involving semi-structured interviews (held at six time-points), with participants who each initiated LAIB for the first time. Data analysis for this article focuses exclusively upon the experiences of those who had continued with LAIB treatment throughout one year (11 participants). Framework and thematic narrative analyses of 64 interviews with 11 participants sought to identify 'retention-narratives' that would indicate a 'retention journey' associated with LAIB treatment. FINDINGS Shared treatment experiences consisted of three distinct phases (Withdrawal and Separation, Transformation, and Engagement) that progressed in a linear and intersecting manner through time. Each phase had features that defined treatment experiences at a given time but changed as treatment progressed. All 11 participants experienced multiple features within each of the three treatment phases and all participants reported separation from their respective service provider throughout the first 12 months of treatment. Although some valued the latter separation, most were dissatisfied by reduced levels of contact. CONCLUSION Retention in treatment for OUD with LAIB, for at least 12-months, can be conceptualised as a journey. This conceptualisation emphasises the benefits (and challenges) clinicians and patients may expect to encounter during the first year of a LAIB treatment programme. An added implication of conceptualising LAIB treatment in this manner is that optimal benefits of the medication (as observed by participants) began to emerge during 'months 7-12' of the retention journey.
Collapse
Affiliation(s)
- Stephen Parkin
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK.
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK; Centre for Social Research in Health, University of New South Wales, NSW 2052, Australia
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK; South London & Maudsley (SLaM) NHS Foundation Trust, London SE5 8AZ, UK
| |
Collapse
|
33
|
Weimer MB, Herring AA, Kawasaki SS, Meyer M, Kleykamp BA, Ramsey KS. ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids. J Addict Med 2023; 17:632-639. [PMID: 37934520 DOI: 10.1097/adm.0000000000001202] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
ABSTRACT Treatment of opioid use disorder (OUD) with buprenorphine has evolved considerably in the last decade as the scale of the OUD epidemic has increased along with the emergence of high-potency synthetic opioids (HPSOs) and stimulants in the drug supply. These changes have outpaced the development of prospective research, so a clinical consideration document based on expert consensus is needed to address pressing clinical questions. This clinical considerations document is based on a narrative literature review and expert consensus and will specifically address considerations for changes to the clinical practice of treatment of OUD with buprenorphine for individuals using HPSO. An expert panel developed 6 key questions addressing buprenorphine initiation, stabilization, and long-term treatment for individuals with OUD exposed to HPSO in various treatment settings. Broadly, the clinical considerations suggest that individualized strategies for buprenorphine initiation may be needed. The experience of opioid withdrawal negatively impacts the success of buprenorphine treatment, and attention to its management before and during buprenorphine initiation should be proactively addressed. Buprenorphine dose and dosing frequency should be individualized based on patients' treatment needs, the possibility of novel components in the drug supply should be considered during OUD treatment, and all forms of opioid agonist treatment should be offered and considered for patients. Together, these clinical considerations attempt to be responsive to the challenges and opportunities experienced by frontline clinicians using buprenorphine for the treatment of OUD in patients using HPSOs and highlight areas where prospective research is urgently needed.
Collapse
Affiliation(s)
- Melissa B Weimer
- From the Yale School of Medicine, Program in Addiction Medicine, New Haven, CT (MBW); Yale School of Public Health, New Haven, CT (MBW); Division of Addiction Medicine, Highland Hospital-Alameda Health System, Oakland, CA (AAH); Department of Psychiatry and Internal Medicine, Penn State Health, Hershey, PA (SSK); University of Vermont, Burlington, VT (MM); BAK and Associates, Baltimore, MD (BAK); NYS Office of Addiction Services and Supports (OASAS), Albany, NY (KSR)
| | | | | | | | | | | |
Collapse
|
34
|
Björnsson M, Acharya C, Strandgården K, Tiberg F. Population Pharmacokinetic Analysis Supports Initiation Treatment and Bridging from Sublingual Buprenorphine to Subcutaneous Administration of a Buprenorphine Depot (CAM2038) in the Treatment of Opioid Use Disorder. Clin Pharmacokinet 2023; 62:1427-1443. [PMID: 37584841 PMCID: PMC10520114 DOI: 10.1007/s40262-023-01288-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND OBJECTIVE In treating opioid use disorder (OUD), subcutaneous (SC) extended-release buprenorphine (BPN) depots, e.g., CAM2038, have been shown to provide smaller and less frequent fluctuations in BPN plasma concentrations and pharmacodynamic responses, improve outcomes, reduce treatment burden, and lower risks of misuse and diversion compared to daily sublingual (SL) BPN. This analysis characterized the pharmacokinetics (PK) of BPN following intravenous and SL administration, and administration of SC CAM2038 weekly and monthly. METHODS Pharmacokinetic data from two Phase 1 and two Phase 2 trials in healthy participants and participants with OUD, respectively, were used to develop a population PK model using non-linear mixed effects modelling. The analysis included data from 252 participants and 10,658 BPN observations. RESULTS The disposition of BPN was best described by a three-compartment model with first-order elimination, and absorption of SL BPN and SC CAM2038 weekly and monthly by dual parallel absorption pathways. Model diagnostics indicated good predictive performance of BPN concentrations. Buprenorphine plasma concentration-time profiles were simulated for treatment initiation, switching from SL BPN to CAM2038 weekly and monthly, and tapering after interrupting treatment with CAM2038. Simulations predicted CAM2038 weekly and monthly doses that provided BPN plasma maximum concentration (Cmax) and trough concentration (Ctrough) values at steady state within those observed following SL BPN administration. CONCLUSIONS This population PK model supports the use of CAM2038 doses as individualized treatment for OUD across different treatment stages, including initiation, switching from SL BPN according to established dose conversion schedules, and tapering. TRIAL REGISTRATIONS ISRCTN41550730 (05/19/2014), ISRCTN24987553 (07/29/2014), NCT02611752 (11/23/2015), NCT02710526 (03/16/2016).
Collapse
|
35
|
Maremmani I, Dematteis M, Gorzelanczyk EJ, Mugelli A, Walcher S, Torrens M. Long-Acting Buprenorphine Formulations as a New Strategy for the Treatment of Opioid Use Disorder. J Clin Med 2023; 12:5575. [PMID: 37685642 PMCID: PMC10488107 DOI: 10.3390/jcm12175575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/12/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Long-acting buprenorphine formulations have been recently marketed for the Opioid Agonist Treatment (OAT) of opioid use disorder (OUD) associated with medical, social, and psychological support. Their duration of action ranges from one week up to 6 months. The non-medical use of opioids is increasing with a parallel rise in lethal overdoses. Methadone and buprenorphine are the standard treatment for opioid dependence. Methadone Maintenance Treatment (MMT) is widely recognized as one of the most effective ways of reducing the risks of overdose, crime, and transmission of HIV (Human Immunodeficiency Virus) in people who use opioids; however, its effectiveness has been hindered by low rates of uptake and retention in treatment. Furthermore, both methadone and buprenorphine are widely diverted and misused. Thus, a crucial aspect of treating OUD is facilitating patients' access to treatment while minimizing substance-related harm and improving quality of life. The newly developed long-acting buprenorphine formulations represent a significant change in the paradigm of OUD treatment, allowing an approach individualized to patients' needs. Strengths of this individualized approach are improved adherence (lack of peaks and troughs in blood concentrations) and a reduced stigma since the patient doesn't need to attend their clinic daily or nearly daily, thus facilitating social and occupational integrations as the quality of life. However, less frequent attendance at the clinic should not affect the patient-physician relationship. Therefore, teleconsulting or digital therapeutic services should be developed in parallel. In addition, diversion and intravenous misuse of buprenorphine are unlikely due to the characteristics of these formulations. These features make this approach of interest for treating OUD in particular settings, such as subjects staying or when released from prison or those receiving long-term residential treatment for OUD in the therapeutic communities. The long-lasting formulations of buprenorphine can positively impact the OUD treatment and suggest future medical and logistic developments to maximize their personalized management and impact.
Collapse
Affiliation(s)
- Icro Maremmani
- VP Dole Research Group, G. De Lisio Institute of Behavioural Sciences, Via di Pratale 3, 56121 Pisa, Italy;
- UniCamillus, International Medical University in Rome, Via di Sant’Alessandro 8, 00131 Rome, Italy
| | - Maurice Dematteis
- Department of Pharmacology and Addiction Medicine, Grenoble-Alpes University Hospital, Grenoble Alpes University, Rue de la Chantourne, 38043 Grenoble, France;
| | - Edward J. Gorzelanczyk
- Department of Theoretical Basis of Biomedical Sciences and Medical Informatics, Nicolaus Copernicus University, Collegium Medicum, 85-067 Bydgoszcz, Poland;
- Faculty of Philosophy, Kazimierz Wielki University, 85-092 Bydgoszcz, Poland
- The Society for the Substitution Treatment of Addiction ”Medically Assisted Recovery”, 85-791 Bydgoszcz, Poland
| | - Alessandro Mugelli
- Department of Neurosciences, Psychology, Drug Research and Child Health (NeuroFarBa), University of Florence, Via della Pergola, 50121 Firenze, Italy;
| | - Stephan Walcher
- CONCEPT Center for Addiction Medicine, Kaiserstrasse 1, D-80801 Munich, Germany;
| | - Marta Torrens
- Addiction Research Group, Hospital del Mar Research Institute Barcelona, 08003 Barcelona, Spain
| |
Collapse
|
36
|
Parkin S, Neale J, Strang J. Non-Prescribed Substance Use during the First Month of Treatment by People Receiving Depot Buprenorphine for Opioid Use Disorder. Subst Use Misuse 2023; 58:1696-1706. [PMID: 37571999 DOI: 10.1080/10826084.2023.2244064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
Background: Non-prescribed substance use (NPSU) during the treatment of opioid use disorder (OUD) is a recognized phenomenon. The use of non-prescribed substances is associated with discontinuing treatment and drop-out can occur within the early weeks of treatment, before benefit from treatment occurs. Recent developments in treatment include long-acting, slow-release depot buprenorphine injections. This article focuses on NPSU during the first month of treatment with depot buprenorphine, addressing the frequency with which it occurs, the substances used, and reasons for use. Methods: 70 semi-structured interviews (held at three time-points) were conducted with 26 patients initiating depot buprenorphine as part of a longitudinal qualitative study. Analysis prioritized content and framework analyses. Findings: 17/26 participants self-reported NPSU at various times during the first month of treatment. NPSU typically involved heroin, crack-cocaine and some use of benzodiazepines and/or cannabis. Participants' reasons for heroin use were connected to their subjective accounts of opioid withdrawal symptoms, the management of pain, and experimentation (to test the blockade effect of buprenorphine). Frequency of heroin use was typically episodic rather than sustained. Participants associated crack-cocaine use with stimulant-craving and social connections, and considered their use of this substance to be difficult to manage. Conclusions: Patients' initial engagement with treatment for OUD is rarely examined in qualitative research. This study highlights how NPSU amongst patients receiving new forms of such treatment continues to be a challenge. As such, shared decision-making (between providers and patients) regarding treatment goals and NPSU should be central to the delivery of depot buprenorphine treatment programmes.
Collapse
Affiliation(s)
- Stephen Parkin
- Institute of Psychiatry, National Addiction Centre, King's College London, London, UK
| | - Joanne Neale
- Institute of Psychiatry, National Addiction Centre, King's College London, London, UK
- Centre for Social Research in Health, University of New South Wales, Kensington, Australia
| | - John Strang
- Institute of Psychiatry, National Addiction Centre, King's College London, London, UK
- South London & Maudsley (SLaM), NHS Foundation Trust, London, UK
| |
Collapse
|
37
|
Hard B, DeSilva M. Evaluating the feasibility of prolonged-release buprenorphine formulations as an alternative to daily opioid agonist therapy regardless of prior treatment adherence: a pilot study. Pilot Feasibility Stud 2023; 9:113. [PMID: 37403145 DOI: 10.1186/s40814-023-01348-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 06/20/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Effective opioid agonist therapy (OAT) depends on good patient adherence. However, the daily, supervised administration of standard OAT represents a significant burden to patients and often drives poor adherence. Prolonged-release buprenorphine (PRB) formulations may mitigate some of this burden, enabling clinic visits to be substantially reduced. For treatment guidelines to be effective, the likely benefit of a transition to PRB therapy in different patient populations must be established. METHODS The aim was to determine the feasibility of assessing PRB as an alternative to daily OAT in two groups: those currently adhering well to daily OAT (group 1, N = 5) and those not currently showing adherence or a positive response to daily OAT (group 2, N = 10). This open-label, prospective, non-controlled pilot study was conducted at the Kaleidoscope Drug Project in South Wales, UK. Participants were assessed for history, drug use, psychosocial assessment scores, and clinical severity at baseline and after 6 months of treatment. Primary outcomes were the feasibility of assessing PRB as an alternative to daily OAT and the acceptability of PRB therapy in each group. Secondary outcomes were treatment response, on-top drug use, psychosocial measures, and assessment of clinical severity. RESULTS Participants from both groups demonstrated high levels of participation with assessment protocols at both baseline and 6-month follow-up, indicating study feasibility. PRB treatment was acceptable to the majority of participants, with all of group 1 and 70% of group 2 adhering to PRB therapy for the duration of the study and opting to persist with PRB therapy over other OAT options after study completion. All participants who remained on treatment demonstrated marked improvements in psychosocial and clinical severity assessment scores, with some returning to employment or education. On-top drug use remained absent in group 1 and was reduced in group 2. CONCLUSIONS Evaluation of transition of participants from daily OAT to PRB therapy was shown to be feasible, acceptable, and effective across both groups. A larger randomised controlled trial is warranted, particularly to assess PRB therapy in participants with a history of poor treatment engagement, as the need for therapy is greater in this group and their management is associated with higher costs of care.
Collapse
Affiliation(s)
- Bernadette Hard
- Kaleidoscope Drug Project, Resolven House, St Mellons Business Park, Fortran Rd Cardiff, Wales, CF3 0EY, UK.
| | - Mohan DeSilva
- Kaleidoscope Drug Project, Resolven House, St Mellons Business Park, Fortran Rd Cardiff, Wales, CF3 0EY, UK
| |
Collapse
|
38
|
Moses TEH, Waineo E, Levine D, Greenwald MK. Optimizing buprenorphine training during undergraduate medical education: Medical student feedback and attitudes. Am J Addict 2023; 32:376-384. [PMID: 36850044 PMCID: PMC10313763 DOI: 10.1111/ajad.13395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Strong evidence supports efficacy of medications for opioid use disorder (MOUD), but stringent prescribing policies impair access. Many physicians report discomfort prescribing MOUD due to inadequate knowledge. Most medical students believe MOUD training should occur during undergraduate medical education (UME). As legislation surrounding buprenorphine prescribing shifts, it is timely to consider how best to incorporate MOUD training into UME. METHODS At the start of 3rd year, all students (n = 290) received a survey regarding experiences working with people with OUDs, and beliefs and knowledge regarding harm reduction and treatment. During orientation, students completed an 8-h online MOUD training. Afterwards, students completed another survey, including questions about training perceptions. RESULTS One-third of students (32.8%) completed MOUD training and both surveys. Before training, 60.0% had not heard of the waiver, but 82.1% endorsed interest in prescribing buprenorphine. Despite mixed feelings about training content and delivery, 79.1% believed future classes should receive it. Most thought it should be integrated longitudinally throughout the curriculum rather than as separate online training. CONCLUSION AND SCIENTIFIC SIGNIFICANCE Medical students want more MOUD education throughout their training; however, the 8-h online training may be less-than-optimal. As this training is no longer required to prescribe buprenorphine, there is an opportunity to modify the content presented. There is an urgent need for physicians with the knowledge and willingness to treat patients with OUD. Introducing integrated training about MOUD should help future physicians feel confident in their knowledge to treat patients and comfortable applying for the waiver.
Collapse
Affiliation(s)
- Tabitha E H Moses
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Eva Waineo
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Diane Levine
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Mark K Greenwald
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| |
Collapse
|
39
|
Seval N, Nunez J, Roth PMD, Meredith S, Strong M, Frank CA, Litwin AH, Levin FR, Brady KT, Nunes EV, Springer SA. Inpatient Low-dose Transitions From Full Agonist Opioids Including Methadone Onto Long-acting Depot Buprenorphine: Case Series From a Multicenter Clinical Trial. J Addict Med 2023; 17:e232-e239. [PMID: 37579095 PMCID: PMC10368784 DOI: 10.1097/adm.0000000000001136] [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] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Persons with opioid use disorder (OUD) suffer disproportionately from morbidity and mortality related to serious addiction-related infections requiring hospitalization. Long-acting buprenorphine (LAB) is an underused medication for OUD that may facilitate linkage to care and treatment retention when administered before hospital discharge. Transition onto buprenorphine in the inpatient setting is often complicated by pain, active infection management, potential surgical interventions, and risk of opioid withdrawal in transition from full agonists to a partial agonist. METHODS The COMMIT Trial is a randomized controlled trial evaluating LAB administered by infectious disease physicians and hospitalists compared with treatment as usual for persons with OUD hospitalized with infections. We report a case series of participants on full agonist opioids including methadone who were transitioned to sublingual buprenorphine using low-dose ( microdosing ) strategies followed by LAB injection. RESULTS Seven participants with current opioid use disorder and life-threatening infections, all with significant concurrent pain and many requiring surgical intervention, underwent low-dose transitions starting at buccal buprenorphine doses ranging from 225 μg to 300 μg 3 times a day on the first day. All were well tolerated with average time to LAB injection of 7.5 days (range, 5-10 days). CONCLUSIONS Inpatient low-dose buprenorphine transition from full agonist opioids including methadone onto LAB is feasible even in those with complex hospitalizations for concurrent infections and/or surgery. This strategy facilitates dosing of LAB before hospital discharge when risk of opioid relapse and overdose are significant.
Collapse
Affiliation(s)
- Nikhil Seval
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Disease. Yale AIDS Program. New Haven, CT
| | - Johnathan Nunez
- Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Division of Infectious Diseases and Epidemiology, Department of Medicine. Hershey, PA
| | - Prerana MD Roth
- Prisma Health, Department of Internal Medicine, Addiction Medicine Center, Greenville, SC
| | - Schade Meredith
- Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Division of Infectious Diseases and Epidemiology, Department of Medicine. Hershey, PA
| | - Michelle Strong
- Prisma Health, Department of Internal Medicine, Addiction Medicine Center, Greenville, SC
| | - Cynthia A. Frank
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Disease. Yale AIDS Program. New Haven, CT
| | - Alain H. Litwin
- Prisma Health, Department of Internal Medicine, Addiction Medicine Center, Greenville, SC
- University of South Carolina School of Medicine – Greenville, Greenville, SC
| | - Frances R. Levin
- Columbia University Irving Medical Center, Department of Psychiatry and New York State Psychiatric Institute
| | - Kathleen T. Brady
- Medical University of South Carolina, Clinical Neuroscience Division, Department of Psychiatry and Behavioral Sciences. Charleston, SC
| | - Edward V. Nunes
- University of South Carolina School of Medicine – Greenville, Greenville, SC
| | - Sandra A. Springer
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Disease. Yale AIDS Program. New Haven, CT
| |
Collapse
|
40
|
Neale J, Parkin S, Strang J. Patients' goals when initiating long-acting injectable buprenorphine treatment for opioid use disorder: findings from a longitudinal qualitative study. Subst Abuse Treat Prev Policy 2023; 18:37. [PMID: 37349776 PMCID: PMC10288705 DOI: 10.1186/s13011-023-00551-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/16/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Long-acting injectable buprenorphine (LAIB) is a new treatment for opioid use disorder that has been introduced against an international policy backdrop of recovery and person-centred care. This paper explores the goals that people want to achieve from LAIB to identify potential implications for policy and practice. METHODS Data derive from longitudinal qualitative interviews conducted with 26 people (18 male; 8 female) initiating LAIB in England and Wales, UK (June 2021-March 2022). Participants were interviewed up to five times by telephone over six months (107 interviews in total). Transcribed interview data relating to each participant's treatment goals were coded, summarised in Excel, and then analysed via a process of Iterative Categorization. RESULTS Participants often articulated a desire to be abstinent without defining exactly what they meant by this. Most intended to reduce their dosage of LAIB but did not want to rush. Although participants seldom used the term 'recovery', almost all identified objectives consistent with current definitions of this concept. Participants articulated broadly consistent goals over time, although some extended the timeframes for achieving treatment-related goals at later interviews. At their last interview, most participants remained on LAIB, and there were reports that the medication was enabling positive outcomes. Despite this, participants were aware of the complex personal, service-level, and situational factors that hindered their treatment progress, understood the additional support they needed to achieve their goals, and voiced frustrations when services failed them. CONCLUSIONS There is a need for wider debate regarding the goals people initiating LAIB are seeking and the diverse range of positive treatment outcomes LAIB could potentially generate. Those providing LAIB should offer regular on-going contact and other forms of non-medical support so that patients have the best opportunity to succeed. Policies relating to recovery and person-centred care have previously been criticised for responsibilising patients and service users to take better care of themselves and to change their own lives. In contrast, our findings suggest that these policies may, in fact, be empowering people to expect a greater range of support as part of the package of care they receive from service providers.
Collapse
Affiliation(s)
- Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, SE5 8BB UK
- Centre for Social Research in Health, University of New South Wales, Sydney, NSW 2052 Australia
| | - Stephen Parkin
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, SE5 8BB UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, SE5 8BB UK
- South London & Maudsley (SLaM) NHS Foundation Trust, London, SE5 8AZ UK
| |
Collapse
|
41
|
Guillery SPE, Reiners S, Fahrner M, Enge S, Hellweg R, Kunte H, Kronenberg G. The switching process from buprenorphine sublingual tablets to the monthly buprenorphine subcutaneous depot injection in opioid dependent patients. Addict Biol 2023; 28:e13275. [PMID: 37186443 DOI: 10.1111/adb.13275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/27/2023] [Accepted: 03/20/2023] [Indexed: 05/17/2023]
Abstract
The 2018 European Union (EU) approved weekly and monthly subcutaneous buprenorphine depot injection (BUP-XR), for opioid substitution medication proved to offer some specific treatment benefits. The present study examines the process of switching from buprenorphine sublingual tablets (BUP-SL) to BUP-XR from a patient's point of view. In total, nine patients were surveyed by means of an open-answer questionnaire regarding course and side effects of the medication switch. Six of these patients were surveyed in more detail under BUP-SL, as well as 4 and 16 weeks after the switch to BUP-XR by means of a test battery of questions on socio-demography, withdrawal symptoms, craving, physical well-being, treatment satisfaction and concomitant use of illegal substances. Patients reported significant worse physical well-being and lower treatment satisfaction in 4 weeks compared with 16 weeks after the medication switch to the BUP-XR. Furthermore, they reported significant more frequent co-use of illicit drugs, worse physical well-being, lower treatment satisfaction and more craving experience 4 weeks after the switch compared with the treatment under BUP-SL. Patients 16 weeks under BUP-XR reported significant more illicit co-use and lower treatment satisfaction compared with patients under BUP-SL. Connections between therapy dissatisfaction, physical discomfort, experienced craving and drug co-consumption were discovered. In the first weeks after the medication switch, patients experience potentially distressing symptoms, which, however, seem to diminish over time. Close supervision and comprehensive patient education on possible burdens of the medication switch to the BUP-XR might prevent unfavourable treatment courses and premature therapy dropouts.
Collapse
Affiliation(s)
- Stephanie Paula Elisabeth Guillery
- Clinic for Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Psychology, MSB - Medical School Berlin, Berlin, Germany
| | - Sven Reiners
- KMV Krankenhaus des Maßregelvollzugs Berlin, Berlin, Germany
| | | | - Sören Enge
- Department of Psychology, MSB - Medical School Berlin, Berlin, Germany
| | - Rainer Hellweg
- Clinic for Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hagen Kunte
- MSH - Medical School Hamburg, Hamburg, Germany
| | - Golo Kronenberg
- Psychiatrisches Universitätsklinikum Zürich, Zürich, Switzerland
| |
Collapse
|
42
|
Health and correctional staff acceptability of depot buprenorphine in NSW prisons. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 114:103978. [PMID: 36870227 DOI: 10.1016/j.drugpo.2023.103978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Provision of opioid agonist treatment (OAT) in custodial settings is resource-intensive and may be associated with diversion, non-medical use, and violence. A clinical trial of a new OAT, depot buprenorphine (the UNLOC-T study), provided the opportunity to obtain health and correctional staff perspectives regarding this treatment prior to widespread roll-out. METHODS Sixteen focus groups with 52 participants were conducted, including 44 health staff (nurses, nurse practitioners, doctors, and operational staff) and eight correctional staff. RESULTS Key challenges to providing OAT identified as potentially being addressed by depot buprenorphine included 1) patient access, 2) OAT program capacity, 3) treatment administration procedures, 4) medication diversion and other safety issues and, 5) impact on other service delivery. CONCLUSIONS The introduction of depot buprenorphine into correctional settings was considered to have the potential to increase safety for patients, improve staff / patient relations and advance patient health outcomes via expanded treatment coverage and efficiencies gained through enhanced health service delivery. Support was almost universal from both correctional and health staff participating in this study. These findings build on emerging research regarding the positive impact of more flexible OAT programs and could be used to engage support for the implementation of depot buprenorphine from staff in other secure settings.
Collapse
|
43
|
Walter SD, Blaha O, Esserman D. Taking a chance: How likely am I to receive my preferred treatment in a clinical trial? Stat Methods Med Res 2023; 32:572-592. [PMID: 36628522 PMCID: PMC9983058 DOI: 10.1177/09622802221146305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Researchers should ideally conduct clinical trials under a presumption of clinical equipoise, but in fact trial patients will often prefer one or other of the treatments being compared. Receiving an unblinded preferred treatment may affect the study outcome, possibly beneficially, but receiving a non-preferred treatment may induce 'reluctant acquiescence', and poorer outcomes. Even in blinded trials, patients' primary motivation to enrol may be the chance of potentially receiving a desirable experimental treatment, which is otherwise unavailable. Study designs with a higher probability of receiving a preferred treatment (denoted as 'concordance') will be attractive to potential participants, and investigators, because they may improve recruitment and hence enhance study efficiency. Therefore, it is useful to consider the concordance rates associated with various study designs. We consider this question with a focus on comparing the standard, randomised, two-arm, parallel group design with the two-stage randomised patient preference design and Zelen designs; we also mention the fully randomised and partially randomised patient preference designs. For each of these designs, we evaluate the concordance rate as a function of the proportions randomised to the alternative treatments, the distribution of preferences over treatments, and (for the Zelen designs) the proportion of patients who consent to receive their assigned treatment. We also examine the equity of each design, which we define as the similarity between the concordance rates for participants with different treatment preferences. Finally, we contrast each of the alternative designs with the standard design in terms of gain in concordance and change in equity.
Collapse
Affiliation(s)
- Stephen D Walter
- Department of Health Research Methodology, Evidence, and Impact, 3710McMaster University, Hamilton, Ontario, Canada
| | - Ondrej Blaha
- Department of Biostatistics, 50296Yale School of Public Health, New Haven, CT, USA
| | - Denise Esserman
- Department of Biostatistics, 50296Yale School of Public Health, New Haven, CT, USA
| |
Collapse
|
44
|
Torres-Terán I, Venczel M, Stieler T, Parisi L, Kloss A, Klein S. Prediction of subcutaneous drug absorption - characterization of subcutaneous interstitial fluids as a basis for developing biorelevant in vitro models. Int J Pharm 2023; 638:122906. [PMID: 37001831 DOI: 10.1016/j.ijpharm.2023.122906] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
Unlike orally administered drugs, the absorption profile of subcutaneously injectable drugs in humans is difficult to predict from preclinical studies. Since the subcutaneous interstitial fluid (ISF) is the first fluid interacting with the administered formulation before the respective drug is absorbed, it could critically affect bioavailability. The aim of the present study was to gain a better understanding of the similarities and differences of ISF of different species. For this purpose, ISF was isolated from subcutaneous tissues of five preclinical animal species, i.e., mice, rats, minipig, landrace pig, non-human primates, and humans, using a centrifugation method, and characterized with respect to its major constituents and physicochemical properties. The results show trends between animal species, with ISF from non-human primates differing significantly from that of the other preclinical species for most parameters analyzed and showing similarities to ISF of human origin. Although from a statistical point of view it will be necessary to further increase the existing data sets, the presented data provide valuable information for the development of biorelevant in vitro models to predict the in vivo performance of subcutaneously administered formulations, as they provide fundamental information for the design of biorelevant ISF media for both preclinical species and humans.
Collapse
|
45
|
Heidbreder C, Fudala PJ, Greenwald MK. History of the discovery, development, and FDA-approval of buprenorphine medications for the treatment of opioid use disorder. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 6:100133. [PMID: 36994370 PMCID: PMC10040330 DOI: 10.1016/j.dadr.2023.100133] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/12/2023]
Abstract
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.
Collapse
Affiliation(s)
| | - Paul J. Fudala
- Indivior Plc, North Chesterfield, VA, United States of America
| | - Mark K. Greenwald
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| |
Collapse
|
46
|
Neale J, Parkin S, Strang J. How do patients feel during the first 72 h after initiating long-acting injectable buprenorphine? An embodied qualitative analysis. Addiction 2023. [PMID: 36808168 DOI: 10.1111/add.16171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/06/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND AND AIMS Long-acting injectable buprenorphine (LAIB) is a new treatment for opioid use disorder that is generating positive outcomes. Negative effects are typically mild and transient, but can occasionally be serious, resulting in treatment discontinuation/non-adherence. This paper aims to analyse patients' accounts of how they felt during the first 72 h after initiating LAIB. METHODS Semi-structured interviews were conducted (June 2021-March 2022) with 26 people (18 males and 8 females) who had started LAIB within the previous 72 h. Participants were recruited from treatment services in England and Wales and were interviewed by telephone using a topic guide. Interviews were audio-recorded, transcribed and coded. The concepts of embodiment and embodied cognition framed the analyses. Data on participants' substance use, initiation onto LAIB and feelings were tabulated. Next, participants' accounts of how they felt were analysed following the stages of Iterative Categorization. RESULTS Participants reported complex combinations of changing negative and positive feelings. Bodily experiences included withdrawal symptoms, poor sleep, injection-site pain/soreness, lethargy and heightened senses inducing nausea ('distressed bodies'), but also enhanced somatic wellbeing, improved sleep, better skin, increased appetite, reduced constipation and heightened senses inducing pleasure ('returning body functions'). Cognitive responses included anxiety, uncertainties and low mood/depression ('the mind in crisis') and improved mood, greater positivity and reduced craving ('feeling psychologically better'). Whereas most negative effects reported are widely recognized, the early benefits of treatment described are less well-documented and may be an overlooked distinctive feature of LAIB. CONCLUSIONS During the first 72 h after initiating long-acting injectable buprenorphine, new patients report experiencing a range of interconnected positive and negative short-term effects. Providing new patients with information about the range and nature of these effects can prepare them for what to expect and help them manage feelings and reduce anxiety. In turn, this may increase medication adherence.
Collapse
Affiliation(s)
- Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8BB, UK.,Centre for Social Research in Health, University of New South Wales, New South Wales, NSW 2052, Australia
| | - Stephen Parkin
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8BB, UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8BB, UK.,South London and Maudsley (SLaM) NHS Foundation Trust, London, SE5 8AZ, UK
| |
Collapse
|
47
|
Cuperfain AB, Katznelson G, Costa T, Wong P, Beyraghi N, George TP, Lofwall MR, Chopra N. Factors to guide the use of extended-release buprenorphine formulations for specific patient populations. JOURNAL OF SUBSTANCE USE 2023. [DOI: 10.1080/14659891.2023.2174908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- Ari B. Cuperfain
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gali Katznelson
- Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tianna Costa
- Addictions Division and Centre for Complex Interventions, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Wong
- Addictions Division and Centre for Complex Interventions, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Narges Beyraghi
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Addictions Division and Centre for Complex Interventions, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Tony P. George
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Addictions Division and Centre for Complex Interventions, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Michelle R. Lofwall
- Departments of Behavioral Science and Psychiatry, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Nitin Chopra
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Addictions Division and Centre for Complex Interventions, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
48
|
Neale J, Parkin S, Strang J. Qualitative study of patients’ decisions to initiate injectable depot buprenorphine for opioid use disorder: the role of information and other factors. DRUGS: EDUCATION, PREVENTION AND POLICY 2023. [DOI: 10.1080/09687637.2023.2165041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - Stephen Parkin
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- South London & Maudsley (SLaM), NHS Foundation Trust, London, UK
| |
Collapse
|
49
|
Martin RA, Berk J, Rich JD, Kang A, Fritsche J, Clarke JG. Use of long-acting injectable buprenorphine in the correctional setting. J Subst Abuse Treat 2022; 142:108851. [PMID: 35939914 PMCID: PMC9743485 DOI: 10.1016/j.jsat.2022.108851] [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: 04/22/2022] [Revised: 06/29/2022] [Accepted: 07/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND As overdoses due to opioids rise, medications for opioid use disorder (MOUD) continue to be underemployed, resulting in limited access to potentially life-saving treatment. Substance use disorders are prevalent in individuals who are incarcerated, and these individuals are at increased risk for death postrelease due to overdose. Few jails and prisons offer MOUD and most limit access. Extended-release buprenorphine (XR-BUP), a novel monthly injectable MOUD formulation, could be uniquely poised to address treatment access in correctional settings. METHODS This study linked a retrospective cohort design of statewide datasets to evaluate the real-world use of XR-BUP. The study included individuals (N = 54) who received XR-BUP while incarcerated from January 2019 through February 2022. The study was conducted at the Rhode Island Department of Corrections, with the nation's first comprehensive statewide correctional MOUD program. RESULTS Fifty-four individuals received a combined total of 162 injections during the study period. The study found no evidence of tampering with the injection site, indicating no attempts by participants to remove, hoard, or divert the medication. Sixty-one percent reported at least one adverse effect after injections were received, with an average of 2.8 side effects. Sixty-one percent of those released on XR-BUP engaged in MOUD after release, 30 % continued with XR-BUP. CONCLUSIONS XR-BUP is feasible and acceptable in correctional settings. XR-BUP addresses administrative concerns of diversion that obstruct lifesaving MOUD and offers another safe and effective treatment option. Further studies and trials should continue to assess this novel medication's ability to treat opioid addiction in the correctional setting and upon release to the community.
Collapse
Affiliation(s)
- Rosemarie A Martin
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA.
| | - Justin Berk
- Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA; Rhode Island Department of Corrections, 40 Howard Avenue, Cranston, RI 02920, USA
| | - Josiah D Rich
- Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA; Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA; The Center for Health and Justice Transformation, The Miriam Hospital, 1125 N. Main Street Providence, RI 02904, USA; Center of Biomedical Research Excellence on Opioids and Overdose, The Rhode Island Hospital, Providence, RI, USA
| | - Augustine Kang
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA; Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
| | - John Fritsche
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA
| | - Jennifer G Clarke
- Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA
| |
Collapse
|
50
|
Pedersen MH, Danø A, Gibbons C, Jensen R. Administration and patient-incurred costs associated with opioid agonist treatment in Norway. Curr Med Res Opin 2022; 38:1959-1965. [PMID: 36172758 DOI: 10.1080/03007995.2022.2129230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Opioid use disorder is associated with high rates of mortality and has become an escalating global health issue. Opioid agonist treatment (OAT) with oral methadone or daily sublingual buprenorphine hydrochloride, either administered separately or in combination with naloxone hydrochloride (SL-BPN, SL-BPN/NX), is supervised by a healthcare professional experienced in treating opioid use disorder to ensure proper dosing and prevent misuse. For that reason, there may be substantial direct and indirect costs associated with OAT. Recently, weekly and monthly subcutaneous depot formulations of buprenorphine (SC-BPN) have been approved. This study aimed to estimate management and patient-incurred costs associated with the most commonly used OATs compared to the cost of weekly and monthly SC-BPN. METHODS We conducted a cost-minimisation analysis comparing the monthly costs of OAT treatment with oral formulations, i.e. oral methadone, SL-BPN, SL-BPN/NX and SC-BPN. The analysis assessed treatment acquisition costs and costs associated with management, supervision and administration of therapy, patients' transportation costs and the indirect costs associated with patients' time-use. The model was set up to reflect the Norwegian medically assisted rehabilitation system and considered the costs of a stable maintenance OAT regimen given continuously to patients already initiated and titrated on the therapy. RESULTS OAT management with monthly formulation of SC-BPN was associated with a reduction in monthly costs of €605, €586, and €411 per month compared to SL-BPN, SL-BPN/NX and oral methadone, respectively. Similar results were estimated when comparing to the weekly formulation of SC-BPN. CONCLUSION The analysis showed that the monthly formulation of SC-BPN was the cost-minimising alternative, followed by the weekly formulation, when considering all cost components.
Collapse
|