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Alrawashdeh M, Rhee C, Klompas M, Larochelle MR, Poland RE, Guy JS, Kimmel SD. Association of Early Opioid Withdrawal Treatment Strategy and Patient-Directed Discharge Among Hospitalized Patients with Opioid Use Disorder. J Gen Intern Med 2023; 38:2289-2297. [PMID: 36788169 PMCID: PMC10406767 DOI: 10.1007/s11606-023-08059-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/26/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Medical hospitalizations for people with opioid use disorder (OUD) frequently result in patient-directed discharges (PDD), often due to untreated pain and withdrawal. OBJECTIVE To investigate the association between early opioid withdrawal management strategies and PDD. DESIGN Retrospective cohort study using three datasets representing 362 US hospitals. PARTICIPANTS Adult patients hospitalized between 2009 and 2015 with OUD (as identified using ICD-9-CM codes or inpatient buprenorphine administration) and no PDD on the day of admission. INTERVENTIONS Opioid withdrawal management strategies were classified based on day-of-admission receipt of any of the following treatments: (1) medications for OUD (MOUD) including methadone or buprenorphine, (2) other opioid analgesics, (3) adjunctive symptomatic medications without opioids (e.g., clonidine), and (4) no withdrawal treatment. MAIN MEASURES PDD was assessed as the main outcome and hospital length of stay as a secondary outcome. KEY RESULTS Of 6,715,286 hospitalizations, 127,158 (1.9%) patients had OUD and no PDD on the day of admission, of whom 7166 (5.6%) had a later PDD and 91,051 (71.6%) patients received some early opioid withdrawal treatment (22.3% MOUD; 43.4% opioid analgesics; 5.9% adjunctive medications). Compared to no withdrawal treatment, MOUD was associated with a lower risk of PDD (adjusted odds ratio [aOR] = 0.73, 95%CI 0.68-0.8, p < .001), adjunctive treatment alone was associated with higher risk (aOR = 1.13, 95%CI: 1.01-1.26, p = .031), and treatment with opioid analgesics alone was associated with similar risk (aOR 0.95, 95%CI: 0.89-1.02, p = .148). Among those with PDD, both MOUD (adjusted incidence rate ratio [aIRR] = 1.24, 95%CI: 1.17-1.3, p < .001) and opioid analgesic treatments (aIRR = 1.39, 95%CI: 1.34-1.45, p < .001) were associated with longer hospital stays. CONCLUSIONS MOUD was associated with decreased risk of PDD but was utilized in < 1 in 4 patients. Efforts are needed to ensure all patients with OUD have access to effective opioid withdrawal management to improve the likelihood they receive recommended hospital care.
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Affiliation(s)
- Mohammad Alrawashdeh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
- Jordan University of Science and Technology, Irbid, Jordan.
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marc R Larochelle
- Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Russell E Poland
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- HCA Healthcare, Nashville, TN, USA
| | | | - Simeon D Kimmel
- Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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Brooks O, Ng JC, Ickowicz S. Outpatient Rapid Titration of Slow Release Oral Morphine for the Treatment of Opioid Use Disorder in a Canadian Setting: A Case Series. J Addict Med 2023; 17:e240-e245. [PMID: 37579101 PMCID: PMC10481425 DOI: 10.1097/adm.0000000000001149] [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: 03/07/2023]
Abstract
INTRODUCTION In the midst of unprecedented opioid overdose deaths, opioid agonist therapy induction strategies that allow for rapid titration to therapeutic doses for individuals at high risk of overdose are needed. Slow release oral morphine (SROM) is an effective treatment for opioid use disorder; however, current guideline-recommended titration strategies require weeks to achieve therapeutic dose for individuals with high opioid tolerance. Individuals may be lost to care or experience overdose due to ongoing use of unregulated opioids during this time. After years of experience titrating SROM doses rapidly in the inpatient setting, we developed a protocol using short-acting morphine (MOS) to allow for rapid SROM titration in the outpatient setting. CASES Patients (n = 4) were eligible if they met the criteria for opioid use disorder and had evidence of high opioid tolerance. Patients received supervised MOS doses in the outpatient setting, which were consolidated into a 12-hour extended-release morphine dose (to a maximum of 500 mg) on the evening of the titration. The total titration-day MOS and 12-hour extended-release morphine were summed into the post-titration-day SROM dose, to a maximum of 1000 mg. DISCUSSION In the cases described, substantial reductions in unregulated fentanyl use and social gains, such as obtaining housing, employment, and enrollment in inpatient treatment programs, were observed after rapid SROM titration. No overdoses occurred during rapid SROM titration or during SROM treatment. More research is needed to determine the role for rapid SROM titrations as a stabilization option for outpatients.
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Affiliation(s)
- Olivia Brooks
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
| | - Joan C.Y. Ng
- Providence Health Care, Vancouver, BC, Canada
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Sarah Ickowicz
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
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Modeling the cost and impact of injectable opioid agonist therapy on overdose and overdose deaths. J Subst Abuse Treat 2022; 143:108871. [PMID: 36182753 DOI: 10.1016/j.jsat.2022.108871] [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: 09/21/2021] [Revised: 07/21/2022] [Accepted: 09/01/2022] [Indexed: 01/04/2023]
Abstract
AIMS Unsupervised injectable opioid agonist therapy (iOAT) may decrease the unmet treatment needs for people who inject opioids. We aimed to model whether unsupervised iOAT may be effective in reducing fatal and non-fatal overdose, and estimate the cost per life saved. METHODS The study used a decision tree model based on Australian and international parameters for overdose risk in people who inject opioids who are: not on OAT; new/stable to methadone/buprenorphine treatment; on iOAT; or on unsupervised iOAT. We modeled scenarios of (1) current OAT only (status quo), or current OAT plus either (2) 5% supervised iOAT, (3) 5% supervised or 5.69% unsupervised iOAT (based on willingness to enroll), OR (4) 1.2% supervised and 10% unsupervised iOAT (the same cost as scenario 2). The study measured overdoses (fatal and nonfatal) and treatment costs per 10,000 people who inject opioids per annum, and cost-per deaths averted on implementation of iOAT. RESULTS With current OAT, the study found an estimated 1655.5 (1552.7-1705.3) overdoses, 19.3 (17.9-20.3) overdose deaths and AUD 23,335,081 in treatment costs per 10,000 people per annum. Implementation of 5% enrollment in supervised iOAT costs an additional AUD 14,807,855 and showed a reduction of 122.9 (95% UI 114.2-130.5) overdoses and 2.0 (1.8-2.0) overdose deaths per 10,000 people per annum ($7,774,172 [7,283,182-8,146,989] per death averted). For the same treatment costs, additional coverage of 10% unsupervised iOAT and 1.2% supervised iOAT could be achieved, which the study estimated to prevent 269.0 (95% UI 250.0-278.7) overdoses and 4.0 (3.7-4.2) overdose deaths per 10,000 people per annum ($3,723,340 (3,385,878-3,894,379) per death averted), alongside further benefits of treatment unaccounted for in this study. CONCLUSION An implementation scenario with greater unsupervised iOAT compared to supervised iOAT allows for an increased reduction in overdose and overdose deaths per annum at the same cost, with the additional benefit of increased treatment coverage among people who inject opioids.
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Brothers TD, Fraser J, MacAdam E, Morgan B, Webster D. Uptake of slow-release oral morphine as opioid agonist treatment among hospitalised patients with opioid use disorder. Drug Alcohol Rev 2022; 41:430-434. [PMID: 34347327 PMCID: PMC8814044 DOI: 10.1111/dar.13365] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/11/2021] [Accepted: 07/13/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Buprenorphine and methadone are highly effective first-line medications for opioid agonist treatment (OAT) but are not acceptable to all patients. We aimed to assess the uptake of slow-release oral morphine (SROM) as second-line OAT among medically ill, hospitalised patients with opioid use disorder who declined buprenorphine and methadone. METHODS This study included consecutive hospitalised patients with untreated moderate-to-severe opioid use disorder referred to an inpatient addiction medicine consultation service, between June 2018 and September 2019, in Nova Scotia, Canada. We assessed the proportion of patients initiating first-line OAT (buprenorphine or methadone) in-hospital, and the proportion initiating SROM after declining first-line OAT. We compared rates of outpatient OAT continuation (i.e., filling outpatient OAT prescription or attending first outpatient OAT clinic visit) by medication type, and compared OAT selection between patients with and without chronic pain, using χ2 tests. RESULTS Thirty-four patients were offered OAT initiation in-hospital; six patients (18%) also had chronic pain. Twenty-one patients (62%) initiated first-line OAT with buprenorphine or methadone. Of the 13 patients who declined first-line OAT, seven (54%) initiated second-line OAT with SROM in-hospital. Rates of outpatient OAT continuation after hospital discharge were high (>80%) and did not differ between medications (P = 0.4). Patients with co-existing chronic pain were more likely to choose SROM over buprenorphine or methadone (P = 0.005). DISCUSSION AND CONCLUSIONS The ability to offer SROM (in addition to buprenorphine or methadone) increased rates of OAT initiation among hospitalised patients. Increasing access to SROM would help narrow the opioid use disorder treatment gap of unmet need.
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Affiliation(s)
- Thomas D Brothers
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada.,UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - John Fraser
- Mobile Outreach Street Health, North End Community Health Centre, Halifax, Canada.,Department of Anesthesia, Pain Management and Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Emily MacAdam
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Brendan Morgan
- Department of Anesthesia, Pain Management and Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Duncan Webster
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada.,Division of Infectious Diseases, Saint John Regional Hospital, Saint John, Canada
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Peterkin A, Laks J, Weinstein ZM. Current Best Practices for Acute and Chronic Management of Patients with Opioid Use Disorder. Med Clin North Am 2022; 106:61-80. [PMID: 34823735 DOI: 10.1016/j.mcna.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This comprehensive review on opioids summarizes the scope of the current opioid epidemic, the diagnosis and treatment of opioid use disorder, and the medical and psychiatric complications of opioid use.
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Affiliation(s)
- Alyssa Peterkin
- Grayken Center for Addiction Medicine, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Avenue, Room 2070, Boston, MA 02118, USA.
| | - Jordana Laks
- Grayken Center for Addiction Medicine, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Avenue, Room 2103B, Boston, MA 02118, USA
| | - Zoe M Weinstein
- Grayken Center for Addiction Medicine, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Avenue, Room 2039, Boston, MA 02118, USA
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Kimmel S, Bach P, Walley AY. Treatment of Refractory Opioid Use Disorder : Comparison of Treatment Options for Refractory Opioid Use Disorder in the United States and Canada: A Narrative Review. J Gen Intern Med 2021; 36:1793. [PMID: 33772440 PMCID: PMC8175604 DOI: 10.1007/s11606-021-06727-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Simeon Kimmel
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, USA.
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, USA.
- Boston University School of Medicine, Boston, USA.
| | - Paxton Bach
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Alexander Y Walley
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, USA
- Boston University School of Medicine, Boston, USA
- Massachusetts Department of Public Health, Boston, USA
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Yen Li M, Mitton JA, Bearnot BI. Treatment of Refractory Opioid Use Disorder. J Gen Intern Med 2021; 36:1792. [PMID: 33826061 PMCID: PMC8175523 DOI: 10.1007/s11606-021-06718-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 03/14/2021] [Indexed: 11/25/2022]
Affiliation(s)
| | - Julian A Mitton
- Enterprise Population Health, CommonSpirit Health, San Francisco, CA, USA
| | - Benjamin I Bearnot
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine and Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
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Busch M, Klein C, Uhl A, Haltmayer H, Cabanis M, Westenberg JN, Vogel M, Krausz RM. Retention in the Austrian opioid agonist treatment system: a national prospective cohort study. Harm Reduct J 2021; 18:25. [PMID: 33627159 PMCID: PMC7903033 DOI: 10.1186/s12954-021-00473-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/11/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Retention in care is a prerequisite for successful recovery, especially for a chronic condition like opioid dependence. Though retention varies greatly depending on the different substitution medication and treatment model, treatment retention is used as an indicator of treatment quality and effectiveness of care on a system and individual level. To monitor the overall quality of the Austrian opioid agonist treatment (OAT) system and to monitor patient satisfaction within the system, a new online-based registry called "eSuchmittel" was introduced in Austria at the beginning of 2011. The objective of this study is to analyze retention rates within the Austrian treatment system and to identify patient characteristics associated with retention, using data collected by the substitution registry. METHODS The complete Austrian sample of 4778 registered patients starting treatment between 1.1.2011 to 31.12.2012 were included in the prospective cohort study using data from the Austrian substitution registry. For the statistical analysis, multivariate Cox Regression and Kaplan-Meier survival analysis were used to evaluate retention in treatment. RESULTS The retention rate of the total cohort after two years was around 61%. Retention rates were significantly lower for men (exp(B) = .806, 95% CI 0.714-0.908) and significantly higher for patients aged 30 and older (exp(B) = 1.155, 95% CI 1.044-1.279), among patients located in Vienna (exp(B) = 1.439, 95% CI 1.273-1.626) and among patients prescribed oral slow-release morphine (SROM) (exp(B) = 2.141, 95% CI 1.885-2.430). CONCLUSIONS Average retention in the Austrian system is high in comparison to international retention rates. Nationally, SROM demonstrates higher treatment retention when compared to other available substitution medications. Sociodemographic and regional indicators also contribute to higher retention in care. A systematic monitoring of retention rates within a national registry is an important tool helping to evaluate the quality of care. In this study, the Austrian OAT system proves very high retention in care, an important success criterion.
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Affiliation(s)
- Martin Busch
- Gesundheit Österreich GmbH (GÖG), Vienna, Austria
| | | | - Alfred Uhl
- Gesundheit Österreich GmbH (GÖG), Vienna, Austria
- Sigmund Freud University, Vienna, Austria
| | | | - Maurice Cabanis
- Zentrum Für Seelische Gesundheit, Klinikum Stuttgart, Stuttgart, Germany
| | - Jean Nicolas Westenberg
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, University of British Columbia, David Strangway Building, 5950 University Boulevard, Vancouver, BC V6T 1Z3 Canada
| | - Marc Vogel
- Psychiatrische Klinik Münsterlingen, Münsterlingen, Switzerland
| | - R. Michael Krausz
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
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