Depression and Outcomes of Methadone and Buprenorphine Treatment Among People with Opioid Use Disorders: A Literature Review

Impact of Depressive Symptom Severity on Buprenorphine/Naloxone and Methadone Outcomes in People With Prescription-Type Opioid Use Disorder: Results From a Pragmatic Randomized Controlled Trial

OBJECTIVE

To evaluate the impact of depressive symptom severity on opioid use and treatment retention in individuals with prescription-type opioid use disorder (POUD).

METHOD

We analyzed data from a multi-centric, pragmatic, open-label, randomized controlled trial comparing buprenorphine/naloxone to methadone models of care in 272 individuals with POUD. Opioid use was self-reported every two weeks for 24 weeks using the Timeline Followback. Depressive symptom severity was self-reported with the Beck Depression Inventory at baseline, week 12 and week 24.

RESULTS

Baseline depressive symptom severity was not associated with opioid use nor treatment retention. At week 12, moderate depressive symptoms were associated with greater opioid use while mild to severe depressive symptoms were associated with lowered treatment retention. At week 24, moderate depressive symptoms were associated with greater opioid use.

CONCLUSIONS

Ongoing depressive symptoms lead to poorer outcomes in POUD. Clinicians are encouraged to use integrative approaches to optimize treatment outcomes. This study was registered in ClinicalTrials.gov (NCT03033732) on January 27th, 2017, prior to participants enrollment.

Benzodiazepine use, quality of life and psychiatric symptom burden in oral and injectable opioid agonist treatment: a cross-sectional study

BACKGROUND

Use of benzodiazepines (BZD) in patients receiving opioid agonist treatment (OAT) is common and associated with a variety of negative health and social outcomes. This cross-sectional study investigates the impact of BZD use in OAT patients on their quality of life (QoL).

METHODS

A convenience sample of patients receiving oral OAT or heroin-assisted treatment in two outpatient centres in Basel, Switzerland was investigated. Participants (n = 141) completed self-report questionnaires on psychiatric symptoms and psychological distress (The Symptom Checklist 27, SCL-27), depressive state (German version of the Center for Epidemiological Studies Depression Scale), quality of life (Lancashire Quality of Life Profile, LQOLP) and use of BZD and other drugs (self-report questionnaire). Substance use was assessed by urine toxicology testing.

RESULTS

In bivariate analysis, total QoL scores were significantly lower for lifetime, current, and prolonged BZD users compared to participants without the respective use patterns. There was no significant relationship between BZD dose and QoL. In multivariable linear regression models controlling for psychiatric symptom load and depressive state, only lifetime use predicted lower QoL, whereas other BZD use patterns were not significantly associated.

CONCLUSIONS

The association of lower QoL and BZD use in OAT patients is strongly confounded by co-occurring depressive state and psychiatric symptoms. Careful diagnosis and treatment of co-occurring mental disorders in OAT is paramount to improve QoL in this patient population and may also help reduce BZD use.

Opioid agonist therapy switching among individuals with prescription-type opioid use disorder: Secondary analysis of a pragmatic randomized trial

BACKGROUND

Engagement and retention in opioid agonist therapy (OAT) remains a challenge. This study evaluated the impact of initial randomized OAT allocation on subsequent switching among people with prescription-type opioid use disorder (POUD).

METHODS

Secondary analysis of a 24-week Canadian multicenter, pragmatic, randomized trial conducted between 2017 and 2020 comparing flexible take-home buprenorphine/naloxone versus supervised methadone models of care for POUD. We used Cox Proportional Hazards modeling to assess for impact of treatment assignment on time to OAT switching, adjusting for important confounders. For clinical correlates, we analyzed data from baseline questionnaires on demographic, substance use, and health factors as well as urine drug screen.

RESULTS

Of 272 randomized participants, 210 initiated OAT within 14 days per trial protocol, of whom 103 participants were randomized to buprenorphine/naloxone and 107 to methadone. Within 24-week follow-up, 41 (20.5%) of all participants switched OAT with 25 (24.3%, median 27 days, 88.4 per 100 person-years) and 16 participants (15.0%, median 53.5 days, 46.1 per 100 person-years) switching from buprenorphine/naloxone and methadone arms, respectively. In adjusted analysis, allocation to buprenorphine/naloxone was associated with significantly higher risk of switching (aHR = 2.31, 95% CI 1.22 - 4.38).

CONCLUSIONS

OAT switching was common in this sample of individuals with POUD, with individuals randomly allocated to buprenorphine/naloxone being more than twice as likely to switch versus methadone. This may reflect a stepped care approach in OUD management. More research is needed to evaluate overall retention and outcomes with the different observed risks of switching between methadone and buprenorphine/naloxone.

Exploring potential moderators of depressive symptoms and treatment outcomes among patients with opioid use disorder

BACKGROUND

Depressive symptoms are common in patients seeking medication treatment for opioid use disorder (MOUD treatment) and decrease quality of life but have been inconsistently related to opioid treatment outcomes. Here, we explore whether depressive symptoms may only be related to adverse treatment outcomes among individuals reporting high opioid use-related coping motives (i.e., use of opioids to change affective states) and high trait impulsivity, two common treatment targets.

METHODS

Patients seeking MOUD treatment (N = 118) completed several questionnaires within two weeks of their treatment intake. Treatment outcomes (opioid-positive urine screens and days retained in treatment) were extracted from treatment records. Moderation analyses controlling for demographic characteristics and main effects were conducted to explore interaction effects between depressive symptoms and two distinct moderators.

RESULTS

Depressive symptoms were only related to opioid use during early treatment among patients reporting high opioid use-related coping motives (B = 2.67, p =.004) and patients reporting high trait impulsivity (B = 2.01, p =.039). Further, depressive symptoms were only inversely related to days retained among individuals with high opioid use-related coping motives (B = -10.12, p =.003).

CONCLUSIONS

Individuals presenting to treatment with opioid-related coping motives and/or impulsivity in the context of depressive symptoms may confer unique risk for adverse treatment outcomes. Clinicians may wish to consider these additive risk factors when developing their treatment plan.

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

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

Intra-individual variability and stability of affect and craving among individuals receiving medication treatment for opioid use disorder

Affect and craving are dynamic processes that are clinically relevant in opioid use disorder (OUD) treatment, and can be quantified in terms of intra-individual variability and stability. The purpose of the present analysis was to explore associations between opioid use and variability and stability of affect and craving among individuals receiving medication treatment for OUD (MOUD). Adults (N = 224) with OUD in outpatient methadone or buprenorphine treatment completed ecological momentary assessment (EMA) prompts assessing positive affect, negative affect, opioid craving, and opioid use. Dynamic structural equation modeling (DSEM) was used to quantify person-level indices of magnitude and stability of change. Beta regression was used to examine associations between intra-individual variability and stability and proportion of opioid-use days, when controlling for overall intensity of affect and craving. Results suggested that greater magnitude of craving variability was associated with opioid use on a greater proportion of days, particularly among individuals with lower average craving. Low average positive affect was also associated with higher proportion of days of use. Individuals who experience substantial craving variability in the context of lower average craving may be particularly vulnerable to opioid use during treatment. Ongoing assessment of craving may be useful in identifying treatment needs. Examining correlates of intra-individual variability and stability in MOUD treatment remains a relevant direction for future work.

Buprenorphine as a Treatment for Major Depression and Opioid Use Disorder

Rates of major depressive disorder (MDD) are disproportionally high in subjects with opioid use disorder (OUD) relative to the general population. MDD is often more severe in OUD patients, leading to compliance issues with maintenance therapies and poor outcomes. A growing body of literature suggests that endogenous opioid system dysregulation may play a role in the emergence of MDD. Buprenorphine, a mixed opioid receptor agonist/antagonist approved for the treatment of OUD and chronic pain, may have potential as a novel therapeutic for MDD, especially for patients with a dual diagnosis of MDD and OUD. This paper presents a comprehensive review of papers relevant to the assessment of buprenorphine as a treatment for MDD, OUD, and/or suicide compiled using electronic databases per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The principal goal of this literature review was to compile the clinical studies that have interrogated the antidepressant activity of buprenorphine in opioid naïve MDD patients and OUD patients with comorbid MDD. Evidence supporting buprenorphine's superiority over methadone for treating comorbid OUD and MDD was also considered. Finally, recent evidence for the ability of buprenorphine to alleviate suicidal ideation in both opioid-naïve patients and opioid-experienced patients was evaluated. Synthesizing all of this information, buprenorphine emerges as a potentially effective therapeutic for the dual purposes of treating MDD and OUD.

Analysis of genetic and clinical factors associated with buprenorphine response

BACKGROUND

Buprenorphine, approved for treating opioid use disorder (OUD), is not equally efficacious for all patients. Candidate gene studies have shown limited success in identifying genetic moderators of buprenorphine treatment response.

METHODS

We studied 1616 European-ancestry individuals enrolled in the Million Veteran Program, of whom 1609 had an ICD-9/10 code consistent with OUD, a 180-day buprenorphine treatment exposure, and genome-wide genotype data. We conducted a genome-wide association study (GWAS) of buprenorphine treatment response [defined as having no opioid-positive urine drug screens (UDS) following the first prescription]. We also examined correlates of buprenorphine treatment response in multivariable analyses.

RESULTS

Although no variants reached genome-wide significance, 6 loci were nominally significant (p < 1 × 10^-5), four of which were located near previously characterized genes: rs756770 (ADAMTSL2), rs11782370 (SLC25A37), rs7205113 (CRISPLD2), and rs13169373 (LINC01947). A higher maximum daily buprenorphine dosage (aOR = 0.98; 95 %CI: 0.97, 0.995), greater number of UDS (aOR = 0.97; 95 %CI: 0.96, 0.99), and history of hepatitis C (HCV) infection (aOR = 0.71; 95 %CI: 0.57, 0.88) were associated with a reduced odds of buprenorphine response. Older age (aOR: 1.01; 95 %CI: 1.000, 1.02) was associated with increased odds of buprenorphine response.

CONCLUSIONS

This study had limited statistical power to detect genetic variants associated with a complex human phenotype like buprenorphine treatment response. Meta-analysis of multiple data sets is needed to ensure adequate statistical power for a GWAS of buprenorphine treatment response. The most robust phenotypic predictor of buprenorphine treatment response was intravenous drug use, a proxy for which was HCV infection.

Maintaining treatment and prevention programs for opioid use disorders during the coronavirus disease 2019 pandemic

PURPOSE OF REVIEW

The current article reviews the impact of the biggest health crisis for many decades, coronavirus disease 2019 (COVID-19), on opioid treatment programs and the strategies adopted for maintaining opioid treatment programs during the pandemic.

RECENT FINDINGS

The difficulty of access to opioid treatment services and the mental health problems accompanying opioid use disorders are the two main challenges to maintaining accessible and effective opioid treatment. Many countries and institutions issued guidance and recommendations to address these challenges. General coping strategies, loosening of policies, telemedicine, and depot buprenorphine are four main strategies to cope with the challenges posed by the pandemic.

SUMMARY

There were considerable obstacles to maintaining opioid intervention programs during the COVID-19 pandemic. Strategies addressing the obstacles are identified. Research in this area needs to be strengthened.

Associations of retention on buprenorphine for opioid use disorder with patient characteristics and models of care in the primary care setting

INTRODUCTION

Buprenorphine, a medication for opioid use disorder (OUD), can be administered within primary care; however, little is known about characteristics associated with retention on buprenorphine in these settings. This study examines patient correlates of buprenorphine retention and whether an integrated, interdisciplinary treatment model (buprenorphine and behavioral health) is associated with higher odds of buprenorphine retention than a primarily medication-only treatment model.

METHODS

Electronic health record data from adult patients with an OUD, ≥1 buprenorphine order and ≥1 visit to either of two primary care clinics between 9/2/2014-6/27/2018 were extracted (N = 494 patients). Two research team members reviewed the medication start and stop dates for each buprenorphine order and classified as retained (≥6 months of orders) or not retained (<6 months of orders). Logistic regressions estimated the odds of retention on buprenorphine by 1) patient characteristics and 2) timing of patient's engagement in buprenorphine treatment (pre- or post-implementation of an integrated treatment model).

RESULTS

Of the study sample, 53% had ≥6 months of buprenorphine orders. Almost two times higher odds of retention were found among patients with ≥1 psychiatric comorbidity (versus none) and among those with buprenorphine orders in the post- versus pre-period.

CONCLUSIONS

An integrated, interdisciplinary model of OUD treatment was associated with ≥6 months of buprenorphine orders among our study population. Continued research is needed in real-world primary care settings to understand the impact of OUD treatment models on patient outcomes. A more nuanced examination of the associations between psychiatric diagnoses and buprenorphine treatment retention is warranted.

Multidisciplinary treatment of opioid use disorder in primary care using the collaborative care model

Background: Treatment of opioid use disorder (OUD) is highly effective, but access is limited and care is often fragmented. Treatment in primary care can improve access to treatment and address psychiatric and physical co-morbidities in a holistic, efficient, and non-stigmatizing way. The Collaborative Care Model (CCM) of behavioral health integration into primary care has been widely disseminated and shown to improve outcomes and lower costs when studied for depression, but its use in treating substance use disorders has not been well documented. Methods: We used a mixed-methods approach to examine the impact of implementing multidisciplinary treatment of OUD in our health system's five primary care clinics using the framework of the CCM, with care shared between the primary care clinician (PCP), behavioral health clinician, and medical assistant. The implementation included staff education, creation of electronic health record tools, and implementation support, and was evaluated using data from the electronic health record, the medical staff office, and a clinician survey. Results: Over the last 2 years of implementation, the number of waivered providers increased from 11 to 35, providers prescribing for 5 or more patients increased from 2 to 18, and patients initiated on buprenorphine increased from 4/month to 18/month. 180-day treatment retention was 53%, and 81% of patients had consistently negative urine drug testing. Psychiatric and medical comorbidities were common, 70 and 44%, respectively. Although PCPs who prescribed buprenorphine found working in this model enjoyable and effective, the majority of non-waivered PCPs remained reluctant to participate. Conclusions: In our experience, treatment of OUD in primary care utilizing the CCM effectively addresses OUD and commonly comorbid anxiety and depression, and leads to an expansion of treatment. Successful implementation of OUD treatment requires addressing negative attitudes and perceptions.

Impact of a videoconferencing educational programme for the management of concurrent disorders on nurses' competency development and clinical practice: protocol for a convergent mixed methods study

INTRODUCTION

Extension for Community Healthcare Outcomes (Project ECHO©) is an innovative model for continuing professional development that uses videoconferencing technology to support and train general practitioners remotely. The model has been replicated to a variety of settings and locations for capacity building in healthcare professionals caring for patients with chronic and complex health conditions. Limited research has been conducted so far on the impact of ECHO in the field of concurrent mental health and substance use disorders (ie, concurrent disorders (CDs)). Therefore, this mixed methods study aims to develop a comprehensive understanding of an ECHO programme impact for CD management on nurses' competency development and clinical practice.

METHODS AND ANALYSIS

The proposed mixed methods study, based on a convergent parallel design, will be conducted in the province of Quebec, Canada, to collect, analyse and interpret quantitative (QUAN) and qualitative (QUAL) data from a specific ECHO Program on CDs. In the QUAN component, an observational prospective cohort study will be conducted over a 12-month period. All nurses who participated in the programme between 2018 and 2020 and who consent to research will be recruited to collect data on the extent of their learning and practice outcomes at three time points. Alongside the surveys, nurses will be invited to participate in individual semistructured interviews. In-depth QUAL data will be subjected to a thematic analysis and will assist in exploring how and in which conditions nurses developed and mobilised their competencies in clinical practice. A comparison-of-results strategy will be used in the final integration component of the study.

ETHICS AND DISSEMINATION

This study protocol was approved by the Ethics Committee of the Université de Montréal Hospital Center (#19.295) and the Université de Montréal Ethics Committee (CERSES-20-017 R). We aim to disseminate the findings through international academic conferences, international peer-reviewed journals and professional media.

Understanding barriers to treatment among individuals not engaged in treatment who misuse opioids: A structural equation modeling approach

Background: Many individuals misusing opioids do not enter into treatment. The question of who enters into treatment for their opioid abuse and under what circumstances is complex and shaped by multiple factors. The objective of the current study is to explore the risk factors for wide-ranging and numerous barriers to treatment among social media users. Method: Opioid-related forums within a popular social media platform were used to recruit non-treatment engaged individuals (≥15 years) who had misused opioids in the past month (n = 144; 66% male; median age 28). Four treatment barrier factors were identified utilizing principle component analysis: (1) stigma, (2) awareness, (3) attitudinal, and (4) denial. A structural equation model (SEM) was then created to explore the risk factors for different types of barriers to OUD treatment. Results: The most common barriers among participants not engaged in treatment for their opioid misuse were the belief that one should be able to help themselves with their condition (66%), treatment was too expensive (63%), and worries about being labeled or judged (57%). Additionally, SEM results demonstrate stigma barriers, awareness, and attitudinal barriers were associated with mental health comorbidities, opioid abuse and dependence severity, and treatment history. Denial barriers, however, were only associated with treatment history, and structural/financial barriers were only associated with opioid abuse and dependence severity. Conclusions: Our research findings are relevant for underscoring the wide-ranging and numerous barriers to treatment faced by individuals misusing opioids that are especially concentrated among those who also struggle with comorbid mental illness.

Risk of PTSD Due to the COVID-19 Pandemic Among Patients in Opioid Substitution Treatment

Background: The impact of the COVID-19 pandemic on the mental health of patients suffering from addictive disorders is of major concern. This study aimed to explore the presence and potential increase in post-traumatic stress disorder (PTSD) symptoms, depression, and anxiety since the beginning of the pandemic for patients in opioid substitution therapy (OST). Methods: This cross-sectional survey study evaluated a clinical sample of patients in OST (N = 123). Symptoms of post-traumatic stress disorder (PTSD) due to the COVID-19 pandemic were assessed by an adapted version of the impact of event scale (IES-R), resulting in two subgroups of low and high risk for PTSD. The depression, anxiety, and stress scale (DASS-21) was applied to collect data on the respective symptoms, and changes since the onset of the pandemic were reported on separate scales. Sociodemographic and COVID-19 related factors, as well as data on craving, consumption patterns, concomitant use, and the drug market were further assessed. Results: A binary logistic regression analysis confirmed the impact of self-perceived higher burden by psychological and economic factors on the elevated risk for PTSD due to the pandemic. The high-risk PTSD group also showed higher levels of depression, anxiety and stress, as well as a more pronounced deterioration in these symptoms since the pandemic. While reported levels of craving did not differ between the two groups, the high-risk PTSD group indicated a significantly higher increase in craving since the crisis, when compared to the low-risk group. Discussion: Our findings demonstrate elevated levels of clinical symptoms among patients in OST, with more than a quarter of patients found at risk for PTSD due to the COVID-19 pandemic. Furthermore, about 30-50% of our patients reported concerning levels of depression, anxiety, or stress. Special attention should be drawn to these findings, and potential deterioration of the situation should be addressed by health care facilities. Particularly, psychological, and financial burden due to the crisis were identified as factors increasing the risk for PTSD. These factors can easily be evaluated during routine anamneses, and might be a valuable source of information, when special attention is needed.