Mandatory naltrexone treatment prevents relapse among opiate-dependent anesthesiologists returning to practice

A historical perspective on clonidine as an alpha-2A receptor agonist in the treatment of addictive behaviors: Focus on opioid dependence

Clonidine operates through agonism at the alpha-2A receptor, a specific subtype of the alpha-2-adrenergic receptor located predominantly in the prefrontal cortex. By inhibiting the release of norepinephrine, which is responsible for withdrawal symptoms, clonidine effectively addresses withdrawal-related conditions such as anxiety, hypertension, and tachycardia. The groundbreaking work by Gold et al. demonstrated clonidine's ability to counteract the effects of locus coeruleus stimulation, reshaping the understanding of opioid withdrawal within the field. In the 1980s, the efficacy of clonidine in facilitating the transition to long-acting injectable naltrexone was confirmed for individuals motivated to overcome opioid use disorders (OUDs), including physicians and executives. Despite challenges with compliance, naltrexone offers sustained blockade of opioid receptors, reducing the risk of overdose, intoxication, and relapse in motivated patients in recovery. The development of clonidine and naltrexone as treatment modalities for OUDs, and potentially other addictions, including behavioral ones, underscores the potential for translating neurobiological advancements from preclinical models (bench) to clinical practice (bedside), ushering in innovative approaches to addiction treatment.

Association between body mass index and treatment completion in extended-release naltrexone-treated patients with opioid dependence

Background

Excessive consumption of opioids is associated with impaired metabolic function including increased body mass index (BMI). Opioid antagonist naltrexone (NTX) is an effective treatment for opioid use disorder (OUD) that has the potential to mitigate such metabolic disturbances. Understanding the relationship between treatment adherence and BMI in NTX-treated OUD patients may provide valuable insights into optimizing clinical outcomes.

Methods

Patients with opioid dependence were offered up to three monthly injections of extended-release (XR) NTX. Treatment completers (n = 41) were defined as those who had received all three XR-NTX injections, and non-completers (n = 20) as those missing at least one injection. Logistic regression was performed to examine the association between pre-treatment BMI and treatment completion.

Results

BMI was positively associated with treatment completion. This association remained significant after adjusting for potentially confounding variables.

Conclusion

Our findings suggest that baseline BMI may serve as a potential predictor of XR-NTX treatment adherence in patients with OUD and could help healthcare providers and policy makers alike in developing strategies to improve retention and tailor interventions for specific patient subgroups.

Relapse Prevention and Prediction Strategies in Substance Use Disorder: A Scoping Review

BACKGROUND

Relapse prevention for those with substance use disorder (SUD) is an evolving practice. Initiatives focused on relapse prevention from other populations may provide the foundation for future considerations and recommendations for recovering anesthesia providers in the workplace. The purpose of this scoping review was to examine what is known about return-to-use prediction and prevention strategies in various populations struggling with SUDs to inform future considerations and implications for recovering anesthesia providers with a history of SUD.

METHODS

The Arksey and O'Malley framework was used to conduct a scoping review of the literature. A systematic search was conducted across three databases (PubMed, CINAHL, and PsycInfo) for relevant literature. Search terms used were "measures predicting relapse in substance use disorder" and "relapse prevention in substance use disorder AND anesthesia." Data from articles that met the eligibility criteria were extracted and summarized by the primary author.

RESULTS

The search identified 46 articles highlighting various relapse prediction and prevention strategies related to craving and stress, underlying biological factors, neuroimaging, and mindfulness. Relapse prediction and prevention strategies ranged from cell phone applications, monitoring biological markers, and functional neuroimaging of the brain.

CONCLUSIONS

Relapse is a concern for individuals with a history of SUD. For anesthesia providers, immediate access to powerful anesthesia medications requires return-to-use prediction and prevention strategies when anesthesia providers return to work after SUD treatment. Although some identified strategies are practical, more research is needed to predict and prevent return to use for recovering anesthesia providers.

Burnout und Abhängigkeit bei ärztlichem Personal zeitlos und während der COVID-19-Pandemie am Beispiel der Chirurgie und Anästhesie

Hintergrund

Die COVID-19(„coronavirus disease 2019“)-Pandemie wirkt sich auf die psychische Gesundheit und das berufliche Verhalten von Chirurgen und Chirurginnen und Anästhesisten und Anästhesistinnen aus und scheint einen Einfluss auf die Substanzabhängigkeit zu haben.

Fragestellung

Welche Gründe gibt es für das Auftreten einer Substanzabhängigkeit und einem Burnout bei Chirurgen und Chirurginnen und Anästhesisten und Anästhesistinnen zeitlos und während der COVID-19-Pandemie und welche Verbesserungsmaßnahmen könnten im klinischen Alltag helfen?

Material und Methoden

Es wurde eine Literaturrecherche in Form einer systematischen Übersicht („systematic review“) zu Studien und Übersichtsarbeiten durchgeführt, die für das Thema relevant sind.

Ergebnisse

Im Laufe der Jahre hat sich gezeigt, dass Chirurgen bzw. Chirurginnen und Anästhesisten bzw. Anästhesistinnen aufgrund ihres direkten Zugangs zu Medikamenten in der Klinik und der arbeitsbezogenen Stressbelastung zur Drogenabhängigkeit neigen. Insbesondere Chirurgen und Chirurginnen und Anästhesisten und Anästhesistinnen schienen eine erhöhte Neigung zur Suchterkrankungen und ein erhöhtes Burnout-Risiko in der Pandemie vorzuweisen.

Schlussfolgerungen

Präventive Maßnahmen zugunsten besserer Arbeitsbedingungen in der Chirurgie und Anästhesie und eine bessere Drogenkontrolle (nicht nur wegen der Ausgabe, sondern auch wegen der richtigen Drogentests) sowie mehr Therapie- und Wiedereingliederungsprogramme unter psychiatrischer Begleitung und in Zusammenarbeit mit einem multidisziplinären Team sind sinnvoll.

Substance use disorder in anaesthetists: A personal perspective

In this article, I present a firsthand account as an anaesthetist with substance use disorder who has been through rehabilitation and returned to clinical anaesthesia, followed by an overview of substance use disorder in anaesthesia. Substance use disorder is prevalent within the anaesthesia community and can result in tragic consequences, including death in many cases. The incidence is around one to two per 1000 anaesthetist years and this appears to be rising, perhaps mirroring the population-wide increase in substance use disorder as a result of the opioid epidemic. Recognising substance use disorder in a colleague and intervening to try and help them and protect patients can be immensely challenging. Carrying out a successful intervention requires careful planning and coordination in order to protect the affected individual, their colleagues and patients. Returning to clinical anaesthesia following a diagnosis of substance use disorder is also contentious, with the high abstinence rate (relative to the wider substance use disorder population) having to be balanced against the risk of death following relapse. Any return to practice must be well planned and supported, and include appropriate toxicology screening. With such measures, rehabilitation and a return to clinical anaesthesia is possible in certain cases. For the affected individual regaining, then maintaining, their professional identity can be a powerful motivator to remain abstinent. Drug diversion and substance use disorder in anaesthesia is unlikely ever to be fully preventable, but strategies such as biometric dispensing, analysis of unused drugs, random toxicology and ongoing education may help to keep it to a minimum.

Success Rates of Monitoring for Healthcare Professionals with a Substance Use Disorder: A Meta-Analysis

In the past decades, monitoring programs have been developed for healthcare professionals with substance use disorders. We aimed to explore estimates of abstinence and work retention rates after participation in such monitoring programs. A literature search was performed using PubMed, Embase, PsycINFO, and CINAHL. Twenty-nine observational studies reporting on success rates (abstinence and work retention) of monitoring for healthcare professionals with a substance use disorder were included in the meta-analysis. Quality-effects models calculated pooled success rates and corresponding 95%-Confidence Intervals (CI), with subgroup analyses on monitoring elements and patient characteristics. Pooled success rates were 72% for abstinence (95%-CI = 63–80%) and 77% for work retention (95%-CI = 61–90%). Heterogeneity across studies was partly explained by the starting moment of monitoring, showing higher abstinence rates for studies that started monitoring after treatment completion (79%; 95%-CI = 72–85%) compared to studies that started monitoring with treatment initiation (61%; 95%-CI = 50–72%). About three-quarters of healthcare professionals with substance use disorders participating in monitoring programs are abstinent during follow-up and working at the end of the follow-up period. Due to selection and publication bias, no firm conclusions can be drawn about the effectiveness of monitoring for healthcare professionals with SUD.

The Association of State Opioid Misuse Prevention Policies With Patient- and Provider-Related Outcomes: A Scoping Review

Policy Points This scoping review reveals a growing literature on the effects of certain state opioid misuse prevention policies, but persistent gaps in evidence on other prevalent state policies remain. Policymakers interested in reducing the volume and dosage of opioids prescribed and dispensed can consider adopting robust prescription drug monitoring programs with mandatory access provisions and drug supply management policies, such as prior authorization policies for high-risk prescription opioids. Further research should concentrate on potential unintended consequences of opioid misuse prevention policies, differential policy effects across populations, interventions that have not received sufficient evaluation (eg, Good Samaritan laws, naloxone access laws), and patient-related outcomes.

CONTEXT

In the midst of an opioid crisis in the United States, an influx of state opioid misuse prevention policies has provided new opportunities to generate evidence of policy effectiveness that can inform policy decisions. We conducted a scoping review to synthesize the available evidence on the effectiveness of US state interventions to improve patient and provider outcomes related to opioid misuse and addiction.

METHODS

We searched six online databases to identify evaluations of state opioid policies. Eligible studies examined legislative and administrative policy interventions that evaluated (a) prescribing and dispensing, (b) patient behavior, or (c) patient health.

FINDINGS

Seventy-one articles met our inclusion criteria, including 41 studies published between 2016 and 2018. These articles evaluated nine types of state policies targeting opioid misuse. While prescription drug monitoring programs (PDMPs) have received considerable attention in the literature, far fewer studies addressed other types of state policy. Overall, evidence quality is very low for the majority of policies due to a small number of evaluations. Of interventions that have been the subject of considerable research, promising means of reducing the volume and dosages of opioids prescribed and dispensed include drug supply management policies and robust PDMPs. Due to low study number and quality, evidence is insufficient to draw conclusions regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws.

CONCLUSIONS

Recent research has improved the evidence base on several state interventions targeting opioid misuse. Specifically, moderate evidence suggests that drug supply management policies and robust PDMPs reduce opioid prescribing. Despite the increase in rigorous evaluations, evidence remains limited for the majority of policies, particularly those targeting patient health-related outcomes.

Improving naltrexone compliance and outcomes with putative pro- dopamine regulator KB220, compared to treatment as usual

A recent analysis from Stanford University suggested that without any changes in currently available treatment, prevention, and public health approaches, we should expect to have 510,000 deaths from prescription opioids and street heroin from 2016 to 2025 in the US. In a recent review, Mayo Clinic Proceedings (October 2019), Gold and colleagues at Mayo Clinic reviewed the available medications used in opioid use disorders and concluded that in private and community practice adherence is more important as a limiting factor to retention, relapse, and repeat overdose. It is agreed that the primary utilization of known opioid agonists like methadone, buprenorphine and naloxone combinations, while useful as a way of reducing societal harm, is limited by 50% of more discontinuing treatment within 6 months, their diversion, and addiction liability. Opioid agonists may have other unintended consequences, like continuing the down regulation of dopamine systems. While naltrexone would be expected to have opposite effects, adherence is also low even after detoxification and long acting naltrexone injections. Recent studies have shown Naltrexone is beneficial by attenuation of craving via “psychological extinction” and reducing relapse. Buprenorphine is the MAT of choice currently but injectable Naltrexone plus an agent to improve dopaminergic function and tone may renew interest amongst addiction physicians and patients. Understanding this dilemma there is increasing movement to opt for the non-addicting narcotic antagonist Naltrexone. Even with extended injectable option there is still poor compliance. As such, we describe an open label investigation in humans showing improvement of naltrexone compliance and outcomes with dopamine augmentation with the pro- dopamine regulator KB220 (262 days) compared to naltrexone alone (37days). This well studied complex consists of amino-acid neurotransmitter precursors and enkephalinase inhibitor therapy compared to treatment as usual. Consideration of this novel paradigm shift may assist in not only addressing the current opioid epidemic but the broader question of reward deficiency in general.

Potential uses of naltrexone in emergency department patients with opioid use disorder

Introduction: Despite widespread recognition of the opioid crisis, opioid overdose remains a common reason for Emergency Department (ED) utilization. Treatment for these patients after stabilization often involves the provision of information for outpatient treatment options. Ideally, an ED visit for overdose would present an opportunity to start treatment for opioid use disorder (OUD) immediately. Although widely recognized as effective, opioid agonist therapy with methadone and buprenorphine commonly referred to as "medication-assisted therapy" but more correctly as "medication for addiction treatment" (MAT), can be difficult to access even for motivated individuals due to shortages of prescribers and treatment programs. Moreover, opioid agonist therapy may not be appropriate for all patients, as many patients who present after overdose are not opioid dependent. More treatment options are required to successfully match patients with diverse needs to an optimal treatment plan in order to avoid relapse. Naltrexone, a long-acting opioid antagonist, available orally and as a monthly extended-release intramuscular injection, may represent another treatment option. Methods: We conducted a literature search of MEDLINE and PubMed. We aimed to capture references related to naltrexone and is use as MAT for OUD, as well as manuscripts that discussed naltrexone in comparison toother agents used for MAT, opioid detoxification, and naltrexone metabolism. Our initial search logic returned a total of 618 articles. Following individual evaluation for relevance, we selected 65 for in-depthreview. Manuscripts meeting criteria were examined for citations meriting further review, leading to the addition of 30 manuscripts Conclusions: Here, we review the pharmacology of naltrexone as it relates to OUD, its history of use, and highlight recent studies and new approaches for use of the drug as MAT including its potential initiation after ED visit for opioid overdose.

Naltrexone: A History and Future Directions

Trying to kick drug addiction without medicines is said to be like relying on willpower to overcome diabetes or asthma. Enter naltrexone, which has been around since 1984 and reduces the cravings for drugs and alcohol by fine-tuning the brain's chemical reward system. Why has it recently increased in popularity? How does it compare to similar strategies? Has it made a difference? Our authors, who have long studied addiction and the brain, confront a drug and alcohol addiction problem that today kills more Americans each day than gun violence or car accidents.

Open-label Study of Injectable Extended-release Naltrexone (XR-NTX) in Healthcare Professionals With Opioid Dependence

OBJECTIVES

Healthcare professionals (HCPs) with opioid dependence are at risk for relapse and death, particularly in the first year of recovery; however, maintenance treatment with opioid agonists is controversial in this safety-sensitive group. We evaluated long-term safety, tolerability, and treatment outcomes of injectable, intramuscular, extended-release naltrexone (XR-NTX) in opioid-dependent HCPs.

METHODS

This single-arm, multisite, open-label study was conducted in opioid-dependent HCPs who had been detoxified from opioids for at least 2 weeks. Subjects received monthly XR-NTX injections for up to 24 months, combined with counseling via intensive outpatient substance abuse treatment programs. Assessments included monthly urine opioid drug tests and routine safety assessments, along with a trimonthly short form (36) Health Survey, opioid craving questionnaire, and Treatment Satisfaction Questionnaire for Medication.

RESULTS

Of 49 opioid-dependent HCPs screened, 38 enrolled and received at least 1 XR-NTX injection. Most were female (n = 31) and nurses or nursing assistants (n = 30). More than half (n = 21; 55.3%) received at least 12 injections. Seven discontinued due to adverse events (3 anxiety, 2 headache, 1 injection-site mass, 1 derealization). None experienced relapses to opioid dependence necessitating detoxification, overdose, or death during treatment. At 24 months, mean opioid craving fell by 45.2%, and short form (36) mental component scores improved by 31.1% from baseline and approached normal levels. Of 22 unemployed subjects at baseline, 45.5% improved employment status at 24 months.

CONCLUSIONS

Long-term (2 years) XR-NTX was associated with no new safety concerns, and, compared with shorter-term studies in the general population, similar or better rates of retention, opioid-negative urines, opioid craving reduction, mental health functional quality of life improvement, and re-employment.

Outcomes for Physicians With Opioid Dependence Treated Without Agonist Pharmacotherapy in Physician Health Programs

AIMS

To compare treatment outcome among substance dependent physicians enrolled in a physician health program (PHP) who have a history of alcohol use only, any opioid use, or non-opioid drug use, in order to determine whether the distinctive PHP system of care management is as effective for individuals with opioid use disorders as for those with alcohol or other drug use disorders.

METHODS

A 5-year, retrospective chart review, intent-to-treat analysis was conducted for all physicians admitted to 16 physician health programs (N=702; 85.5% male; age range=24-75). Analyses compared treatment outcomes for participants based upon their substance(s) of abuse [i.e., 1) "Alcohol Only" (n=204), 2) "Any Opioid" with or without alcohol use (n=339), and 3) "Non-Opioid" drug use with or without alcohol use (n=159)].

RESULTS

In this sample, 75-80% of physicians across the three groups never tested positive for alcohol or drugs during their extended care management period with random drug testing. This included physicians with opioid dependence who did not receive opioid substitution therapy (OST). Of the 22.1% of physicians who had a positive test, two thirds (i.e., 14.5% of the total sample) had just one positive test, and only one third (i.e., 7.6% of the total sample) had more than one positive test. These results were similar in all three groups.

CONCLUSIONS

These results indicate that individuals with opioid use disorders who are managed by PHPs can achieve long-term abstinence from opioids, alcohol, and other drugs without OST through participation in abstinence-based psychosocial treatment with extended, intensive care management following discharge.

A systematic review and meta-analysis of naltrexone implants for the treatment of opioid dependence

INTRODUCTION AND AIMS

Naltrexone implants are used to treat opioid dependence, but their safety and efficacy remain poorly understood. We systematically reviewed the literature to assess the safety and efficacy of naltrexone implants for treating opioid dependence.

DESIGN AND METHODS

Studies were eligible if they compared naltrexone implants with another intervention or placebo. Examined outcomes were induction to treatment, retention in treatment, opioid and non-opioid use, adverse events, non-fatal overdose and mortality. Quality of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. Data from randomised studies were combined using meta-analysis. Data from non-randomised studies were presented narratively.

RESULTS

Five randomised trials (n = 576) and four non-randomised studies (n = 8358) were eligible for review. The quality of the evidence ranged from moderate to very low. Naltrexone implants were superior to placebo implants [risk ratio (RR): 0.57; 95% confidence interval (CI) 0.48, 0.68; k = 2] and oral naltrexone (RR: 0.57; 95% CI 0.47, 0.70; k = 2) in suppressing opioid use. No difference in opioid use was observed between naltrexone implants and methadone maintenance (standardised mean difference: -0.33; 95% CI -0.93, 0.26; k = 1); however, this finding was based on low-quality evidence from one study.

DISCUSSION

The evidence on safety and efficacy of naltrexone implants is limited in quantity and quality, and the evidence has little clinical utility in settings where effective treatments for opioid dependence are used.

CONCLUSION

Better designed research is needed to establish the safety and efficacy of naltrexone implants. Until such time, their use should be limited to clinical trials. [Larney S, Gowing L, Mattick RP, Farrell M, Hall W, Degenhardt L. A systematic review and meta-analysis of naltrexone implants for the treatment of opioid dependence.

Maintenance medication for opiate addiction: the foundation of recovery

Illicit use of opiates is the fastest growing substance use problem in the United States, and the main reason for seeking addiction treatment services for illicit drug use throughout the world. It is associated with significant morbidity and mortality related to human immunodeficiency virus, hepatitis C, and overdose. Treatment for opiate addiction requires long-term management. Behavioral interventions alone have extremely poor outcomes, with more than 80% of patients returning to drug use. Similarly poor results are seen with medication-assisted detoxification. This article provides a topical review of the three medications approved by the Food and Drug Administration for long-term treatment of opiate dependence: the opioid-agonist methadone, the partial opioid-agonist buprenorphine, and the opioid-antagonist naltrexone. Basic mechanisms of action and treatment outcomes are described for each medication. Results indicate that maintenance medication provides the best opportunity for patients to achieve recovery from opiate addiction. Extensive literature and systematic reviews show that maintenance treatment with either methadone or buprenorphine is associated with retention in treatment, reduction in illicit opiate use, decreased craving, and improved social function. Oral naltrexone is ineffective in treating opiate addiction, but recent studies using extended-release naltrexone injections have shown promise. Although no direct comparisons between extended-release naltrexone injections and either methadone or buprenorphine exist, indirect comparison of retention shows inferior outcome compared with methadone and buprenorphine. Further work is needed to directly compare each medication and determine individual factors that can assist in medication selection. Until such time, selection of medication should be based on informed choice following a discussion of outcomes, risks, and benefits of each medication.