The global epidemiology and burden of opioid dependence: results from the global burden of disease 2010 study

Burden of Substance Use Disorders in the Middle East and North Africa from 1990 to 2019

Background

Studies on the burden and epidemiological aspects of substance-use disorders in the Middle East and North Africa (MENA) are limited.

Aims

To evaluate the burden and epidemiology of substance-use disorders in MENA countries during 1990-2019.

Study Design

Ecological study.

Methods

Data from the global burden of disease study were used in the current study. The incidence, prevalence, mortality, years of life lost from mortality, years of healthy life lost due to disability, and disability-adjusted life years (DALY) rates attributable to each group of disorders across age groups, genders, years, and countries were retrieved along with their corresponding age-standardized values. Age-standardized DALYs rates of alcohol-use disorders, drug-use disorders, and substanceuse disorders associated with sociodemographic index across MENA countries and over 30 years were examined.

Results

The age-standardized DALY rate of substance-use disorders in MENA had risen from 190.1 in 1990 to 234.93 per 100,000 in 2019, indicating a 23.57% increase. In both genders, the DALY rate was highest in the 25-29-years age group in 2019 (440.81 per 100,000 in females and 645.97 per 100,000 in males). In addition, in 2019, age-standardized DALY rates of alcohol-use disorder were the highest in the United Arab Emirates (77.08 per 100,000), Afghanistan (67.77 per 100,000), and Bahrain (60.35 per 100,000). In almost all these countries, opioid-use disorder had the highest age-standardized DALY rate in 2019.

Conclusion

The burden of substance-use disorders has increased from 1990 to 2019 in the MENA region in contrast to the global trend. This study findings highlight that the current interventions and laws implemented in this region to address drug trafficking and substance-use disorders may be insufficient and ineffective, warranting further international collaboration and implementation of more effective strategies to reduce the overall burden of substance-use disorders.

Investigating outcomes in a substance use treatment provider: a cross-sectional comparison of long-acting injectable buprenorphine and oral medication for opioid use disorder

OBJECTIVES

Advances in the treatment of opioid use disorder (OUD) have seen the development of long-acting injectable opioid substitutes which could improve outcomes for people with OUD. However, comparative quantitative analysis of individual outcomes is lacking. The present study sought to investigate factors associated with prescribing long-acting injectable buprenorphine (LAIB), and changes in outcome variables compared with oral medication for OUD.

DESIGN

Cross-sectional retrospective analysis of electronic health records.

SETTING

Community substance use treatment service Via. Six sites shared their data between 15 August 2022 and 15 August 2023.

PARTICIPANTS

Anonymised data were extracted for 235 people receiving LAIB and 266 people receiving oral medication for OUD.

PRIMARY AND SECONDARY OUTCOMES

Prescribing data, sociodemographic information (age, sex, indices of multiple deprivation decile of individual's residence, primary and secondary substance, number of previous treatment episodes, employment and ethnicity) and treatment outcome profiles (substance use, physical and mental health, quality of life, employment) were extracted and analysed. To examine predictors of receiving LAIB (vs medication for OUD), we conducted logistic regression including the demographic predictors. Psychological health, physical health and quality of life scores were analysed using Welch's t-tests.

RESULTS

LAIB was associated with positive changes in quality of life between the first and last assessments. Demographic and situational factors were predictors of LAIB initiation, indicating the potential for increasing health inequalities in substance use treatment.

CONCLUSIONS

LAIB is associated with changes in quality of life over a 1-year period. Further research is needed to investigate the aetiology of improved well-being and outcomes over time.

Left ventromedial prefrontal cortex inhibitory rTMS as an anti-stress intervention in opioid use disorder: Trial design

Background

In people with substance use disorders (SUDs), stress-exposure can impair executive function, and increase craving and likelihood of drug-use recurrence. Research shows that acute stressors increase drug-seeking behavior; however, mechanisms underlying this effect are incompletely understood. The Competing Neurobehavioral Decisions System theory posits that persons with SUDs may have hyperactive limbic reward circuitry and hypoactive executive control circuitry.

Objective

To investigate how inhibitory repetitive transcranial magnetic stimulation (rTMS) targeting the left ventromedial prefrontal cortex (vmPFC) may alter stress-induced executive dysfunction, emotion dysregulation, and drug-seeking in people with opioid use disorder.

Methods

We will examine effects of a psychological stressor combined with inhibitory (1Hz) left vmPFC rTMS in participants (N = 24) receiving opioid agonist treatment. Participants undergo guided imagery of autobiographical stressors paired with 10 sessions of active vmPFC rTMS vs. sham (within-subject randomized crossover). Stress-induced dysfunction will be indexed with cognitive (e.g., executive function), affective (e.g., emotional arousal), and behavioral (e.g., opioid-seeking) measures pre- and post-rTMS. To confirm changes are associated with altered neural activity in targeted regions, we will measure event-related potentials during key tasks using EEG. We hypothesize that stressors will increase executive dysfunction, emotion dysregulation, and drug-seeking, and that left vmPFC inhibitory rTMS will decrease limbic activation, which could translate to reduced craving and drug-seeking.

Conclusion

Our findings should offer insights into how neural networks modulate drug-seeking and associated dysfunctions in people with SUDs. The results of this and similar studies can advance theory and neuromodulation interventions for people with SUDs.

Validity, reliability and clinical utility of ASSIST-Y in assessing risk of substance-related harm and dependence in Spanish male adolescents

BACKGROUND

Substance use among adolescents is strongly associated with adverse physical, mental health, and social outcomes. Prevention and early intervention can reduce the likelihood of future problems, but requires valid and reliable screening tools capable of assessing risk across a range of substances. This study assessed the validity, reliability, and clinical utility of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST-Y) for adolescents aged 15-17 years.

METHODS

A sample of adolescent males (N = 101), aged 15-17 years, held in a juvenile detention facility on substance-related offences in Barcelona, Spain were eligible. Participants were administered a battery of standardized substance-use screening tools by a clinical psychologist, and underwent a diagnostic interview assessing DSM-IV-TR substance abuse and dependence by an addiction medicine specialist. Scores on the various assessments were compared to establish validity (concurrent with interview, convergent with other measures), reliability, and clinical utility of ASSIST-Y.

RESULTS

Majority of participants (n = 77) completed assessments. While tobacco was not assessed as part of the interview, concurrent validity in detecting substance abuse was established for all remaining substances. Concurrent validity for detecting dependence was established for alcohol, cannabis, cocaine, stimulants and sedatives. Fewer numbers in higher-risk groups for inhalants, opioids and hallucinogen use limited confirmation of validity for those substances. ASSIST-Y also demonstrated good convergent validity with the other screening tools for all substances, except hallucinogens. Reliability for each subscale was established, except for tobacco (too few items), sedatives, and hallucinogens. Finally, clinical utility indices were significant for most substances (except sedatives and opioids); whilst clinical utility indices were significant for ruling out cases of non-dependence (all substances).

CONCLUSIONS

As a screening tool, the purpose of ASSIST-Y is designed to help identify adolescents who may be at-risk of substance-related harm. While the instrument was found to be valid and reliable in identifying risky use across a variety of substances, further research is needed to validate the instrument in other population groups, and for other substances. Future research should investigate the effect of the linked brief intervention to reduce risk of harm, especially for non-specialist clinicians.

Direct analysis in real time mass spectrometry (DART-MS/MS) for rapid urine opioid detection in a clinical setting

BACKGROUND AND AIMS

Current laboratory methods for opioid detection involve an initial screening with immunoassays which offers efficient but non-specific results and a subsequent liquid chromatography-tandem mass spectrometry (LC-MS/MS) confirmation which offers accurate results but requires extensive sample preparation and turnaround time. Direct Analysis in Real Time (DART) tandem mass spectrometry is evaluated as an alternative approach for accurate opioid detection with efficient sample preparation and turnaround time.

MATERIALS AND METHODS

DART-MS/MS was optimized by testing the method with varying temperatures, operation modes, extraction methods, hydrolysis times, and vortex times. The method was evaluated for 12 opioids by testing the analytical measurement range, percent carryover, precision studies, stability, and method-to-method comparison with LC-MS/MS.

RESULTS

DART-MS/MS shows high sensitivity and specificity for the detection of 6-acetylmorphine, codeine, hydromorphone, oxymorphone, hydrocodone, naloxone, buprenorphine, norfentanyl, and fentanyl in urine samples. However, its performance was suboptimal for norbuprenorphine, morphine and oxycodone.

CONCLUSION

In this proof-of-concept study, DART-MS/MS is evaluated for its rapid quantitative definitive testing of opioids drugs in urine. Further research is needed to expand its application to other areas of drug testing.

Intrinsic anti-inflammatory nanomedicines for enhanced pain management

Introduction

Effective postoperative pain management remains a significant challenge due to the severe side effects of opioids and the limitations of existing analgesic delivery systems. Inflammation plays a critical role in pain exacerbation, highlighting the need for therapies that combine analgesic effects with intrinsic anti-inflammatory properties.

Methods

Herein, we develop an intrinsic anti-inflammatory nanomedicine designed to enhance pain management by integrating controlled anesthetic release with inherent anti-inflammatory activity. Our nanoplatform utilizes dendritic mesoporous silica nanoparticles (MSNs) loaded with levobupivacaine and coated with Rg3-based liposomes derived from ginsenoside Rg3, termed LMSN-bupi.

Results

The MSNs enable sustained and controlled release of the local anesthetic, while the Rg3-liposome coating provides intrinsic anti-inflammatory effects by inhibiting macrophage activation. In animal models, LMSN-bupi demonstrates significantly prolonged analgesic effects and attenuated inflammatory responses compared to traditional liposome-decorated nanoparticles (TMSN-bupi) (n = 5).

Discussion

These findings underscore the potential of intrinsic anti-inflammatory nanomedicines in enhancing pain management, offering a promising strategy to overcome the limitations of current therapies and improve patient outcomes in postoperative care.

Strategies for improving treatment retention for buprenorphine/naloxone for opioid use disorder: a qualitative study of issues and recommendations from prescribers

BACKGROUND

Opioid use disorder (OUD) remains a significant public health issue as the number of opioid-related overdose deaths continues to reach new highs each year. Buprenorphine/Naloxone is a medication that has been shown to be highly effective for the treatment of OUD. However, the clinical management of patients on this medication is challenging as many patients discontinue treatment prematurely. We conducted a qualitative study focusing on experienced prescribers of buprenorphine to learn about what they believe are key challenges in prescribing this medication to patients with OUD and related strategies for improving treatment outcomes.

METHODS

We conducted two rounds of interviews with 12 prescribers who were either trained as a primary care physician, nurse practitioner, or physician assistant. These prescribers were recruited from an academically-based treatment program, a community health center, and a commercial substance use disorder treatment facility. Interview data were coded and analyzed in accordance with a grounded theory approach.

RESULTS

Key findings and related recommendations emerged for patient monitoring, integration of behavioral health with prescribing, patient volume requirements, and use of telehealth.

CONCLUSION

The interviews generated a number of recommendations for improving patient outcomes from buprenorphine treatment. Some of these recommendations can be implemented quite readily whereas others entail more substantial resources and time commitments.

Nationally Representative Rates of Incident Prescription Opioid Use Among United States Adults and Selected Subpopulations: Longitudinal Cohort Study From the National Health Interview Survey, 2019 to 2020

Nationally representative rates of incident prescription opioid use in the United States adult population and selected subpopulations are unknown. Using the National Health Interview Survey (2019-2020) longitudinal cohort, a cohort with 1-year follow-up created using random cluster probability sampling of noninstitutionalized civilian U.S. adults, we estimated rates and predictors of incident opioid use. Of 21,161 baseline (2019) participants randomly chosen for follow-up, the final analytic sample included 10,415 who also participated in 2020. Exposure variables were selected per the socio-behavioral model of health care utilization: predisposing characteristics (sex, age, race, etc), enabling characteristics (socioeconomic status, insurance status), health status (pain, disability, comorbidities, etc), and health care use (office visits, emergency room visits, and hospitalizations). Among adults who did not use prescription opioids in 2019, a 1-year cumulative incidence of 4.1% (95% confidence interval [CI]: 3.5-4.6) was seen in 2020, with an incidence rate (IR) of 32.6 cases of new prescription opioid use per 1,000 person-years (PYs). Cumulative incidence, IR, and adjusted relative risk (RR) varied by participant characteristics. We observed the highest IR in those with ineffective pain treatment (81.6 cases per 1,000 PY) and those who visited the emergency room ≥3 times (93.8 cases per 1,000 PY). Participants reporting ≥4 painful conditions had an adjusted RR of 2.9 (95% CI: 2.0-4.1), while the RR for those with sleep problems was 2.3 (95% CI: 1.7-3.1). Overall, this study presents nationally representative rates of incident prescription opioid use and suggests that some participants are using prescription opioids as an early-resort analgesic contrary to best-practice guidelines. PERSPECTIVE: This longitudinal cohort study presents nationally representative rates of incident prescription opioid use in U.S. adults and selected subpopulations. Our data suggest that some participants are using prescription opioids as a first-line or early-resort analgesic, contrary to best-practice guidelines.

Caregivers' Attitudes Toward Treatment Length for Persons in Swedish Opioid Agonist Treatment. A Qualitative Interview Study

Although opioid agonist treatment (OAT) has several beneficial effects, the issue of optimal treatment length remains unresolved. It is plausible that caregivers' attitudes toward treatment length are of importance to whether, how and when tapering off will take place. In this study, we investigated caregivers' attitudes toward treatment length by interviewing 15 caregivers from a variety of professions working in seven OAT treatment programs in Sweden. Data were analyzed using applied thematic analysis. The participants were generally hesitant concerning the idea of tapering off. Few of them had experiences of patients tapering off successfully. Many of them never brought up the subject unless the patient did so her-/himself. Only younger, socially stable patients were perceived to be suitable for tapering off. Participants also expressed a need among staff for education and ethical discussions on treatment length. A person-centered focus may be promoted by recurrently discussing treatment goals and by co-operating with patients to map the recovery capital of those interested in tapering. To further support caregivers in developing person-centered care, more knowledge of opioid use disorder and professional and interprofessional discussions of caregivers' own attitudes and beliefs are paramount.

The impact of tightened prescribing restrictions for PBS-subsidised opioid medicines and the introduction of half-pack sizes, Australia, 2020-21: an interrupted time series analysis

OBJECTIVES

To evaluate the impact of the tightened Pharmaceutical Benefits Scheme (PBS) prescribing rules for immediate release (IR) and controlled release (CR) opioid medicines (1 June 2020), which also eliminated repeat dispensing without authorisation for codeine/paracetamol and tramadol IR and introduced half-pack size item codes for IR formulations.

DESIGN, SETTING

Population-based interrupted time series analysis of PBS dispensing data claims for a 10% sample of PBS-eligible residents and IQVIA national opioid medicine sales data (PBS-subsidised and private prescriptions), 28 May 2018 - 6 June 2021.

MAIN OUTCOME MEASURES

Mean amount of PBS-subsidised opioid medicines dispensed per day and mean overall amount sold per day - each expressed as oral morphine equivalent milligrams (OME) - overall, by formulation type (IR, CR), and by specific formulation.

RESULTS

During the twelve months following the PBS changes, daily PBS-subsidised opioid medicine dispensing was 81 565 OME lower (95% CI, -106 146 to -56 984 OME) than the mean daily level for 2018-20, a decline of 3.8% after adjusting for the pre-intervention trend; the relative reduction was greater for IR (8.4%) than CR formulations (2.6%). Total daily sales of all, IR formulation, and CR formulation opioid medicines did not change significantly after the PBS changes. Repeat dispensing of prescriptions comprised 7.4% of PBS-subsidised opioid dispensing before 1 June 2020, and 1.3% after the changes. Half-pack sizes comprised 8.4% of PBS-subsidised IR opioid medicine dispensing and 2.8% of all opioid medicines sold in the twelve months after the PBS changes.

CONCLUSIONS

The introduction of new PBS rules for subsidised opioid medicines was followed by a decline in PBS-subsidised dispensing. Some people may have bypassed the new restrictions by switching to private prescriptions, but our findings suggest that opioid medicine use in Australia declined as a result of the new restrictions.

Cytokines in hepatitis C-infected patients with or without opioid maintenance therapy

OBJECTIVE

Both chronic hepatitis C virus (HCV) infection and opioids cause altered blood levels of cytokines. Previous studies have investigated levels of selected groups of cytokines in patients on opioid maintenance treatment. Little is known about the levels of multiple cytokines in patients with chronic HCV infection on opioid maintenance treatment. Our aim was to investigate the cytokine profile in patients with active HCV infection with and without opioid maintenance treatment.

METHODS

We conducted a cross-sectional study in an out-patients population included upon referral for antiviral hepatitis C infection treatment. The level of 27 cytokines was measured in serum using multiplex technology. Patients were interviewed using a modified version of the European addiction severity index. Data pertaining to weight, height, current medication, smoking habits, allergies, previous medical history and ongoing withdrawal symptoms were collected. Non-parametric testing was used to investigate differences in levels of cytokines between the two groups. A 3-model hierarchical regression analysis was used to analyse associations between cytokines and confounding variables.

RESULTS

Out of 120 included patients, 53 were on opioid maintenance treatment. Median duration of opioid treatment was 68.4 months. There were no demographical differences between the two groups other than age. IL-1β was lower and eotaxin-1 higher in the group on opioid maintenance treatment than in the non-opioid group. No other inter-group differences in the remaining cytokine levels were found.

CONCLUSION

In HCV infection patients, the impact of chronic opioid administration on peripheral circulating cytokine level is minimal.

Opioid use following cardio-thoracic intensive care: risk factors and outcomes: a cohort study

Opioid misuse has become a serious public health problem. Patients admitted to cardio-thoracic critical care are usually exposed to opioids, but the incidence and effects of chronic opioid use are not known. The primary objective was to describe opioid use after admission to a cardio-thoracic intensive care unit. Secondary objectives were to identify factors associated with chronic opioid usage and analyze risk of death. This cohort study included all cardio-thoracic ICU care episodes in Sweden between 2010 and 2018. Among the 34,200 patients included in the final study cohort, 4050 developed persistent opioid use after ICU care. Younger age, preadmission opioid use, female sex, presence of comorbidities and earlier year of ICU admission were all found to be associated with persistent opioid use. The adjusted hazard ratio for mortality between 6 and 18 months after admission among individuals with persistent opioid use was 2.2 (95% CI 1.8-2.6; P < 0.001). For opioid-naïve patients before ICU admission, new onset of chronic opioid usage was significant during the follow-up period of 24 months. Despite the absence of conclusive evidence supporting extended opioid treatment, the average opioid consumption remains notably elevated twelve months subsequent to cardio-thoracic ICU care.

Who receives heroin-assisted treatment? A comparison of patients receiving opioid maintenance treatment in Denmark

BACKGROUND

Since 2010, heroin-assisted treatment (HAT) has been one of the treatment options available to people with opioid use disorder (OUD) in Denmark. This study aimed to characterize HAT patients at treatment start and compare their individual characteristics to those of patients entering traditional opioid maintenance treatment (OMT) with methadone or buprenorphine during the same period.

METHODS

Patients who initiated HAT or OMT with methadone or buprenorphine in Denmark from 2010 to 2018 were included (n=6798). Multiple national registers were linked to compare treatment groups in terms of socio-demographic variables, previous OUD treatment episodes, hospital-based care, and criminal conviction history.

RESULTS

Nearly all HAT patients had a history of methadone treatment (91%) and half had residential treatment experience (48%). In the year previous to admission, HAT patients recorded the highest percentages of non-fatal overdoses (12%) and chronic hepatitis C diagnoses (16%), and the lowest percentages of psychiatric disorders (11%) compared to traditional OMT patients. Criminal convictions were also common: 39% of the HAT group had committed a property crime and 18% a drug-related crime the year before HAT entry. During the study period, an overall reduction in OMT enrollments for each year was recorded. The HAT proportion to the total remained fairly stable (4%-10%), while the buprenorphine proportion increased.

CONCLUSIONS

In Denmark, OMT patients exhibited numerous vulnerabilities at treatment start, and among the patient groups, HAT patients were the most burdened. HAT seems to reach the target group and adhere to formulated eligibility criteria.

Prevalence of substance use disorder diagnoses in patients with chronic pain receiving reimbursed opioids: An epidemiological study of four Norwegian health registries

OBJECTIVES

Since 2008, patients have had access to reimbursed analgesics, including opioids, for chronic pain in Norway. There is a need for knowledge on the occurrence and trends over time of substance use disorder (SUD) diagnoses among patients who receive reimbursed opioids for chronic pain. The primary aim of this study was to investigate the prevalence of SUD diagnoses in patients with chronic pain using reimbursed opioids from 2010 to 2019 in Norway. The secondary aim was to investigate the prevalence of other mental health diagnoses among those receiving reimbursed opioids in the subgroups with and without SUD diagnoses.

METHODS

A cross-sectional design utilising data from four Norwegian nationwide registries.

RESULTS

The annual number of individuals with SUD diagnoses increased from 377 to 932 from 2010 to 2019, while the annual prevalence of individuals with SUD remained relatively stable at around 5%. There was a higher prevalence for all categories of other mental health diagnoses among individuals with a SUD diagnosis, compared to those without a SUD diagnosis.

CONCLUSION

The prevalence of SUD diagnoses was low in the population using reimbursed opioids for chronic pain in Norway, but the number of patients increased in the study period because the number of individuals receiving reimbursed opioids increased. Patients with a SUD used on average twice the daily doses of opioids compared to patients without a SUD. They were also more likely to have an additional mental health diagnosis.

Experiences and Outcomes of Using e-Prescribing for Opioids: Rapid Scoping Review

BACKGROUND

e-Prescribing is designed to assist in facilitating safe and appropriate prescriptions for patients. Currently, it is unknown to what extent e-prescribing for opioids influences experiences and outcomes. To address this gap, a rapid scoping review was conducted.

OBJECTIVE

This rapid scoping review aims to (1) explore how e-prescribing has been used clinically; (2) examine the effects of e-prescribing on clinical outcomes, the patient or clinician experience, service delivery, and policy; and (3) identify current gaps in the present literature to inform future studies and recommendations.

METHODS

A rapid scoping review was conducted following the guidance of the JBI 2020 scoping review methodology and the World Health Organization guide to rapid reviews. A comprehensive literature search was completed by an expert librarian from inception until November 16, 2022. Three databases were electronically searched: MEDLINE (Ovid), Embase (Ovid), and Scopus (Elsevier). The search criteria were as follows: (1) e-prescribing programs targeted to the use or misuse of opioids, including those that were complemented or accompanied by clinically focused initiatives, and (2) a primary research study of experimental, quasi-experimental, observational, qualitative, or mixed methods design. An additional criterion of an ambulatory component of e-prescribing (eg, e-prescribing occurred upon discharge from acute care) was added at the full-text stage. No language limitations or filters were applied. All articles were double screened by trained reviewers. Gray literature was manually searched by a single reviewer. Data were synthesized using a descriptive approach.

RESULTS

Upon completing screening, 34 articles met the inclusion criteria: 32 (94%) peer-reviewed studies and 2 (6%) gray literature documents (1 thesis study and 1 report). All 33 studies had a quantitative component, with most highlighting e-prescribing from acute care settings to community settings (n=12, 36%). Only 1 (3%) of the 34 articles provided evidence on e-prescribing in a primary care setting. Minimal prescriber, pharmacist, and clinical population characteristics were reported. The main outcomes identified were related to opioid prescribing rates, alerts (eg, adverse drug events and drug-drug interactions), the quantity and duration of opioid prescriptions, the adoption of e-prescribing technology, attitudes toward e-prescribing, and potential challenges with the implementation of e-prescribing into clinical practice. e-Prescribing, including key features such as alerts and dose order sets, may reduce prescribing errors.

CONCLUSIONS

This rapid scoping review highlights initial promising results with e-prescribing and opioid therapy management. It is important that future work explores the experience of prescribers, pharmacists, and patients using e-prescribing for opioid therapy management with an emphasis on prescribers in the community and primary care. Developing a common set of quality indicators for e-prescribing of opioids will help build a stronger evidence base. Understanding implementation considerations will be of importance as the technology is integrated into clinical practice and health systems.

A Guide to Expanding the Use of Buprenorphine Beyond Standard Initiations for Opioid Use Disorder

Buprenorphine has become an important medication in the context of the ongoing opioid epidemic. However, complex pharmacologic properties and varying government regulations create barriers to its use. This narrative review is intended to facilitate buprenorphine use-including non-traditional initiation methods-by providers ranging from primary care providers to addiction specialists. This article briefly discusses the opioid epidemic and the diagnosis and treatment of opioid use disorder (OUD). We then describe the basic and complex pharmacologic properties of buprenorphine, linking these properties to their clinical implications. We guide readers through the process of initiating buprenorphine in patients using full agonist opioids. As there is no single recommended approach for buprenorphine initiation, we discuss the details, advantages, and disadvantages of the standard, low-dose, bridging-strategy, and naloxone-facilitated initiation techniques. We consider the pharmacology of, and evidence base for, buprenorphine in the treatment of pain, in both OUD and non-OUD patients. Throughout, we address the use of buprenorphine in children and adolescent patients, and we finish with considerations related to the settings of pregnancy and breastfeeding.

The Spanish language version of the TAPS tool: protocol for a validation and implementation study in primary care

BACKGROUND

The TAPS Tool ("Tobacco, Alcohol, Prescription drug, and illicit Substance use") is a screening and brief assessment for detecting unhealthy substance use in healthcare settings that was developed by the National Institute on Drug Abuse Clinical Trials Network and validated in a multisite study. Our team developed a Spanish language version of the TAPS Tool that supports provider- and self-administration screening using a mobile/web-based platform, the TAPS Electronic Spanish Platform (TAPS-ESP).

METHODS

This article describes the protocol and rationale for a study to validate the TAPS-ESP in a sample of Spanish-speaking primary care patients recruited from a network of community-based clinics in Texas (target N = 1,000). The TAPS-ESP will be validated against established substance use disorder diagnostic measures, alternative screening tools, and substance use biomarkers. The study will subsequently examine barriers and facilitators to screening with the TAPS-ESP from a provider workflow perspective using qualitative interviews with providers.

DISCUSSION

Validating a Spanish language version of the TAPS Tool could expand access to evidence-based, linguistically accurate, and culturally relevant substance use screening and brief assessment for an underserved health disparity population.

TRIAL REGISTRATION

The study was registered with www.

CLINICALTRIALS

gov : NCT05476588, 07/22/2022.

A qualitative study on people with opioid use disorders' perspectives on smoking and smoking cessation interventions

Introduction

Smoking-related diseases are major contributors to disability and shorter life expectancy among opioid-dependent patients. Smoking prevalence is considerably higher for opioid-dependent persons than among the general population, and only a minority quit smoking in treatment settings. Studies show that pharmacological smoking cessation interventions have modest success rates. This study aimed to investigate patients' receiving opioid agonist therapy perspectives on factors affecting behavior and decisions related to smoking cessation, and their experiences with smoking cessation.

Methods

This is a qualitative study using semi-structured individual interviews. The participants were asked, among others, to elaborate on the participants' thoughts about smoking, previous attempts to quit tobacco use, and what could prompt a smoking cessation attempt. We analyzed the transcripts with systematic text condensation. The Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research guidelines were followed. Opioid-dependent patients receiving opioid agonist therapy in outpatient clinics were invited to participate using a purposive sampling method. In total, fourteen individuals participated in this study.

Results

We identified six themes which were: (1) reflections on how smoking affected decisions, (2) smoking and its impact on physical and mental health, (3) the economy as a motivator to stop smoking, (4) emotions, desires, and habits related to smoking, (5) knowledge of smoking, smoking cessation, and quit attempts, and (6) social factors influencing the participants' choices and activities. The participants were well informed about the consequences of smoking and had some knowledge and experience in quitting. The participants' pulmonary health was an important motivational factor for change. Withdrawal symptoms, anxiety, and fear of using other substances discouraged several from attempting to quit smoking. In contrast, social support from partners and access to meaningful activities were considered important factors for success. Few reported being offered help from health professionals to make a smoking cessation attempt.

Discussion

Experiencing social support, being encouraged to quit smoking, and patients' concerns for their physical health were important reasons for wanting to quit smoking. Smoking cessation interventions based on patient preferences and on the behavior change wheel may enable a higher success rate among patients receiving opioid agonist therapy.

Nociceptin Receptor-Related Agonists as Safe and Non-addictive Analgesics

As clinical use of currently available opioid analgesics is often impeded by dose-limiting adverse effects, such as abuse liability and respiratory depression, new approaches have been pursued to develop safe, effective, and non-addictive pain medications. After the identification of the nociceptin/orphanin FQ (N/OFQ) peptide (NOP) receptor more than 25 years ago, NOP receptor-related agonists have emerged as a promising target for developing novel and effective opioids that modulate the analgesic and addictive properties of mu-opioid peptide (MOP) receptor agonists. In this review, we highlight the effects of the NOP receptor-related agonists compared with those of MOP receptor agonists in experimental rodent and more translational non-human primate (NHP) models and the development status of key NOP receptor-related agonists as potential safe and non-addictive analgesics. Several lines of evidence demonstrated that peptidic and non-peptidic NOP receptor agonists produce potent analgesic effects by intrathecal delivery in NHPs. Moreover, mixed NOP/MOP receptor partial agonists (e.g., BU08028, BU10038, and AT-121) display potent analgesic effects when administered intrathecally or systemically, without eliciting adverse effects, such as respiratory depression, itch behavior, and signs of abuse liability. More importantly, cebranopadol, a mixed NOP/opioid receptor agonist with full efficacy at NOP and MOP receptors, produces robust analgesic efficacy with reduced adverse effects, conferring promising outcomes in clinical studies. A balanced coactivation of NOP and MOP receptors is a strategy that warrants further exploration and refinement for the development of novel analgesics with a safer and effective profile.

The effects of childhood trauma and mental disorders on treatment engagement, contact with the criminal justice system, and mortality among people with opioid dependence

BACKGROUND

Childhood trauma and mental disorders increase the risk of opioid dependence. We aimed to examine whether childhood trauma and mental disorders are associated with opioid agonist treatment (OAT) engagement, contact with the criminal justice system, and mortality among people with opioid dependence.

METHODS

This observational study linked survey data from 1482 people receiving OAT in Sydney, Australia (2004-2008) to administrative data on OAT, crime, and mortality through 2017. We used survey data to assess childhood trauma, depression, panic disorder, post-traumatic stress disorder (PTSD), borderline personality disorder, anti-social personality disorder (ASPD), and comorbid substance dependence. We used discrete-time analysis to examine time from opioid dependence onset to OAT entry and mortality. Poisson regressions were used to analyze time receiving OAT and number of charges.

RESULTS

Participants with extensive childhood trauma histories and ASPD were less likely to enter OAT and those with depression were more likely to enter OAT in any given year after opioid dependence onset. Panic disorder, PTSD, and borderline personality disorder were associated with less time in OAT. Extensive histories of childhood trauma, PTSD, ASPD, and comorbid substance dependence increased risk of charges for any offence. There were no significant associations between the exposure variables and mortality.

CONCLUSIONS

Our findings suggest that childhood trauma and mental disorders increase the risk of adverse treatment and social outcomes among people with opioid dependence. Interventions that aim to reduce harm among people with opioid dependence may consider the effect of childhood trauma and mental disorders on OAT engagement and crime.

Patterns and Predictors of Heroin Use, Remission, and Psychiatric Health Among People with Heroin Dependence: Key Findings from the 18-20-Year Follow-Up of the Australian Treatment Outcome Study (ATOS)

This study aimed to investigate the long-term patterns and predictors of heroin use, dependence, and psychiatric health over 18-20 years among a cohort of Australians with heroin dependence, using a prospective longitudinal cohort study conducted in Sydney, Australia. The original cohort consisted of 615 participants, who were followed up at 3 months and 1, 2, 3, 11, and 18-20 years post-baseline; 401 (65.2%) were re-interviewed at 18-20 years. The Australian Treatment Outcome Study structured interview with established psychometric properties was administered to participants at each follow-up, addressing demographics, treatment and drug use history, overdose, crime, and physical and mental health. Overall, 96.7% completed at least one follow-up interview. At 18-20 years, 109 participants (17.7%) were deceased. Past-month heroin use decreased significantly over the study period (from 98.7 to 24.4%), with one in four using heroin at 18-20 years. Just under half were receiving treatment. Reductions in heroin use were accompanied by reductions in heroin dependence, other substance use, needle sharing, injection-related health, overdose, crime, and improvements in general physical and mental health. Major depression and borderline personality disorder (BPD) were consistently associated with poorer outcome. At 18-20 years, there is strong evidence that clinically significant levels of improvement can be maintained over the long term. The mortality rate over 18-20 years was devastating, with over one in six participants deceased. More sustained and targeted efforts are needed in relation to major depression and BPD to ensure evidence-based treatments are delivered to people with heroin dependence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11469-022-01006-6.

Clinical Trial Design Challenges and Opportunities for Emerging Treatments for Opioid Use Disorder: A Review

Importance

Novel treatments for opioid use disorder (OUD) are needed to address both the ongoing opioid epidemic and long-standing barriers to existing OUD treatments that target the endogenous μ-opioid receptor (MOR) system. The goal of this review is to highlight unique clinical trial design considerations for the study of emerging treatments for OUD that address targets beyond the MOR system. In November 2019, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the US Food and Drug Administration sponsored a meeting to discuss the current evidence regarding potential treatments for OUD, including cannabinoids, psychedelics, sedative-hypnotics, and immunotherapeutics, such as vaccines.

Observations

Consensus recommendations are presented regarding the most critical elements of trial design for the evaluation of novel OUD treatments, such as: (1) stage of treatment that will be targeted (eg, seeking treatment, early abstinence/detoxification, long-term recovery); (2) role of treatment (adjunctive with or independent of existing OUD treatments); (3) primary outcomes informed by patient preferences that assess opioid use (including changes in patterns of use), treatment retention, and/or global functioning and quality of life; and (4) adverse events, including the potential for opioid-related relapse or overdose, especially if the patient is not simultaneously taking maintenance MOR agonist or antagonist medications.

Conclusions and Relevance

Applying the recommendations provided here as well as considering input from people with lived experience in the design phase will accelerate the development, translation, and uptake of effective and safe therapeutics for individuals struggling with OUD.

Treatment Experiences for Patients Receiving Buprenorphine/Naloxone for Opioid Use Disorder: A Qualitative Study of Patients' Perceptions and Attitudes

Background: Although buprenorphine/naloxone has been demonstrated to be an effective treatment for patients with opioid use disorder (OUD), treatment retention has been a challenge. This study extends what is presently a limited literature regarding patients' experiences with this medication and the implications for treatment retention. Methods: The study was conducted as a qualitative investigation of patients in treatment for OUD at the time of the study. Forty-three patients (27 men, 15 women, mean age 34.7) were recruited from three clinical settings, a community health center, an academically-based treatment site, and an independent substance abuse treatment facility. Most patients had returned to use in the past after attempts to become abstinent. Results: Patients generally reported positive experiences with this medication noting it helped to reduce opioid cravings quickly. As important considerations for treatment retention, patients emphasized a firm commitment to achieving abstinence when beginning treatment and a prescriber who is informed about and attentive to their emotional state. Diverging attitudes did exist regarding treatment duration as some patients were accepting of long-term treatment while others desired a relatively brief option. Among patients who had returned to use, potentially important issues emerged pertaining to the absence of patient outreach for missed medication appointments and inadequate discharge planning following stays at rehabilitation facilities. Conclusions: While results regarding the importance of patient motivation and strong patient-prescriber relationships have been noted in previous studies, other findings regarding opportunities to improve patient outreach and coordination of care have received relatively less attention and warrant further consideration.

Perceptions and experiences of patients attending an opioid substitution clinic in South Africa

Background

Opioid substitution therapy (OST) is endorsed as the recommended treatment for opioid use disorders. Opioid substitution therapy is not widely used in South Africa, so little is known about its perceived clinical utility in this setting. There is also a paucity of qualitative research that explores the subjective experiences of patients using OST.

Aim

To explore patients' perceptions and experiences attending a South African OST outpatient clinic (OST-OC).

Setting

The OST-OC at Stikland Psychiatric Hospital, Cape Town, South Africa.

Methods

We conducted a qualitative study using semi-structured interviews with eight participants who had been attending the OST-OC for at least 6 months. Transcripts were analysed using Atlas.ti software and thematic content analysis was used to identify themes.

Results

Patients stated that OST helped them to regain and maintain a stable lifestyle. Autonomy and agency, the therapeutic relationship and family support were perceived as contributing to successful patient outcomes. The preference for methadone and buprenorphine treatment depended on individual experiences. Patients valued kindness from staff members but reported that improved interactions with some nonclinical staff could better facilitate treatment. Challenges experienced included stigma and cost.

Conclusions

This study offers insights about OST that are pertinent to low- and middle-income countries. Reducing the cost of OST, collaborative decision-making between staff and patients, and a non-judgemental attitude by clinical staff were recognised as important factors for optimised service delivery.

Contribution

Understanding patients' experiences of OST in a South African setting will allow for future policy development for the treatment of opioid use disorders in similar settings locally and abroad.

Use and misuse of opioid after gynecologic surgery

Postoperative opioid use following gynecologic surgery may be necessary for effective treatment of pain; however, it can result in significant side effects, adverse reactions, and negative health consequences, including prolonged problematic use. Surgeons and healthcare providers of patients recovering from gynecologic procedures should be aware of effective strategies that can decrease the need for opioid use, while providing high-quality pain management. These include adherence to Enhanced Recovery After Surgery Protocols, particularly the use of multimodal analgesia management. When prescribing opioids, providers should adhere to responsible prescribing practices to minimize the risk of inappropriate and/or long-term opioid use.

Mood regulation, alexithymia, and personality disorders in female patients with opioid use disorders

Background

Opioid use disorders are rising among females. So, there is a need for more recognition of the various factors contributing to this trend in women, to help us to plan effective interventions to this group of patients. Hence, we conducted this research to identify risk factors associated with opioid use in females including mood regulation, alexithymia, and personality disorders. The study included 60 females ranging from 18 to 45 years [30 females diagnosed with opioid use disorder according DSM-IV (case group), and 30 females with no mental illness diagnosis according to general health questionnaire (control group)]. The subjects were recruited from inpatients and outpatient clinic of Al-Abbassia Hospital, Cairo, Egypt. Both groups were assessed by the Structured Clinical Interview for DSM-IV axis II disorders (SCID II) for personality, Trait Meta-Mood Scale (TMMS) for emotional regulation and Toronto Alexithymia Scale-20 (TAS-20) for alexithymia.

Results

Regarding sociodemographic data, cases were significantly different from controls as they are less educated (P < 0.001), more 73% (22) unemployed (P <0.001) and 56.7% (17) of cases had positive family history of first degree relatives with drug use (P = 0.001).

SCID II showed more significant personality disorders diagnosis among cases as (borderline, antisocial, paranoid, schizotypal, and schizoid personality disorder) (P < 0.001, < 0.001, 0.01, 0.003, and 0.005, respectively) and also multiple personality disorders (P < 0.001) diagnosis. As regards alexithymia all cases were classified as having alexithymia 100% versus 56.7% among controls. Meanwhile, cases showed more difficulty in identifying (P < 0.001) and describing feelings (P = 0.001) and more externally oriented thinking (P = 0.010). Results of TMMS showed cases had lower total score on TMMS (p = 0.016). Signifying their inability to regulate their emotions in comparison to controls. There was no significant association between alexithymia, sociodemographic data, TMMS, and SCID II among cases group.

Conclusions

The present study found that females with opioid use disorders tend to be less educated, unemployed with positive family history of substance abuse, and diagnosed mainly with cluster A and B personality disorders. Moreover, had difficulty in identifying, describing, and regulating their emotions.

Spouse and Child Abuse Associated With Illicit Drug Use in Iran: A Systematic Review and Meta-Analysis

BACKGROUND

There is a high prevalence of substance use disorders, especially among men, in Iran and is associated with a high burden on families. We aimed to systematically review the association between illicit drug use and spouse and child abuse in Iran.

METHOD

Comprehensive terms were used to search three international databases (ISI, Medline, and Scopus) and a national database of Scientific Information Database up to September 2019. The retrieved citations were screened based on the eligibility criteria and then data were extracted, and the risk of bias was assessed by two independent investigators. Data were analyzed using random-effects model to estimate pooled odds ratios (ORs) and the heterogeneity of studies.

RESULTS

The search yielded 18 articles that met the inclusion criteria. Illicit substance use in husbands was associated with increased odds of current violence (OR = 3.50; 95% CI [2.09, 5.86]), current physical violence (OR = 5.41; 95% CI [3.50, 8.35]), current psychological violence (OR = 6.20; 95% CI [3.74, 10.30]), and current sexual violence (OR = 7.23; 95% CI [4.06, 12.87]) against spouse. In studies on child abuse, the odds of current physical child abuse by parents who used an illicit substance was 3.88 times (95% CI [1.50, 10.01]) higher than parents who did not use any illicit substance.

CONCLUSION

The results of the current study showed that illicit substance use is associated with an increased risk of spouse and child abuse. This is an important social and health consequence of drug use and should be addressed in all drug control plans.

Diagnosis and treatment of opioid-related disorders in a South African private sector medical insurance scheme: A cohort study

BACKGROUND

The use of opioids is increasing globally, but data from low- and middle-income countries on opioid-related mental and behavioural disorders (hereafter referred to as opioid-related disorders) are scarce. This study examines the incidence of opioid-related disorders, opioid agonist use, and excess mortality among persons with opioid-related disorders in South Africa's private healthcare sector.

METHODS

We analysed longitudinal data of beneficiaries (≥ 11 years) of a South African medical insurance scheme using reimbursement claims from Jan 1, 2011, to Jul 1, 2020. Beneficiaries were classified as having an opioid-related disorder if they received an opioid agonist (buprenorphine or methadone) or an ICD-10 diagnosis for harmful opioid use (F11.1), opioid dependence or withdrawal (F11.2-4), or an unspecified or other opioid-related disorder (F11.0, F11.5-9). We calculated adjusted hazard ratios (aHR) for factors associated with opioid-related disorders, estimated the cumulative incidence of opioid agonist use after receiving an ICD-10 diagnosis for opioid dependence or withdrawal, and examined excess mortality among beneficiaries with opioid-related disorders.

RESULTS

Of 1,251,458 beneficiaries, 1286 (0.1%) had opioid-related disorders. Between 2011 and 2020, the incidence of opioid-related disorders increased by 12% (95% CI 9%-15%) per year. Men, young adults in their twenties, and beneficiaries with co-morbid mental health or other substance use disorders were at increased risk of opioid-related disorders. The cumulative incidence of opioid agonist use among beneficiaries who received an ICD-10 diagnosis for opioid dependence or withdrawal was 18.0% (95% CI 14.0-22.4) 3 years after diagnosis. After adjusting for age, sex, year, medical insurance coverage, and population group, opioid-related disorders were associated with an increased risk of mortality (aHR 2.28, 95% CI 1.84-2.82). Opioid-related disorders were associated with a 7.8-year shorter life expectancy.

CONCLUSIONS

The incidence of people diagnosed with or treated for an opioid-related disorder in the private sector is increasing rapidly. People with opioid-related disorders are a vulnerable population with substantial psychiatric comorbidity who often die prematurely. Evidence-based management of opioid-related disorders is urgently needed to improve the health outcomes of people with opioid-related disorders.

A randomized, sham-controlled, quintuple-blinded trial to evaluate the NET device as an alternative to medication for promoting opioid abstinence

Background

There is an unmet need for non-medication approaches to illicit opioid discontinuation and relapse prevention. The NET (NeuroElectric Therapy) Device is a non-invasive, battery-operated, portable, re-useable device designed to deliver bilateral transcranial transcutaneous alternating current electrical stimulation, and is intended to treat opioid use disorder (OUD) without medication. The device is a CE-marked Class IIa, non-significant risk, investigational medical device.

Objective

This prospective trial (NRC021) tests the hypothesis that the NET Device provides safe and effective neurostimulation treatment for persons with OUD who express a desire to be opioid abstinent without medications for opioid use disorder (MOUD).

Methods

NRC021 is a randomized, parallel-group, sham-controlled, quintuple-blinded, single-site study. Persons with OUD entering a residential treatment facility for opioid detoxification are assigned to active or sham treatment (n = 50/group). Group assignment is stratified on presence of any current non-opioid substance use disorder and by sex. The biostatistician maintains the blinding so that the study sponsor, principal investigator, research assistants, treatment staff, and participants remain blinded. Following discharge from the inpatient facility, participants are assessed once weekly over 12 weeks for substance use (using timeline followback interview and video assessment of observed oral fluid sample provision and testing). The primary efficacy endpoint is each participant's overall percentage of weekly abstinence from illicit opioid use without use of MOUD. The secondary efficacy endpoint is each participant's percentage of non-opioid drug-free weeks. Safety outcomes are also measured.

Conclusion

NRC021 is designed to assess the efficacy of a novel non-medication treatment for OUD.

Clinical trial registration

ClinicalTrials.gov with the identifier NCT04916600.

Cannabinoids and Their Role in Chronic Pain Treatment: Current Concepts and a Comprehensive Review

For decades, chronic pain was managed with an almost conventional approach of using a wide range of analgesic spectrum, surgical approaches and complex interventional pain techniques to modulate or even interrupt pain pathways. These different approaches carry many pharmacological hazards together with the lack of efficacy and safety of many interventional and surgical management techniques for chronic pain have mandated searching for other effective therapies including alternative treatments. Cannabinoids are naturally occurring substances that are derived from Cannabis sativa L. The usage of cannabinoids and their related synthetic chemical compounds has emerged as a choice in the management of different chronic pain conditions is being evaluated, however, the efficacy is still not consistently established. In the present investigation, therefore, we discuss the different aspects related to cannabinoids and their implications in the management of chronic pain conditions. This review will also discuss the safety profile of the cannabinoids together with the legal considerations that hinder their use in different countries.

The Role of Glia in Addiction: Dopamine as a Modulator of Glial Responses in Addiction

Addiction is a chronic and potentially deadly disease considered a global health problem. Nevertheless, there is still no ideal treatment for its management. The alterations in the reward system are the most known pathophysiological mechanisms. Dopamine is the pivotal neurotransmitter involved in neuronal drug reward mechanisms and its neuronal mechanisms have been intensely investigated in recent years. However, neuroglial interactions and their relation to drug addiction development and maintenance of drug addiction have been understudied. Many reports have found that most neuroglial cells express dopamine receptors and that dopamine activity may induce neuroimmunomodulatory effects. Furthermore, current research has also shown that pro- and anti-inflammatory molecules modulate dopaminergic neuron activity. Thus, studying the immune mechanisms of dopamine associated with drug abuse is vital in researching new pathophysiological mechanisms and new therapeutic targets for addiction management.

Long-term opioid use and mortality in patients with chronic non-cancer pain: Ten-year follow-up study in South Korea from 2010 through 2019

BACKGROUND

We aimed to investigate the prevalence and factors associated with long-term opioid use among patients with chronic non-cancer pain (CNCP).

METHODS

We extracted data from the National Health Insurance Service (NHIS) database in South Korea. As a nationwide database, the NHIS database contains information regarding all disease diagnoses and prescriptions for any drug and/or procedures. A total of 2.5% of adult patients (≥20 years of age) who were diagnosed with musculoskeletal diseases and CNCP from 2010 to 2019 were selected using a stratified random sampling technique and included in the analysis. Patients who were prescribed opioids continuously for ≥90 days were classified as long-term opioid users.

FINDINGS

A total of 19,645,161 patients with CNCP were included in the final analysis. The prevalence of long-term opioid use was 0.47% (95% confidence interval [CI]: 0.46%, 0.48%; 8421/1,808,043) in 2010, which gradually increased to 2.63% (95% CI: 2.61%, 2.66%; 49,846/1,892,913) in 2019. Among the 2010 cohort (n = 1,804,019), in multivariable logistic regression: old age, underlying disability, increased Charlson comorbidity index, use of benzodiazepine or Z-drug, rheumatoid arthritis, osteoarthritis, and low back pain were associated with an increased prevalence of long-term opioid use among patients with CNCP. In a multivariable Cox regression, the 10-year all-cause mortality in long-term opioid users was found to be 1·21-fold (hazard ratio: 1.21, 95% CI: 1.13, 1.31; P<0·001) higher than that in opioid-naive patients with CNCP.

INTERPRETATION

Long-term opioid use increased in patients with CNCP in South Korea from 2010 to 2019. Certain factors were potential risk factors for long-term opioid use. Moreover, long-term opioid use was associated with increased 10-year all-cause mortality among patients with CNCP.

FUNDING

None.

Long-term patient outcomes following buprenorphine/naloxone treatment for opioid use disorder: a retrospective analysis in a commercially insured population

Background: While buprenorphine/naloxone (buprenorphine) has been demonstrated to be an effective medication for treating opioid use disorder (OUD), an important question exists about how long patients should remain in treatment.Objective: To examine the relationship between treatment duration and patient outcomes for individuals with OUD who have been prescribed buprenorphine.Methods: We conducted a retrospective, longitudinal study using the Massachusetts All Payer Claims Database, 2013 to 2017. The study comprised over 2,500 patients, approximately one-third of whom were female, who had been prescribed buprenorphine for OUD. The outcomes were hospitalizations and emergency room (ER) visits at 36 months following treatment initiation and 12 months following treatment discontinuation. Patients were classified into four groups based on treatment duration and medication adherence: poor adherence, duration <12 months; good adherence, duration <6 months; good adherence, duration 6 to 12 months, and good adherence, duration >12 months. We conducted analyses at the patient level of the relationship between duration and outcomes.Results: Better outcomes were observed for patients whose duration was greater than 12 months. Patients in the other groups had higher odds of hospitalization at 36 months following treatment initiation: poor adherence (2.71), <6 months (1.53), and 6 to 12 months (1.42). They also had higher odds of ER visits: poor adherence (1.69), <6 months (1.51), and 6 to 12 months (1.30). Similar results were observed following treatment discontinuation.Conclusions: OUD treatment with buprenorphine should be continued for at least 12 months to reduce hospitalizations and ED visits.

Urinalysis based assessment of compliance and drug use patterns in patients prescribed tramadol: A cross-sectional study from a tertiary care centre

BACKGROUND

Strict adherence to pharmacological dosage regimens is a prerequisite to the success of most treatments, particularly for patients in drug abuse programs. The compliance of tramadol, an atypical non-scheduled narcotic analgesic, using objective method has not been adequately studied in an Indian setting.

AIM

To evaluate the compliance and pattern of drug use among opioid-dependent subjects prescribed tramadol based on urinalysis.

METHOD

Fifty male opioid-dependent patients (ICD 10), seeking treatment at a tertiary de-addiction treatment centre of North India on tramadol prescription for atleast past four weeks were included. Self-reported substance use was recorded using semi-structured proforma. Ten ml of urine was collected for the assessment of compliance of tramadol of other substance use (morphine, buprenorphine, dextropropoxyphene, pentazocine, cannabis, benzodiazepines, pheniramine). All these drugs were analyzed using the immunoassay-based Cassette test and Gas Chromatography in human urine.

RESULT

Mean age of the participants was 42.8 years and the mean duration of opioid use was 15.9years. The urine specimen of all subjects tested positive for tramadol. Urinalysis revealed benzodiazepines, cannabis, and pheniramine to be the most common substances of use in this population. It was seen that agreement of self-reporting and urine test results was good for morphine (κ = 0.558) and cannabis (κ = 0.312) and was poor for buprenorphine, pentazocine, and pheniramine.

CONCLUSION

The study demonstrates the continued use of several illicit or non-prescribed medications in a medication-assisted opioid treatment population. The results affirm the reliability of urinalysis as an adjunct for testing compliance in such a population.

Community-based naloxone coverage equity for the prevention of opioid overdose fatalities in racial/ethnic minority communities in Massachusetts and Rhode Island

BACKGROUND AND AIMS

Opioid-related overdose death rates continue to rise in the United States, especially in racial/ethnic minority communities. Our objective was to determine if US municipalities with high percentages of non-white residents have equitable access to the overdose antidote naloxone distributed by community-based organizations.

METHODS

We used community-based naloxone data from the Massachusetts Department of Public Health and the Rhode Island non-pharmacy naloxone distribution program for 2016-18. We obtained publicly available opioid-related overdose death data from Massachusetts and the Office of the State Medical Examiners in Rhode Island. We defined the naloxone coverage ratio as the number of community-based naloxone kits received by a resident in a municipality divided by the number of opioid-related overdose deaths among residents, updated annually. We used a Poisson regression with generalized estimating equations to analyze the relationship between the municipal racial/ethnic composition and naloxone coverage ratio. To account for the potential non-linear relationship between naloxone coverage ratio and race/ethnicity we created B-splines for the percentage of non-white residents; and for a secondary analysis examining the percentage of African American/black and Hispanic residents. The models were adjusted for the percentage of residents in poverty, urbanicity, state and population size.

RESULTS

Between 2016 and 2018, the annual naloxone coverage ratios range was 0-135. There was no difference in naloxone coverage ratios among municipalities with varying percentages of non-white residents in our multivariable analysis. In the secondary analysis, municipalities with higher percentages of African American/black residents had higher naloxone coverage ratios, independent of other factors. Naloxone coverage did not differ by percentage of Hispanic residents.

CONCLUSIONS

There appear to be no municipal-level racial/ethnic inequities in naloxone distribution in Rhode Island and Massachusetts, USA.

Preoperative Opioid Dose and Surgical Outcomes in Colorectal Surgery

BACKGROUND

The worsening opioid epidemic has led to an increased number of surgical patients with chronic preoperative opioid use. However, the impact of opioids on perioperative outcomes has yet to be fully elucidated. The purpose of this study was to assess the association between preoperative opioid dose and surgical outcomes among colectomy patients.

METHODS

Adult colectomy patients in the IBM MarketScan database (2010-2017) were stratified based on preoperative opioid dose, calculated as the average opioid dose in morphine milligram equivalents (MME) in the 90 days prior to surgery: 0 MME, 1 to 49 MME, and 50 or more MME. The association between preoperative opioid dose and anastomotic leak, the primary outcome of interest, as well as other postoperative complications, was assessed using multivariable regression.

RESULTS

Among 45,515 adult colectomy patients, 71.4% did not use opioids (0 MME), 27.4% had an opioid dose between 1 and 49 MME, and 1.2% had an opioid dose at or above 50 MME. Patients with preoperative opioid use exhibited a higher incidence of anastomotic leak (0 MME: 4.8%, 1-49 MME: 5.5%, ≥50 MME: 8.3%; p trend = 0.001). Multivariable analysis demonstrated a dose-response relationship between preoperative opioids and surgical outcomes, as the odds of anastomotic leak worsened with increasing opioid dose (1-49 MME: OR 1.19, 95% CI 1.08-1.31, p < 0.001; ≥50 MME: OR 1.64, 95% CI 1.20-2.24, p = 0.002). Similar dose-response relationships were seen after risk-adjustment for lung complications, pneumonia, delirium, and 30-day readmission (p < 0.05 for all).

CONCLUSIONS

Providers should exercise caution when prescribing opioids preoperatively, as increasing doses of preoperative opioids were associated with worse surgical outcomes and higher 30-day readmission among adult colectomy patients.

A systematic review of assessment approaches to predict opioid misuse in people with cancer

Context

Cancer prevalence is increasing, with many patients requiring opioid analgesia. Clinicians need to ensure patients receive adequate pain relief. However, opioid misuse is widespread, and cancer patients are at risk.

Objectives

This study aims (1) to identify screening approaches that have been used to assess and monitor risk of opioid misuse in patients with cancer; (2) to compare the prevalence of risk estimated by each of these screening approaches; and (3) to compare risk factors among demographic and clinical variables associated with a positive screen on each of the approaches.

Methods

Medline, Cochrane Controlled Trial Register, PubMed, PsycINFO, and Embase databases were searched for articles reporting opioid misuse screening in cancer patients, along with handsearching the reference list of included articles. Bias was assessed using tools from the Joanna Briggs Suite.

Results

Eighteen studies met the eligibility criteria, evaluating seven approaches: Urine Drug Test (UDT) (n = 8); the Screener and Opioid Assessment for Patients with Pain (SOAPP) and two variants, Revised and Short Form (n = 6); the Cut-down, Annoyed, Guilty, Eye-opener (CAGE) tool and one variant, Adapted to Include Drugs (n = 6); the Opioid Risk Tool (ORT) (n = 4); Prescription Monitoring Program (PMP) (n = 3); the Screen for Opioid-Associated Aberrant Behavior Risk (SOABR) (n = 1); and structured/specialist interviews (n = 1). Eight studies compared two or more approaches. The rates of risk of opioid misuse in the studied populations ranged from 6 to 65%, acknowledging that estimates are likely to have varied partly because of how specific to opioids the screening approaches were and whether a single or multi-step approach was used. UDT prompted by an intervention or observation of aberrant opioid behaviors (AOB) were conclusive of actual opioid misuse found to be 6.5–24%. Younger age, found in 8/10 studies; personal or family history of anxiety or other mental ill health, found in 6/8 studies; and history of illicit drug use, found in 4/6 studies, showed an increased risk of misuse.

Conclusions

Younger age, personal or familial mental health history, and history of illicit drug use consistently showed an increased risk of opioid misuse. Clinical suspicion of opioid misuse may be raised by data from PMP or any of the standardized list of AOBs. Clinicians may use SOAPP-R, CAGE-AID, or ORT to screen for increased risk and may use UDT to confirm suspicion of opioid misuse or monitor adherence. More research into this important area is required.

Significance of results

This systematic review summarized the literature on the use of opioid misuse risk approaches in people with cancer. The rates of reported risk range from 6 to 65%; however, true rate may be closer to 6.5–24%. Younger age, personal or familial mental health history, and history of illicit drug use consistently showed an increased risk of opioid misuse. Clinicians may choose from several approaches. Limited data are available on feasibility and patient experience.

PROSPERO registration number.

CRD42020163385.

Patients’ Perspectives on Coming Off Opioid Agonist Treatment: A Qualitative Study

Aims:

Opioid agonist treatment (OAT) programs are life-saving, as they reduce opioid use, overdoses, and criminal activities. Disadvantages reported with long-term OAT include side effects of the medication, especially on cognitive ability and sexual function, which may discourage potential participants. Many of those who participate in OAT have a desire to come off treatment. The aims of this study were to explore patients’ thoughts about coming off OAT and to investigate their perceptions of what support they would need in order to realize a planned withdrawal from OAT.

Methods:

A qualitative interview study with semi-structured interviews, using applied thematic analysis. Persons with experiences of participating in OAT were invited from Swedish programs and a private Facebook community.

Results:

Fifteen persons, with a mean of 9.6 (±6.4) years of treatment experience, were included. The participants underlined the need for a patient-centered focus within the treatment. They wanted to be regarded as capable of deciding if, when, and how a planned ending was to take place. They also called for staff to be supportive in making such decisions. Participants recommended staff to be sensitive to the needs of the specific patient and to have strategies for coming off OAT that could be adjusted for the single person.

Conclusions:

OAT programs need to be continually updated and adapted to the persons who can benefit from them. Applying a person-centered, holistic perspective would enhance the quality of the treatment by emanating from individual goals. Regulatory guidelines need to take into account research on patient experiences and perspectives on coming off.

The Status and Prescription Patterns of Opioid Utilization in a Large Comprehensive Teaching Hospital in China According to the Anatomical Therapeutic Chemical Classification/Defined Daily Dose Methodology

BACKGROUND

Few studies have analyzed opioid consumption and the average daily dose and duration for different patients in hospital settings in China. The aim of this study was to measure the status of and trends in prescribed opioids and the prescribing patterns at the Second Xiangya Hospital.

METHODS

The data were obtained from the prescribed medicine database of the inpatient department. We included patients who were >18 years old and received any level of opioid analgesic between 2012 and 2017. The international Anatomical Therapeutic Chemical Classification/Defined Daily Dose (ATC/DDD) methodology was used to standardize the consumption rates. All opioid units were converted into morphine equivalents (MEs) to analyze the specific opioid usage.

RESULTS

The consumption of prescribed opioids increased from 3.16 to 3.74 DDD/100 bed-days (+18.3%) from 2012 to 2017. Both cancer and noncancer patients had similar administration routes and median daily dosages in MEs, but cancer patients had longer treatment durations (median: 5 days vs. 1 day, respectively). The median average daily dose and treatment duration for all patients were 15 MEs/day and 2 days, respectively, for oral administration, 100 MEs/day and 1 day for parenteral administration, and 47.14 MEs/day and 5 days for both oral and parenteral administration.

CONCLUSION

Although there was a tendency toward an increase in opioid consumption, the overall level of consumption in the Second Xiangya Hospital remained relatively low. Thus, it is urgently necessary to increase the availability of opioids and alter prescription habits for them in order adopt the current concept of pain management developed by the World Health Organization (WHO).

The impact of an easy access drug supply management policy law on the consumption and abuse of opioids in Catalonia: A population-based study

BACKGROUND

Over the last two decades, the rise in opioid prescription has worsened health outcomes worldwide, increasing both levels of abuse and mortality rates. In order to reduce the scale of this public health problem, new policies have been implemented in many countries. In 2012, Spain adopted new legislation on opioid prescription (the ROE law), which meant that practitioners no longer needed to obtain extra authorisation in order to prescribe strong opioids. The objective of the paper is to assess the impact of this law on opioid use and abuse in Catalonia, Spain.

METHODS

We established two measures of the use of strong and weak opioids: DDDs, and abuse. We used benzodiazepines and antidepressants as controls, and adjusted for age, sex, drug co-payment level, death or near death, cancer diagnosis, morbidity group, and type of prescription. The data were obtained from administrative and dispensing drug databases in a population of 7.5 million inhabitants. We estimated two-way fixed effects using difference in difference models.

RESULTS

The ROE law impacted reducing the monthly use of strong opioids by 0.903 DDDs, representing a 3.15% decrease in the mean monthly use of strong opioids. However, abuse rose 1.86 times compared with the average pre-ROE value, which represents an increase of 11,190 months of opioid abuse (i.e., an 11.33% of all monthly opioids use).

CONCLUSION

The abolition of the duplicate prescription programme for strong opioids led to a reduction in the average monthly use of strong opioids, but an increase in abuse.

Feasibility and acceptability of using smartphone-based EMA to assess patterns of prescription opioid and medical cannabis use among individuals with chronic pain

BACKGROUND

Intensive longitudinal studies are needed to examine the co-use of prescription opioid medication and medical cannabis and their effects on chronic pain. The current study sought to investigate the feasibility and participant compliance with a smartphone-based Ecological Momentary Assessment (EMA) data collection protocol among individuals who use multiple substances and suffer from chronic pain.

METHODS

A total of 46 participants (mean age = 44.8 years; 78% female; 85% Non-Hispanic White) were recruited online and completed a 30-day EMA phase where they responded to prompted surveys (four random past-hour surveys and one daily diary per day) about opioid medication use, medical cannabis use, and pain symptoms. Qualitative follow-up interviews were conducted with a subset of 10 participants. Linear and logistic regression models were used to examine baseline participant characteristics in relation to EMA compliance. Qualitative indicators of participant study experience were extracted from interviews.

RESULTS

Participants responded to an average of 70% of past-hour surveys and 92% of daily diaries. Female participants were more likely to complete all daily diaries and at least one past-hour survey per day on all 30 days, respectively (OR = 5.60, 95% CI: 1.02-30.77, p < .05; OR = 7.08, 95% CI: 1.28-39.16, p < .05). Female participants were also more likely to complete at least 75% of their prompted past-hour surveys (OR = 4.67, 95% CI: 1.00-21.69, p < .05). Interview participants reported a positive study experience overall, although some mentioned problems related to smartphone notifications, redundant questions, or being prompted when they were not feeling well. Participants also mentioned problems with reporting the amount of medical cannabis used (e.g., milliliters of vaping liquid).

CONCLUSIONS

Study results demonstrate both feasibility and acceptability of using EMA methodology to examine use patterns of medical cannabis and prescription opioid medication among individuals with chronic pain.

Naturalistic follow-up after a trial of medications for opioid use disorder: Medication status, opioid use, and relapse

AIM

This report examined naturalistic opioid use outcomes and utilization of medications for opioid use disorder (MOUD) 36 weeks post-randomization in the National Drug Abuse Treatment Clinical Trials Network (CTN) Extended-Release Naltrexone (XR-NTX) versus Buprenorphine-Naloxone (BUP-NX) for Opioid Treatment trial (CTN-0051, X:BOT).

DESIGN

X:BOT was a multisite, randomized, 24-week comparative effectiveness trial of BUP-NX (N = 287) and XR-NTX (N = 283). Study medications were discontinued following treatment completion, relapse, or dropout. Participants were encouraged to continue MOUD. This report examined opioid use outcomes in 428 (75%) of the 570 participants who attended the 36-week follow-up visit.

SETTING AND PARTICIPANTS

Adults with opioid use disorder recruited from 8 community treatment programs across the United States.

MEASUREMENTS

Outcomes included medication status (on/off MOUD), type of MOUD (BUP-NX, XR-NTX, or methadone), abstinence from non-prescribed opioids, opioid use days, relapse, and other substance use 30 days prior to the 36-week visit. Relapse was defined as opioid use for 4 consecutive weeks or 7 consecutive days in the past month. Baseline and clinical variables included opioid use severity, intravenous drug use, study medication assignment, and induction status.

FINDINGS

Of the 428 participants who completed the 36-week visit, 225 (53%) of participants were receiving MOUD and 203 (47%) were not. Compared to those off medication, participants on medication had fewer opioid use days (4.4 days (SD 9.0) versus 9.8 days (SD 12.1)), fewer met relapse criteria (37 (16.4%) versus 79 (38.9%)), and reported less stimulant use (34 (15.2%) versus 56 (27.7%)) and sedative use (14 (6.3%) versus 31 (15.3%)). There was no difference in abstinence rates between those on or off MOUD. A greater proportion of participants on XR-NTX (47 (53.4%) of 88 participants) were abstinent from non-prescribed opioids compared to those on buprenorphine (28 (23.3%) of 120 participants).

CONCLUSIONS

Naturalistic outcomes data showed that despite potential barriers to continuing treatment in the community, about half of individuals were on opioid use disorder pharmacotherapy at follow-up and those on medication generally had better outcomes. Future research should explore barriers and facilitators to treatment retention in community settings; and developing interventions tailored to improve treatment engagement and adherence.

Transition From Full Mu Opioid Agonists to Buprenorphine in Opioid Dependent Patients-A Critical Review

Methadone, a full opioid agonist at the mu-, kappa-, and delta-receptor, and buprenorphine, a partial agonist at the mu receptor, are first-line medications in opioid maintenance treatment. Transition from methadone to buprenorphine may precipitate withdrawal, and no accepted algorithm for this procedure has been developed. Current treatment strategies recommend transfer from methadone to buprenorphine predominantly in patients at low doses of methadone (30-40 mg/day). There are some reports indicating that transition from higher doses of methadone may be possible. A number of dosing strategies have been proposed to soften withdrawal symptoms and facilitate transfer including use of other opioids or medications and especially microdosing techniques for buprenorphine. The case series and studies available thus far are reviewed.

The Effect of Stress Management Techniques on Persons with Addictive Behaviors: a Systematic Review

Background

According to the current state of knowledge, addictions are often developed as a maladaptive coping response to elevated stress levels. Stress management has a beneficial effect on various mental health problems. Yet, there is no strong evidence concerning the effect of stress management on stress levels of individuals with addictive behaviors, although such an effect might benefit their addictive symptoms.

Objective

To investigate the effect of stress management on stress levels of persons with addictive behaviors.

Methods

A systematic review of the literature was carried out on Biomed Central, PubMed, Scopus and Web of Science searching for relevant trials investigating the effect of stress management techniques, specifically of Progressive Muscle Relaxation (PMR), Autogenic Training (AT) and Guided Imagery (GI), on stress levels of individuals with addictive behaviors. In order to be included, the studies had to be randomized trials using an intervention and a non-intervention or a placebo control group, to apply PMR, GI or AT, to include a sample with addictive behaviors, to be published in English, to involve a baseline and at least one subsequent measurement, to be published in peer-review journals and to measure stress through instruments or biochemical assessments. The trials' quality was assessed by the use of the Jadad Scale.

Results

A total of four studies met the inclusion criteria and were further analyzed. The findings indicated that PMR might lead to a reduction of stress levels, while no such evidence is found concerning GI and AT. The quality of all trials was low.

Conclusion

Progressive Muscle Relaxation and GI might have a divergent effect on persons with addictive behaviors. Yet, the low number of the studies and their poor quality debars drawing reliable conclusions for potential beneficial effects.

Potential therapeutic targets for the treatment of opioid abuse and pain

Although μ-opioid peptide (MOP) receptor agonists are effective analgesics available in clinical settings, their serious adverse effects put limits on their use. The marked increase in abuse and misuse of prescription opioids for pain relief and opioid overdose mortality in the past decade has seriously impacted society. Therefore, safe analgesics that produce potent analgesic effects without causing MOP receptor-related adverse effects are needed. This review highlights the potential therapeutic targets for the treatment of opioid abuse and pain based on available evidence generated through preclinical studies and clinical trials. To ameliorate the abuse-related effects of opioids, orexin-1 receptor antagonists and mixed nociceptin/MOP partial agonists have shown promising results in translational aspects of animal models. There are several promising non-opioid targets for selectively inhibiting pain-related responses, including nerve growth factor inhibitors, voltage-gated sodium channel inhibitors, and cannabinoid- and nociceptin-related ligands. We have also discussed several emerging and novel targets. The current medications for opioid abuse are opioid receptor-based ligands. Although neurobiological studies in rodents have discovered several non-opioid targets, there is a translational gap between rodents and primates. Given that the neuroanatomical aspects underlying opioid abuse and pain are different between rodents and primates, it is pivotal to investigate the functional profiles of these non-opioid compounds compared to those of clinically used drugs in non-human primate models before initiating clinical trials. More pharmacological studies of the functional efficacy, selectivity, and tolerability of these newly discovered compounds in non-human primates will accelerate the development of effective medications for opioid abuse and pain.

What Are the Correlates of Global Variations in the Prevalence of Opioid Use Disorders? An Analysis of Data From the Global Burden of Disease Study, 2019

Introduction

The recent opioid crisis in North America has brought the problem of opioid use disorders (OUD) into clinical and public health focus, with experts warning that other countries or regions may be at future risk of experiencing such crises. The existing literature suggests that a wide range of social, cultural and economic factors may be associated with the onset, course and outcome of OUD in individuals. The current study uses data on the estimated prevalence of OUDs across 115 countries, obtained from the Global Burden of Disease Study, 2019, to examine the bivariate and multivariate associations between national prevalence of OUD and these factors.

Methods

Data on the estimated prevalence of OUDs was obtained via a database query from the Global Burden of Disease (GBD) Collaborative Network database for the year 2019. Recent (2018-2019) data on 10 relevant variables identified in the literature (gross national income, economic inequality, urbanization, social capital, religious affiliation and practice, unemployment, divorce, cultural individualism, and prevalence of depression) were obtained from the GBD, World Bank and Our World in Data databases. After transformation to a normal distribution, bivariate and univariate analyses were conducted to identify the significance and strength of the associations between these variables and the prevalence of OUD.

Results

Of the 10 variables studied, all variables except the divorce rate and religious affiliation were significantly correlated with the prevalence of OUD on bivariate analyses, though the strength of these associations was in the poor to fair range. On multivariate analysis, a significant association was observed only for the prevalence of depression, with trends towards a positive association for cultural individualism and unemployment, and a protective trend observed for religious practice.

Discussion

Though subject to certain limitations inherent in cross-sectional analyses, these results suggest that certain variables may be associated with a higher prevalence of OUD at the national level. Replication and refinement of these analyses may prove useful in identifying countries or regions at risk of a future opioid epidemic or crisis, which could facilitate the institution of preventive measures or early intervention strategies.

Evaluation of Opioid Prescribing Patterns and Use Following Hysterectomy for Benign Indication: A Prospective Cohort Study

OBJECTIVES

To evaluate surgeon opioid prescribing patterns for patients undergoing hysterectomy for benign indication, as well as patient use of postoperative medications and satisfaction with postoperative pain management.

METHODS

Patients undergoing hysterectomy for benign indications at Kingston Health Sciences Centre were invited to participate in a telephone survey 2 weeks post-surgery to review their analgesia use and pain management. Patient demographics, medical history, intraoperative surgical details, and postoperative prescriptions were gathered through patient record review. Opioid prescribing and utilization patterns were assessed, as was satisfaction with postoperative pain management.

RESULTS

Of 124 eligible patients 110 (89%) completed the telephone survey, a mean 15.9 ± 2.3 days after surgery. The mean age of participants was 51.6 ± 11.9 years. Most surgeries (84.5%) were minimally invasive, and 45.5% of patients were discharged within 24 hours of surgery. An opioid prescription was given to 71.8% of participants, and 52.7% used at least 1 dose of opioid medication after discharge. Most participants described very good or adequate postoperative pain management (88.2%). Satisfaction with postoperative pain control was not associated with receipt of an opioid prescription (P = 0.89). A greater proportion of those who used 1 or more doses of opioids versus none indicated poor or inadequate pain management (19.0% vs. 4.1%; P = 0.035).

CONCLUSION

Many patients do not use postoperative opioid analgesia following hospital discharge after hysterectomy, without experiencing poor pain management. Surgeons should assess each individual and tailor the analgesia plan as necessary, optimizing non-opioid options.

Recent advances in the treatment of opioid use disorders-focus on long-acting buprenorphine formulations

Oral methadone or sublingual buprenorphine are first-line medications for pharmacotherapy of opioid use disorders (OUDs). Three long-acting buprenorphine depot or implant formulations are currently available for the treatment of OUDs: (1) CAM 2038 (Buvidal) for subcutaneous weekly and monthly application; (2) RBP-6000 (Sublocade™) as a monthly depot formulation; and (3) A six-month buprenorphine implant [Probuphine™]. The pharmacology, clinical efficacy and prospects of these medications are discussed.

Transition from methadone to subcutaneous buprenorphine depot in patients with opioid use disorder in custodial setting - a case series

BACKGROUND

Methadone, a full opioid agonist, and buprenorphine, a partial agonist at the opioid receptor, are established first-line medications for opioid maintenance therapy. Transition from methadone to sublingual buprenorphine may precipitate withdrawal and is usually performed only in patients on low dose of methadone (<30-40 mg). Transition from methadone to a novel subcutaneous buprenorphine depot (Buvidal) has not been previously described.

OBJECTIVES

To test the hypothesis that a rapid transition from methadone to buprenorphine depot after a single dose of buprenorphine 4 mg sublingual is safe and well tolerated.

METHODS

Retrospective chart analysis of a case series of seven opioid users under custodial setting (prison) who were switched from methadone to buprenorphine depot (initial dose 16 mg weekly subcutaneously) after an initial test dose of buprenorphine 4 mg sublingual within 48 hours.

RESULTS

Clinical data indicate that a rapid transition from methadone to depot buprenorphine is feasible (six patients within 48 hours, one within 4 days). All patients were successfully switched to buprenorphine depot and the transfer period was completed without dropouts or major medical problems. Further dose adjustments were performed in 4 of 7 patients.

CONCLUSIONS

Transition of opioid users from methadone to buprenorphine depot is feasible and safe via 4 mg buprenorphine sublingual. This procedure may facilitate induction of buprenorphine depot formulations in patients treated with methadone.

Reduced habenular volumes and neuron numbers in male heroin addicts: a post-mortem study

The Habenula is increasingly being investigated in addiction. Reduced volumes of other relevant brain regions in addiction, such as nucleus accumbens, globus pallidus and hypothalamus have been reported. Reduced volumes of the habenula as well as reduced neuronal cell count in the habenula have also been reported in mood disorders and an overlap between mood disorders and addiction is clinically widely recognized. Thus, our aim was to investigate possible volume and neuronal cell count differences in heroin addicts compared to healthy controls. Volumes of the medial (MHB) and lateral habenula (LHB) in heroin addicts (n = 12) and healthy controls (n = 12) were assessed by morphometry of 20 µm serial whole brain sections. Total brain volume was larger in the heroin group (mean 1466.6 ± 58.5 cm³ vs. mean 1331.5 ± 98.8 cm³), possibly because the heroin group was about 15 years younger (p = 0.001). Despite larger mean whole brain volume, the mean relative volume of the MHB was smaller than in healthy non-addicted controls (6.94 ± 2.38 × 10^-6 vs.10.64 ± 3.22 × 10^-6; p = 0.004). A similar finding was observed regarding relative volumes of the LHB (46.62 ± 10.90 × 10^-6 vs. 63.05 ± 16.42 × 10^-6 p = 0.009). In parallel, neuronal cell numbers were reduced in the MHB of heroin-addicted subjects (395,966 ± 184,178 vs. 644,149 ± 131,140; p < 0.001). These findings were not significantly confounded by age and duration of autolysis. Our results provide further evidence for brain-structural deficits in heroin addiction.