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Westenberg JN, Tai AMY, Elsner J, Kamel MM, Wong JSH, Azar P, Vo DX, Moore E, Mathew N, Seethapathy V, Choi F, Vogel M, Krausz RM. Treatment approaches and outcome trajectories for youth with high-risk opioid use: A narrative review. Early Interv Psychiatry 2022; 16:207-220. [PMID: 33913589 DOI: 10.1111/eip.13155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/22/2021] [Indexed: 12/26/2022]
Abstract
AIM First use of opioids often happens in adolescence and an increasing number of opioid overdoses are being reported among youth. The purpose of this narrative review was to present the treatment approaches for youth with high-risk opioid use, determine whether the literature supports the use of opioid agonist treatment among youth and identify evidence for better treatment outcomes in the younger population. METHODS A search of the literature on PubMed using MeSH terms specific to youth, opioid use and treatment approaches generated 1436 references. Following a screening process, 137 papers were found to be relevant to the treatment of high-risk opioid use among youth. After full-text review, 19 eligible studies were included: four randomized controlled trials, nine observational studies and six reviews. RESULTS Research for the different treatment options among youth is limited. The available evidence shows better outcomes in terms of retention in care and cost-effectiveness for opioid agonist treatment than abstinence-based comparisons. Integrating psychosocial interventions into the continuum of care for youth can be an effective way of addressing comorbid psychiatric conditions and emotional drivers of substance use, leading to improved treatment trajectories. CONCLUSIONS From the limited findings, there is no evidence to deny youth with high-risk opioid use the same treatment options available to adults. A combination of pharmacological and youth-specific psychosocial interventions is required to maximize retention and survival. There is an urgent need for more research to inform clinical strategies toward appropriate treatment goals for such vulnerable individuals.
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Affiliation(s)
- Jean Nicolas Westenberg
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andy M Y Tai
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julie Elsner
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mostafa M Kamel
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Neuropsychiatry, Tanta University, Tanta, Egypt
| | - James S H Wong
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pouya Azar
- Complex Pain and Addiction Services, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Department of Psychiatry, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Dzung X Vo
- Division of Adolescent Health and Medicine, Department of Pediatrics, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Eva Moore
- Division of Adolescent Health and Medicine, Department of Pediatrics, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Nickie Mathew
- Department of Psychiatry, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada.,BC Mental Health & Substance Use Services, Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Vijay Seethapathy
- Department of Psychiatry, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada.,BC Mental Health & Substance Use Services, Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Fiona Choi
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marc Vogel
- Psychiatric University Clinic Basel, Basel, Switzerland
| | - Reinhard M Krausz
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Wong JSH, Nikoo M, Westenberg JN, Suen JG, Wong JYC, Krausz RM, Schütz CG, Vogel M, Sidhu JA, Moe J, Arishenkoff S, Griesdale D, Mathew N, Azar P. Comparing rapid micro-induction and standard induction of buprenorphine/naloxone for treatment of opioid use disorder: protocol for an open-label, parallel-group, superiority, randomized controlled trial. Addict Sci Clin Pract 2021; 16:11. [PMID: 33579359 PMCID: PMC7881636 DOI: 10.1186/s13722-021-00220-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/23/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Buprenorphine/naloxone (Suboxone) is a current first-line treatment for opioid use disorder (OUD). The standard induction method of buprenorphine/naloxone requires patients to be abstinent from opioids and therefore experience withdrawal symptoms prior to induction, which can be a barrier in starting treatment. Rapid micro-induction (micro-dosing) involves the administration of small, frequent does of buprenorphine/naloxone and removes the need for a period of withdrawal prior to the start of treatment. This study aims to compare the effectiveness and safety of rapid micro-induction versus standard induction of buprenorphine/naloxone in patients with OUD. METHODS This is a randomized, open-label, two-arm, superiority, controlled trial comparing the safety and effectiveness of rapid micro-induction versus standard induction of buprenorphine/naloxone for the treatment of OUD. A total of 50 participants with OUD will be randomized at one Canadian hospital. The primary outcome is the completion of buprenorphine/naloxone induction with low levels of withdrawal. Secondary outcomes are treatment retention, illicit drug use, self-reported drug use behaviour, craving, pain, physical health, safety, and client satisfaction. DISCUSSION This is the first randomized controlled trial to compare the effectiveness and safety of rapid micro-induction versus standard induction of buprenorphine/naloxone. This study will thereby generate evidence for a novel induction method which eliminates substantial barriers to the use of buprenorphine/naloxone in the midst of the ongoing opioid crisis. Trial registration ClinicalTrials.gov, NCT04234191; date of registration: January 21, 2020; https://clinicaltrials.gov/ct2/show/NCT04234191.
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Affiliation(s)
- James S H Wong
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, The University of British Columbia, 430-5950, David Strangway Building, Vancouver, BC, V6T 1Z3, Canada.
| | - Mohammadali Nikoo
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, The University of British Columbia, 430-5950, David Strangway Building, Vancouver, BC, V6T 1Z3, Canada
| | - Jean N Westenberg
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, The University of British Columbia, 430-5950, David Strangway Building, Vancouver, BC, V6T 1Z3, Canada
| | - Janet G Suen
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, The University of British Columbia, 430-5950, David Strangway Building, Vancouver, BC, V6T 1Z3, Canada
| | - Jennifer Y C Wong
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, The University of British Columbia, 430-5950, David Strangway Building, Vancouver, BC, V6T 1Z3, Canada
| | - Reinhard M Krausz
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, The University of British Columbia, 430-5950, David Strangway Building, Vancouver, BC, V6T 1Z3, Canada
| | - Christian G Schütz
- Behavioral Reward Affect + Impulsivity Neuroscience Lab, Institute of Mental Health, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Marc Vogel
- Division of Addictive Disorders, University of Basel Psychiatric Hospital, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland
| | - Jesse A Sidhu
- Department of Psychiatry, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada
| | - Jessica Moe
- Department of Emergency Medicine, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada
- BC Centre for Disease Control, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Shane Arishenkoff
- Department of Medicine, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada
| | - Nickie Mathew
- Department of Psychiatry, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada
- BC Mental Health & Substance Use Services, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Pouya Azar
- Department of Psychiatry, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada
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Ho RCM, Chen KY, Broekman B, Mak A. Buprenorphine prescription, misuse and service provision: a global perspective. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.bp.108.005975] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryBuprenorphine, a partial μ-opioid agonist and κ-opioid antagonist, is recommended as safe and effective maintenance treatment for opioid dependence. It offers the possibility of management in primary care settings. However, its prescription has led to diversion for illicit recreational use and resulted in medical complications and, rarely, fatal overdose in combination with other sedatives. The outcome of buprenorphine maintenance programmes varies from country to country and it is determined by the local therapeutic traditions, regulatory restrictions and existing service provision for opioid misusers. This article addresses the pharmacology of buprenorphine, the benefits and drawbacks of its prescription, service provision for opioid misuse around the world, policy recommendations, and prescribing training requirements.
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Abstract
Opioids are very addictive drugs because of their powerful effects on reward and pain pathways in the brain. Opioid addiction is currently a worldwide problem and injecting heroin presents serious health risks including death from overdose. The increase in the nonmedical use of prescription opioids and the increase in overdose deaths are worrying trends in North America. There is therefore an increasing need for access to effective treatments. The 2 major drug treatments, methadone and buprenorphine, have proven efficacy but are not necessarily administered in the most effective doses or under optimum conditions. Alternative approaches such as slow-release oral morphine, tincture of opium, and the use of the opioid antagonist naltrexone to maintain abstinence are used seemingly effectively in some countries but have yet to be fully evaluated in randomized controlled trials. Heroin-assisted treatment has proven to be a valuable and effective treatment when administered in specialized clinics but is only appropriate for those who have failed to improve on optimal methadone or buprenorphine maintenance. Recent innovations and substitution treatment as an alternative to incarceration are described. Drug treatment of opioid addiction is most effective when administered as part of a therapeutic program as demonstrated in the initial methadone evaluations and the more recent trials with heroin-assisted treatment.
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Affiliation(s)
- Alyson J Bond
- Department of Addiction, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - John Witton
- Department of Addiction, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
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Nahar LK, Andrews R, Paterson S. Validated Method for the Quantification of Buprenorphine in Postmortem Blood Using Solid-Phase Extraction and Two-Dimensional Gas Chromatography–Mass Spectrometry. J Anal Toxicol 2015; 39:519-25. [DOI: 10.1093/jat/bkv051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Martinez-Raga J, Gonzalez-Saiz F, Oñate J, Oyagüez I, Sabater E, Casado MA. Budgetary impact analysis of buprenorphine-naloxone combination (Suboxone®) in Spain. HEALTH ECONOMICS REVIEW 2012; 2:3. [PMID: 22828157 PMCID: PMC3402931 DOI: 10.1186/2191-1991-2-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 03/29/2012] [Indexed: 05/13/2023]
Abstract
BACKGROUND Opioid addiction is a worldwide problem. Agonist opioid treatment (AOT) is the most widespread and frequent pharmacotherapeutic approach. Methadone has been the most widely used AOT, but buprenorphine, a partial μ-opiod agonist and a κ-opiod antagonist, is fast gaining acceptance. The objective was to assess the budgetary impact in Spain of the introduction of buprenorphine-naloxone (B/N) combination. METHODS A budgetary impact model was developed to estimate healthcare costs of the addition of B/N combination to the therapeutic arsenal for treating opioid dependent patients, during a 3-year period under the National Health System perspective. Inputs for the model were obtained from the specialized scientific literature. Detailed information concerning resource consumption (drug cost, logistics, dispensing, medical, psychiatry and pharmacy supervision, counselling and laboratory test) was obtained from a local expert panel. Costs are expressed in euros (€, 2010). RESULTS The number of patients estimated to be prescribed B/N combination was 2,334; 2,993 and 3,589 in the first, second and third year respectively. Total budget is €85,766,129; €79,855,471 and €79,137,502 in the first, second and third year for the scenario without B/N combination. With B/N combination the total budget would be €86,589,210; €80,398,259 and €79,708,964 in the first, second and third year of the analyses. Incremental cost/patient comparing the addition of the B/N combination to the scenario only with methadone is €10.58; €6.98 and €7.34 in the first, second and third year respectively. CONCLUSION Addition of B/N combination would imply a maximum incremental yearly cost of €10.58 per patient compared to scenario only with methadone and would provide additional benefits.
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Affiliation(s)
- Jose Martinez-Raga
- Unidad Docente de Psiquiatría y Psicología Médica, University of Valencia Medical School and Unidad de Conductas Adictivas de Gandía, Agencia Valenciana de Salut, Valencia, Spain
| | - Francisco Gonzalez-Saiz
- Unidad de Salud Mental Comunitaria Villamartin. UGC Salud Mental Hospital de Jerez, Servicio Andaluz de Salud, Spain
| | | | - Itziar Oyagüez
- Pharmacoeconomics and Outcomes Research Iberia, C/de la Golondrina 40A. Madrid 28023, Madrid, Spain
| | - Eliazar Sabater
- Pharmacoeconomics and Outcomes Research Iberia, C/de la Golondrina 40A. Madrid 28023, Madrid, Spain
| | - Miguel A Casado
- Pharmacoeconomics and Outcomes Research Iberia, C/de la Golondrina 40A. Madrid 28023, Madrid, Spain
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Amass L, Pukeleviciene V, Subata E, Almeida AR, Pieri MC, D'Egidio P, Stankova Z, Costa A, Smyth BP, Sakoman S, Wei Y, Strang J. A prospective, randomized, multicenter acceptability and safety study of direct buprenorphine/naloxone induction in heroin-dependent individuals. Addiction 2012; 107:142-51. [PMID: 21749526 DOI: 10.1111/j.1360-0443.2011.03577.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To provide controlled data on direct induction with buprenorphine/naloxone (BNX) versus indirect buprenorphine (BPN)-to-BNX induction. DESIGN Phase 4, prospective, randomized, active-drug controlled, parallel-group trial consisting of a 2-day, double-blind, double-dummy induction phase followed by 26 days of open-label treatment with BNX. SETTING Nineteen sites in 10 European countries from March 2008 to December 2009. PARTICIPANTS A total of 187 opioid-dependent men and women ≥ 15 years of age. MEASUREMENTS The primary objective was assessment of patient response to direct and indirect BNX induction [proportion of patients receiving the scheduled 16-mg BNX dose on day 3 (i.e. first day post-induction)]. Secondary assessments included illicit drug use, treatment retention and compliance, withdrawal scale scores, and safety. FINDINGS Patient response to direct- versus indirect-BNX induction was similar [direct 91.4% (85/93) versus indirect 90.4% (85/94); 95% confidence interval (CI): -7.3%, 9.2%]. Rapid dose induction (16 mg of BPN equivalent on day 2) was acceptable and 72% of patients completed treatment (day 28). There were no significant differences in secondary measures across groups. An average BNX maintenance dose of 15.3 mg across groups was associated with substantial reductions in illicit opioid use and no self-reported intravenous misuse. Treatment compliance and retention rates were similar (98.5% and 81.3%, respectively). Treatment-emergent adverse event rates were comparable: 75% versus 74% for direct- versus indirect-induction groups, respectively. CONCLUSIONS Direct buprenorphine/naloxone induction was a safe and effective strategy for maintenance treatment of opioid dependence. Response to high-dose direct buprenorphine/naloxone induction appears to be similar to indirect buprenorphine-to-buprenorphine/naloxone induction and was not associated with reports of intravenous buprenorphine/naloxone misuse.
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Affiliation(s)
- Leslie Amass
- Schering Corporation, A Division of Merck and Company, Kenilworth, NJ 07830, USA.
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Wright NMJ, Sheard L, Adams CE, Rushforth BJ, Harrison W, Bound N, Hart R, Tompkins CNE. Comparison of methadone and buprenorphine for opiate detoxification (LEEDS trial): a randomised controlled trial. Br J Gen Pract 2011; 61:e772-80. [PMID: 22137413 PMCID: PMC3223774 DOI: 10.3399/bjgp11x613106] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 08/19/2011] [Accepted: 09/15/2011] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Many opiate users require prescribed medication to help them achieve abstinence, commonly taking the form of a detoxification regime. In UK prisons, drug users are nearly universally treated for their opiate use by primary care clinicians, and once released access GP services where 40% of practices now treat drug users. There is a paucity of evidence evaluating methadone and buprenorphine (the two most commonly prescribed agents in the UK) for opiate detoxification. AIM To evaluate whether buprenorphine or methadone help to achieve drug abstinence at completion of a reducing regimen for heroin users presenting to UK prison health care for detoxification. DESIGN Open-label, pragmatic, randomised controlled trial in three prison primary healthcare departments in the north of England. METHOD Prisoners (n = 306) using illicit opiates were recruited and given daily sublingual buprenorphine or oral methadone, in the context of routine care, over a standard reduced regimen of not more than 20 days. The primary outcome measure was abstinence from illicit opiates at 8 days post detoxification, as indicated by urine test (self-report/clinical notes where urine sample was not feasible). Secondary outcomes were also recorded. RESULTS Abstinence was ascertained for 73.7% at 8 days post detoxification (urine sample = 52.6%, self report = 15.2%, clinical notes = 5.9%). There was no statistically significant difference in the odds of achieving abstinence between methadone and buprenorphine (odds ratio [OR] = 1.69; 95% confidence interval [CI] = 0.81 to 3.51; P = 0.163). Abstinence was associated solely with whether or not the participant was still in prison at that time (15.22 times the odds; 95% CI = 4.19 to 55.28). The strongest association for lasting abstinence was abstinence at an earlier time point. CONCLUSION There is equal clinical effectiveness between methadone and buprenorphine in achieving abstinence from opiates at 8 days post detoxification within prison.
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Duxbury K, Romagnoli C, Anderson M, Watts R, Waite G. Development of a clinically relevant liquid chromatography tandem mass spectrometry assay for 13 drugs of abuse in urine, designed to meet the needs of the service users. Ann Clin Biochem 2010; 47:415-22. [DOI: 10.1258/acb.2010.010049] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background The clinical requirements of the users of assay results must be at the centre of assay development. We aimed to develop a single liquid chromatography tandem mass spectrometry (LC-MS/MS) assay for drugs of abuse in urine that would meet the needs of our service users and replace the multiple screening and confirmatory techniques previously in use. Methods After discussion with our users, it was decided that 13 drugs and metabolites should be measured in our panel: morphine, codeine, norcodeine, dihydrocodeine, 6-monoacetylmorphine, acetyl codeine, methadone and its metabolite, buprenorphine and its metabolite, amphetamine, benzoylecgonine and cotinine. Urine samples were prepared by the addition of internal standard, enzymatic hydrolysis and solid-phase extraction. Chromatography conditions were optimized so that the analytes were separated within a run time of 6 min. Optimal parent to daughter m/z ion transitions were chosen for all drugs and daughter ion ratios were used. Results The LC-MS/MS assay was successfully validated with acceptable precision and lower limits of quantification for all drugs. No matrix effects were seen. The results produced by the LC-MS/MS assay compared well with the previous combination of techniques in use. Conclusions We have developed and validated a fit-for-purpose LC-MS/MS assay for 13 drugs of abuse in urine that obviates the need for multiple screening and confirmatory analytical techniques.
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Affiliation(s)
- K Duxbury
- Department of Clinical Biochemistry, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK
| | - C Romagnoli
- Department of Clinical Biochemistry, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK
| | - M Anderson
- Department of Clinical Biochemistry, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK
| | - R Watts
- Waters Corporation, MS Technologies Centre, Atlas Park, Simonsway, Manchester, M22 5PP, UK
| | - G Waite
- Department of Clinical Biochemistry, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK
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Luty J, O'Gara C, Sessay M, Sarkhel A. A survey of community drug team prescribing policies and client views. JOURNAL OF SUBSTANCE USE 2010. [DOI: 10.3109/14659890902967073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sheard L, Wright NMJ, Adams CE, Bound N, Rushforth B, Hart R, Tompkins CNE. The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) Prisons Project Study: protocol for a randomised controlled trial comparing methadone and buprenorphine for opiate detoxification. Trials 2009; 10:53. [PMID: 19602218 PMCID: PMC2715402 DOI: 10.1186/1745-6215-10-53] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Accepted: 07/14/2009] [Indexed: 11/25/2022] Open
Abstract
Background In the United Kingdom (UK), there is an extensive market for the class 'A' drug heroin and many heroin users spend time in prison. People addicted to heroin often require prescribed medication when attempting to cease their drug use. The most commonly used detoxification agents in UK prisons are currently buprenorphine and methadone, both are recommended by national clinical guidelines. However, these agents have never been compared for opiate detoxification in the prison estate and there is a general paucity of research evaluating the most effective treatment for opiate detoxification in prisons. This study seeks to address this paucity by evaluating the most routinely used interventions amongst drug users within UK prisons. Methods/Design This study uses randomised controlled trial methodology to compare the open use of buprenorphine and methadone for opiate detoxification, given in the context of routine care, within three UK prisons. Prisoners who are eligible and give informed consent will be entered into the trial. The primary outcome will be abstinence status eight days after detoxification, as determined by a urine test. Secondary outcomes will be recorded during the detoxification and then at one, three and six months post-detoxification. Trial registration Current Controlled Trials ISRCTN58823759
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Affiliation(s)
- Laura Sheard
- Leeds Primary Care Trust based at Leeds Institute for Health Sciences, 101 Clarendon Road, Leeds, LS2 9LJ, UK.
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White R, Beazley P, Thompson M, Charnaud B, Cox D, Griffiths V. Patients' views of treatment: methadone vs. buprenorphine. JOURNAL OF SUBSTANCE USE 2009. [DOI: 10.1080/14659890701289463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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13
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Factors associated with the prescribing of buprenorphine or methadone for treatment of opiate dependence. J Subst Abuse Treat 2009; 37:95-100. [DOI: 10.1016/j.jsat.2008.09.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Revised: 09/18/2008] [Accepted: 09/19/2008] [Indexed: 11/23/2022]
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The implications of medication development in the treatment of substance use disorders in developing countries. Curr Opin Psychiatry 2009; 22:274-80. [PMID: 19346946 DOI: 10.1097/yco.0b013e32832a1dc0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To enquire as to how applicable are the latest developments in pharmacotherapy of substance use disorders (SUDs) to patients in developing countries. We review the latest literature regarding the magnitude of the problem in developing countries. We then present a review of recent developments in pharmacotherapy of SUDs, especially from developing countries. Finally, we discuss the barriers that prevent patients in developing countries from benefiting from these developments. RECENT FINDINGS The problem of SUDs is increasing in developing countries and there is a severe shortage of manpower to manage it. Disulfiram, naltrexone and acamprosate are useful in treating alcohol dependence, and likewise methadone and buprenorphine in treating opioid dependence. Strategies of matching patients to medications and combining the medications have shown promise. There is a parallel benefit of reduction in the risk of HIV spread among injecting drug users. However, many barriers prevent an average patient with SUD from benefiting from these developments. CONCLUSION Medication treatment can improve the outcome of SUDs. Research in this field is catching up in developing countries. However, due to issues of availability, affordability, manpower and governmental policies, a large number of patients in these countries are unable to benefit from recent developments. Urgent efforts are required to fill this gap between research and practice.
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Sheard L, Wright NMJ, El-Sayeh HG, Adams CE, Li R, Tompkins CNE. The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) prisons project: a randomised controlled trial comparing dihydrocodeine and buprenorphine for opiate detoxification. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2009; 4:1. [PMID: 19196468 PMCID: PMC2649065 DOI: 10.1186/1747-597x-4-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Accepted: 02/05/2009] [Indexed: 11/21/2022]
Abstract
Background Many opiate users entering British prisons require prescribed medication to help them achieve abstinence. This commonly takes the form of a detoxification regime. Previously, a range of detoxification agents have been prescribed without a clear evidence base to recommend a drug of choice. There are few trials and very few in the prison setting. This study compares dihydrocodeine with buprenorphine. Methods Open label, pragmatic, randomised controlled trial in a large remand prison in the North of England. Ninety adult male prisoners requesting an opiate detoxification were randomised to receive either daily sublingual buprenorphine or daily oral dihydrocodeine, given in the context of routine care. All participants gave written, informed consent. Reducing regimens were within a standard regimen of not more than 20 days and were at the discretion of the prescribing doctor. Primary outcome was abstinence from illicit opiates as indicated by a urine test at five days post detoxification. Secondary outcomes were collected during the detoxification period and then at one, three and six months post detoxification. Analysis was undertaken using relative risk tests for categorical data and unpaired t-tests for continuous data. Results 64% of those approached took part in the study. 63 men (70%) gave a urine sample at five days post detoxification. At the completion of detoxification, by intention to treat analysis, a higher proportion of people allocated to buprenorphine provided a urine sample negative for opiates (abstinent) compared with those who received dihydrocodeine (57% vs 35%, RR 1.61 CI 1.02–2.56). At the 1, 3 and 6 month follow-up points, there were no significant differences for urine samples negative for opiates between the two groups. Follow up rates were low for those participants who had subsequently been released into the community. Conclusion These findings would suggest that dihydrocodeine should not be routinely used for detoxification from opiates in the prison setting. The high relapse rate amongst those achieving abstinence would suggest the need for an increased emphasis upon opiate maintenance programmes in the prison setting. Trial registration Current Controlled Trials ISRCTN07752728
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Affiliation(s)
- Laura Sheard
- Leeds Institute of Health Sciences, Charles Thackrah Building, 101 Clarendon Road, Leeds, LS2 9LJ, UK.
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Strang J, Manning V, Mayet S, Ridge G, Best D, Sheridan J. Does prescribing for opiate addiction change after national guidelines? Methadone and buprenorphine prescribing to opiate addicts by general practitioners and hospital doctors in England, 1995-2005. Addiction 2007; 102:761-70. [PMID: 17506153 DOI: 10.1111/j.1360-0443.2007.01762.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To assess changes in opiate prescribing (1995-2005) following a decade of national guidelines to address substandard opiate substitution prescribing for heroin addiction. DESIGN A repeat national survey (1995 and 2005) using random one-in-four samples of all community pharmacies in England, achieving response rates of 75% (1847/2475) in 1995 and 95% (2349/2473) in 2005. Data were obtained on 3732 (1995 data) and 9620 (2005 data) prescriptions dispensed in the preceding month from the 936 and 1463 pharmacies who were currently dispensing. MEASUREMENTS We have measured impact on practice for seven specific recommended changes. FINDINGS Between 1995 and 2005 the number of substitute opiate prescriptions doubled (x 2.03). By 2005, methadone still dominated (down from 97% to 83%), buprenorphine increased (from 1% to 16%) and other opiate medications virtually disappeared. Changes in the direction of national guidelines included: increased daily dose of methadone (from 47.3 mg to 56.3 mg), more frequent dispensing (from 38% to 60% as daily installments), more supervised consumption (from 0% to 36%) and fewer methadone tablets (from 10.9% to 1.8%). Nevertheless, despite the increased mean daily dose, only 41.0% of prescriptions for methadone were for daily doses in the recommended 60-120 mg dose range. Only one change was not in the direction of the national guidelines--the proportion of prescriptions from GPs fell from 41% to 30%, although this still represented an approximate 50% increase in the extent of GP prescribing. CONCLUSION Doubling in provision of opiate substitute treatment has occurred, alongside significant improvements in the nature of this treatment. These positive changes have occurred in the direction of six out of seven of the UK national guidelines.
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Affiliation(s)
- John Strang
- National Addiction Centre, Denmark Hill, London, UK.
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Sheard L, Adams CE, Wright NMJ, El-Sayeh H, Dalton R, Tompkins CNE. The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) prisons project pilot study: protocol for a randomised controlled trial comparing dihydrocodeine and buprenorphine for opiate detoxification. Trials 2007; 8:1. [PMID: 17210080 PMCID: PMC1780064 DOI: 10.1186/1745-6215-8-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2006] [Accepted: 01/08/2007] [Indexed: 12/02/2022] Open
Abstract
Background In the United Kingdom (UK), there is an extensive market for the class 'A' drug heroin. Many heroin users spend time in prison. People addicted to heroin often require prescribed medication when attempting to cease their drug use. The most commonly used detoxification agents in UK prisons are buprenorphine, dihydrocodeine and methadone. However, national guidelines do not state a detoxification drug of choice. Indeed, there is a paucity of research evaluating the most effective treatment for opiate detoxification in prisons. This study seeks to address the paucity by evaluating routinely used interventions amongst drug using prisoners within UK prisons. Methods/Design The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) Prisons Pilot Study will use randomised controlled trial methodology to compare the open use of buprenorphine and dihydrocodeine for opiate detoxification, given in the context of routine care, within HMP Leeds. Prisoners who are eligible and give informed consent will be entered into the trial. The primary outcome measure will be abstinence status at five days post detoxification, as determined by a urine test. Secondary outcomes during the detoxification and then at one, three and six months post detoxification will be recorded.
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Affiliation(s)
- Laura Sheard
- Leeds West Primary Care Trust based at Centre for Research in Primary Care, 71-75 Clarendon Road, Leeds, LS2 9PL, UK
| | - Clive E Adams
- Department of Psychiatry, 15 Hyde Terrace, University of Leeds, Leeds, LS2 9LT, UK
| | - Nat MJ Wright
- Leeds West Primary Care Trust based at Centre for Research in Primary Care, 71-75 Clarendon Road, Leeds, LS2 9PL, UK
| | - Hany El-Sayeh
- Craven, Harrogate and Rural District Primary Care Trust, The Briary Wing, Harrogate District Hospital, Lancaster Park Road, Harrogate HG2 7SX, UK
| | - Richard Dalton
- Formerly HMP Leeds, 2 Gloucester Terrace, Armley, Leeds, LS12 2TJ, UK
| | - Charlotte NE Tompkins
- Leeds West Primary Care Trust based at Centre for Research in Primary Care, 71-75 Clarendon Road, Leeds, LS2 9PL, UK
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Wright NMJ, Sheard L, Tompkins CNE, Adams CE, Allgar VL, Oldham NS. Buprenorphine versus dihydrocodeine for opiate detoxification in primary care: a randomised controlled trial. BMC FAMILY PRACTICE 2007; 8:3. [PMID: 17210079 PMCID: PMC1774569 DOI: 10.1186/1471-2296-8-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Accepted: 01/08/2007] [Indexed: 11/22/2022]
Abstract
Background Many drug users present to primary care requesting detoxification from illicit opiates. There are a number of detoxification agents but no recommended drug of choice. The purpose of this study is to compare buprenorphine with dihydrocodeine for detoxification from illicit opiates in primary care. Methods Open label randomised controlled trial in NHS Primary Care (General Practices), Leeds, UK. Sixty consenting adults using illicit opiates received either daily sublingual buprenorphine or daily oral dihydrocodeine. Reducing regimens for both interventions were at the discretion of prescribing doctor within a standard regimen of not more than 15 days. Primary outcome was abstinence from illicit opiates at final prescription as indicated by a urine sample. Secondary outcomes during detoxification period and at three and six months post detoxification were recorded. Results Only 23% completed the prescribed course of detoxification medication and gave a urine sample on collection of their final prescription. Risk of non-completion of detoxification was reduced if allocated buprenorphine (68% vs 88%, RR 0.58 CI 0.35–0.96, p = 0.065). A higher proportion of people allocated to buprenorphine provided a clean urine sample compared with those who received dihydrocodeine (21% vs 3%, RR 2.06 CI 1.33–3.21, p = 0.028). People allocated to buprenorphine had fewer visits to professional carers during detoxification and more were abstinent at three months (10 vs 4, RR 1.55 CI 0.96–2.52) and six months post detoxification (7 vs 3, RR 1.45 CI 0.84–2.49). Conclusion Informative randomised trials evaluating routine care within the primary care setting are possible amongst drug using populations. This small study generates unique data on commonly used treatment regimens.
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Affiliation(s)
- Nat MJ Wright
- Centre for Research in Primary Care, 71-75 Clarendon Road, Leeds, LS2 9PL, UK
| | - Laura Sheard
- Centre for Research in Primary Care, 71-75 Clarendon Road, Leeds, LS2 9PL, UK
| | | | - Clive E Adams
- Department of Psychiatry, 15 Hyde Terrace, Leeds, LS2 9L, UK
| | - Victoria L Allgar
- Centre for Research in Primary Care, 71-75 Clarendon Road, Leeds, LS2 9PL, UK
| | - Nicola S Oldham
- Formerly of NFA Health Centre for Homeless People, 68 York Street, Leeds, LS9 8AA, UK
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