Optimizing opioid detoxification: rearranging deck chairs on the Titanic

Treatment of opioid use disorder in primary care

Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.

Mortality among individuals accessing pharmacological treatment for opioid dependence in California, 2006-10

AIMS

To estimate mortality rates among treated opioid-dependent individuals by cause and in relation to the general population, and to estimate the instantaneous effects of opioid detoxification and maintenance treatment (MMT) on the hazard of all-cause and cause-specific mortality.

DESIGN

Population-based treatment cohort study.

SETTING

Linked mortality data on all individuals first enrolled in publicly funded pharmacological treatment for opioid dependence in California, USA from 2006 to 2010.

PARTICIPANTS

A total of 32 322 individuals, among whom there were 1031 deaths (3.2%) over a median follow-up of 2.6 years (interquartile range = 1.4-3.7).

MEASUREMENTS

The primary outcome was mortality, indicated by time to death, crude mortality rates (CMR) and standardized mortality ratios (SMR).

FINDINGS

Individuals being treated for opioid dependence had a more than fourfold increase of mortality risk compared with the general population [SMR = 4.5, 95% confidence interval (CI) = 4.2, 4.8]. Mortality risk was higher (1) when individuals were out-of-treatment (SMR = 6.1, 95% CI = 5.7, 6.5) than in-treatment (SMR = 1.8, 95% CI = 1.6, 2.1) and (2) during detoxification (SMR = 2.4, 95% CI = 1.5, 3.8) than during MMT (SMR = 1.8, 95% CI = 1.5, 2.1), especially in the 2 weeks post-treatment entry (SMR = 5.5, 95% CI = 2.7, 9.8 versus SMR = 2.5, 95% CI = 1.7, 4.9). Detoxification and MMT both independently reduced the instantaneous hazard of all-cause and drug-related mortality. MMT preceded by detoxification was associated with lower all-cause and other cause-specific mortality than MMT alone.

CONCLUSIONS

In people with opiate dependence, detoxification and methadone maintenance treatment both independently reduce the instantaneous hazard of all-cause and drug-related mortality.

Adoption of evidence-based clinical innovations: the case of buprenorphine use by opioid treatment programs

This article examines changes from 2005 to 2011 in the use of an evidence-based clinical innovation, buprenorphine use, among a nationally representative sample of opioid treatment programs and identifies characteristics associated with its adoption. We apply a model of the adoption of clinical innovations that focuses on the work needs and characteristics of staff; organizations' technical and social support for the innovation; local market dynamics and competition; and state policies governing the innovation. Results indicate that buprenorphine use increased 24% for detoxification and 47% for maintenance therapy between 2005 and 2011. Buprenorphine use was positively related to reliance on private insurance and availability of state subsidies to cover its cost and inversely related to the percentage of clients who injected opiates, county size, and local availability of methadone. The results indicate that financial incentives and market factors play important roles in opioid treatment programs' decisions to adopt evidence-based clinical innovations such as buprenorphine use.

Top manager effects on buprenorphine adoption in outpatient substance abuse treatment programs

To examine the influence of top managers' characteristics on the adoption of buprenorphine for opioid dependence among U.S. outpatient substance abuse treatment units, this investigation analyzed a cross-sectional national study of 547 such units in the 2004-2005 wave of the Drug Abuse Treatment System Survey. Administrators reported their demographics, training, and treatment orientation, as well as features of the unit and its pattern of use of buprenorphine. Nationally, 15.8% of programs offered any buprenorphine services. Greater adoption of buprenorphine correlated with directors' younger age, longer tenure, male gender, and weaker endorsement of abstinence as the most important treatment goal. Availability of naltrexone and medical services also correlated positively with buprenorphine adoption. The authors conclude that leaders' characteristics are related to the adoption of innovative practices in addiction treatment programs. Future work should examine whether leadership development for community addiction programs might speed up the diffusion of buprenorphine and other innovative, evidence-based practices.

Pharmacologic treatments for opioid dependence: detoxification and maintenance options

While opioid dependence has more treatment agents available than other abused drugs, none are curative. They can, however, markedly diminish withdrawal symptoms and craving, and block opioid effects due to lapses.

The most effective withdrawal method is substituting and tapering methadone or buprenorphine, α-2 Adrenergic agents can ameliorate untreated symptoms or substitute for agonists if not available. Shortening withdrawal by precipitating it with narcotic antagonists has been studied, but the methods are plagued by safety issues or persisting symptoms. Neither the withdrawal agents nor the methods are associated with better long-term outcome, which appears mostly related to post-detoxification treatment.

Excluding those with short-term habits, the best outcome occurs with long-term maintenance on methadone or buprenorphine accompanied by appropriate psychosocial interventions. Those with strong external motivation may do well on the antagonist naltrexone. Currently, optimum duration of maintenance on either is unclear. Better agents are needed to impact the brain changes related to addiction.