1
|
Rudolph KE, Williams NT, Goodwin ATS, Shulman M, Fishman M, Díaz I, Luo S, Rotrosen J, Nunes EV. Buprenorphine & methadone dosing strategies to reduce risk of relapse in the treatment of opioid use disorder. Drug Alcohol Depend 2022; 239:109609. [PMID: 36075154 PMCID: PMC9741946 DOI: 10.1016/j.drugalcdep.2022.109609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although there is consensus that having a "high-enough" dose of buprenorphine (BUP-NX) or methadone is important for reducing relapse to opioid use, there is debate about what this dose is and how it should be attained. We estimated the extent to which different dosing strategies would affect risk of relapse over 12 weeks of treatment, separately for BUP-NX and methadone. METHODS This was a secondary analysis of three comparative effectiveness trials. We examined four dosing strategies: 1) increasing dose in response to participant-specific opioid use, 2) increasing dose weekly until some minimum dose (16 mg BUP, 100 mg methadone) was reached, 3) increasing dose weekly until some minimum and increasing dose in response to opioid use thereafter (referred to as the "hybrid strategy"), and 4) keeping dose constant after the first 2 weeks of treatment. We used a longitudinal sequentially doubly robust estimator to estimate contrasts between dosing strategies on risk of relapse. RESULTS For BUP-NX, increasing dose following the hybrid strategy resulted in the lowest risk of relapse. For methadone, holding dose constant resulted in greatest risk of relapse; the other three strategies performed similarly. For example, the hybrid strategy reduced week 12 relapse risk by 13 % (RR: 0.87, 95 %CI: 0.83-0.95) and by 20 % (RR: 0.80, 95 %CI: 0.71-0.90) for BUP-NX and methadone respectively, as compared to holding dose constant. CONCLUSIONS Doses should be targeted toward minimum thresholds and, in the case of BUP-NX, raised when patients continue to use opioids.
Collapse
Affiliation(s)
- Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Nicholas T Williams
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Alicia T Singham Goodwin
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Matisyahu Shulman
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
| | - Marc Fishman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, and Maryland Treatment Centers, Baltimore, MD, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Sean Luo
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
| | - John Rotrosen
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
| | - Edward V Nunes
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
| |
Collapse
|
2
|
Rudolph KE, Shulman M, Fishman M, Díaz I, Rotrosen J, Nunes EV. Association between dynamic dose increases of buprenorphine for treatment of opioid use disorder and risk of relapse. Addiction 2022; 117:637-645. [PMID: 34338389 PMCID: PMC9717480 DOI: 10.1111/add.15654] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 07/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Dynamic, adaptive pharmacologic treatment for opioid use disorder (OUD) has been previously recommended over static dosing to prevent relapse, and is aligned with personalized medicine. However, there has been no quantitative evidence demonstrating its advantage. Our objective was to estimate the extent to which a hypothetical intervention that increased buprenorphine dose in response to opioid use would affect risk of relapse over 24 weeks of follow-up. DESIGN A secondary analysis of the buprenorphine arm of an open-label randomized controlled 24-week comparative effectiveness trial, 2014-17. SETTING Eight community addiction treatment programs in the United States. PARTICIPANTS English-speaking adults with DSM-5 OUD, recruited during inpatient admission (n = 270). Participants were mainly white (65%) and male (72%). INTERVENTION(S) Participants were treated with daily sublingual buprenorphine-naloxone (BUP-NX), with dose based on clinical indication, determined by the provider. We examined a hypothetical intervention of increasing dose in response to opioid use. MEASUREMENTS Outcome was relapse to regular opioid use during the 24 weeks of outpatient treatment, assessed in a survival framework. We estimated the relapse-free survival curves of participants under a hypothetical (i.e. counterfactual) intervention in which their BUP-NX dosage would be increased following their own subject-specific opioid use during the first 12 weeks of treatment versus a hypothetical intervention in which dose would remain constant. FINDINGS We estimated that increasing BUP-NX dose in response to recent opioid use would lower risk of relapse by 19.17 percentage points [95% confidence interval (CI) = -32.17, -6.18) (additive risk)] and 32% (0.68, 95% CI = 0.49, 0.86) (relative risk). The number-needed-to-treat with this intervention to prevent a single relapse is 6. CONCLUSIONS In people with opioid use disorder, a hypothetical intervention that increases sublingual buprenorphine-naloxone dose in response to opioid use during the first 12 weeks of treatment appears to reduce risk of relapse over 24 weeks, compared with holding the dose constant after week 2.
Collapse
Affiliation(s)
- Kara E. Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Matisyahu Shulman
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - Marc Fishman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Maryland Treatment Centers, Baltimore, MD, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - John Rotrosen
- Department of Psychiatry, School of Medicine, New York University, New York, NY, USA
| | - Edward V. Nunes
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| |
Collapse
|
3
|
Rudolph KE, Díaz I, Hejazi NS, van der Laan MJ, Luo SX, Shulman M, Campbell A, Rotrosen J, Nunes EV. Explaining differential effects of medication for opioid use disorder using a novel approach incorporating mediating variables. Addiction 2021; 116:2094-2103. [PMID: 33340181 DOI: 10.1111/add.15377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/28/2020] [Accepted: 12/09/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIMS A recent study found that homeless individuals with opioid use disorder (OUD) had a lower risk of relapse on extended-release naltrexone (XR-NTX) versus buprenorphine-naloxone (BUP-NX), whereas non-homeless individuals had a lower risk of relapse on BUP-NX. This secondary study examined differences in mediation pathways to medication effect between homeless and non-homeless participants. DESIGN Secondary analysis of an open-label randomized controlled, 24-week comparative effectiveness trial, 2014-17. SETTING Eight community addiction treatment programs in the United States. PARTICIPANTS English-speaking adults with DSM-5 OUD, recruited during inpatient admission (n = 570). INTERVENTION(S) Randomization to monthly injection of XR-NTX or daily sublingual BUP-NX. MEASUREMENTS(S) Mediation analysis estimated the direct effect of XR-NTX versus BUP-NX on relapse and indirect effect through mediators of medication adherence, use of illicit opioids, depressive symptoms and pain, separately by homeless status. FINDINGS For the homeless subgroup, the protective indirect path contributed a 3.4 percentage point reduced risk of relapse [95% confidence interval (CI) = -12.0, 5.3] comparing XR-NTX to BUP-NX (explaining 21% of the total effect). For the non-homeless subgroup, the indirect path contributed a 9.4 percentage point increased risk of relapse (95% CI = 3.1, 15.7) comparing XR-NTX to BUP-NX (explaining 57% of the total effect). CONCLUSIONS A novel approach to mediation analysis shows that much of the difference in medication effectiveness (extended-release naltrexone versus buprenorphine-naloxone) on opioid relapse among non-homeless adults with opioid use disorder appears to be explained by mediators of adherence, illicit opioid use, depressive symptoms and pain.
Collapse
Affiliation(s)
- Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Nima S Hejazi
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Sean X Luo
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - Matisyahu Shulman
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - Aimee Campbell
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - John Rotrosen
- Department of Psychiatry, School of Medicine, New York University, New York, NY, USA
| | - Edward V Nunes
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| |
Collapse
|
4
|
Volkow ND, Blanco C. The changing opioid crisis: development, challenges and opportunities. Mol Psychiatry 2021; 26:218-233. [PMID: 32020048 PMCID: PMC7398847 DOI: 10.1038/s41380-020-0661-4] [Citation(s) in RCA: 157] [Impact Index Per Article: 52.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/02/2020] [Accepted: 01/23/2020] [Indexed: 12/16/2022]
Abstract
The current opioid epidemic is one of the most severe public health crisis in US history. Responding to it has been difficult due to its rapidly changing nature and the severity of its associated outcomes. This review examines the origin and evolution of the crisis, the pharmacological properties of opioids, the neurobiology of opioid use and opioid use disorder (OUD), medications for opioid use disorder (MOUD), and existing and promising approaches to prevention. The results of the review indicate that the opioid epidemic is a complex, evolving phenomenon that involves neurobiological vulnerabilities and social determinants of health. Successfully addressing the epidemic will require advances in basic science, development of more acceptable and effective treatments, and implementation of public health approaches, including prevention. The advances achieved in addressing the current crisis should also serve to advance the science and treatment of other substance use disorders.
Collapse
Affiliation(s)
| | - Carlos Blanco
- National Institute on Drug Abuse, Bethesda, MD, 20892, USA.
| |
Collapse
|
5
|
Carroll KM, Weiss RD. The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2020; 17:183-192. [PMID: 32021588 DOI: 10.1176/appi.focus.17206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
(Reprinted with permission from Am J Psychiatry 2017;174:738-747).
Collapse
Affiliation(s)
- Kathleen M Carroll
- Department of Psychiatry, Yale University School of Medicine, West Haven, Conn.; the Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Mass.; and the Department of Psychiatry, Harvard Medical School, Boston
| | - Roger D Weiss
- Department of Psychiatry, Yale University School of Medicine, West Haven, Conn.; the Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Mass.; and the Department of Psychiatry, Harvard Medical School, Boston
| |
Collapse
|
6
|
Marsden J, Tai B, Ali R, Hu L, Rush AJ, Volkow N. Measurement-based care using DSM-5 for opioid use disorder: can we make opioid medication treatment more effective? Addiction 2019; 114:1346-1353. [PMID: 30614096 PMCID: PMC6766896 DOI: 10.1111/add.14546] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/05/2018] [Accepted: 12/28/2018] [Indexed: 12/28/2022]
Abstract
CONTEXT AND PURPOSE Measurement-based care (MBC) is an evidence-based health-care practice in which indicators of disease are tracked to inform clinical actions, provide feedback to patients and improve outcomes. The current opioid crisis in multiple countries provides a pressing rationale for adopting a basic MBC approach for opioid use disorder (OUD) using DSM-5 to increase treatment retention and effectiveness. PROPOSAL To stimulate debate, we propose a basic MBC approach using the 11 symptoms of OUD (DSM-5) to inform the delivery of medications for opioid use disorder (MOUD; including methadone, buprenorphine and naltrexone) and their evaluation in office-based primary care and specialist clinics. Key features of a basic MBC approach for OUD using DSM-5 are described, with an illustration of how clinical actions are guided and outcomes communicated. For core treatment tasks, we propose that craving and drug use response to MOUD should be assessed after 2 weeks, and OUD remission status should be evaluated at 3, 6 and 12 months (and exit from MOUD treatment) and beyond. Each of the 11 DSM-5 symptoms of OUD should be discussed with the patient to develop a case formulation and guide selection of adjunctive psychological interventions, supplemented with information on substance use, and optionally extended with information from other clinical instruments. A patient-reported outcome measure should be recorded and discussed at each remission assessment. CONCLUSIONS MBC can be used to tailor and adapt MOUD treatment to increase engagement, retention and effectiveness. MBC practice principles can help promote patient-centred care in OUD, personalized addiction therapeutics and facilitate communication of outcomes.
Collapse
Affiliation(s)
- John Marsden
- Addictions DepartmentInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonUK
| | - Betty Tai
- National Institute on Drug Abuse, National Institutes of HealthRockvilleMDUSA
| | - Robert Ali
- Discipline of Pharmacology, School of MedicineThe University of AdelaideSouth Australia
| | - Lian Hu
- National Institute on Drug Abuse, National Institutes of HealthRockvilleMDUSA,The Emmes CorporationRockvilleMDUSA
| | - A. John Rush
- Duke‐National University of SingaporeSingapore,Department of PsychiatryDuke University Medical SchoolDurhamUSA,Department of PsychiatryTexas Tech Health Sciences CenterTXUSA
| | - Nora Volkow
- National Institute on Drug Abuse, National Institutes of HealthRockvilleMDUSA
| |
Collapse
|
7
|
Marsden J, Stillwell G, James K, Shearer J, Byford S, Hellier J, Kelleher M, Kelly J, Murphy C, Mitcheson L. Efficacy and cost-effectiveness of an adjunctive personalised psychosocial intervention in treatment-resistant maintenance opioid agonist therapy: a pragmatic, open-label, randomised controlled trial. Lancet Psychiatry 2019; 6:391-402. [PMID: 30952568 DOI: 10.1016/s2215-0366(19)30097-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Opioid use disorder is a chronic, debilitating, and costly disorder that has increased in prevalence in many countries, with an associated sharp rise in mortality. Maintenance opioid agonist therapy is the first-line treatment, but many patients do not stop using illicit or non-prescribed drugs concomitantly. We aimed to test the efficacy and cost-effectiveness of a personalised psychosocial intervention implemented with a toolkit of behaviour-change techniques as an adjunct to opioid agonist therapy. METHODS We did a pragmatic, open-label, randomised controlled trial at a specialist UK National Health Service community addictions clinic in London, UK. Eligible patients were aged 18 years or older, met criteria for opioid or cocaine dependence, or both, in the past 12 months, and voluntarily sought continued oral maintenance opioid agonist therapy, which they had been prescribed for at least 6 weeks. All participants were treatment resistant (ie, had used illicit or non-prescribed opioids or cocaine on one or more days in the past 28 days at study screening, which was verified by positive urine drug screen). Participants were allocated (1:1) by a web-accessed randomisation sequence (stratified by opioid agonist medication, current cocaine use, and current rug use) to receive a personalised psychosocial intervention (comprising a flexible toolkit of psychological-change methods, including contingency management to reinforce abstinence, recovery activities, and clinic attendance) in addition to treatment as usual, or treatment as usual only (control group). The primary outcome was treatment response at 18 weeks, which was defined as abstinence from illicit and non-prescribed opioids and cocaine in the past 28 days, as measured with treatment outcomes profiles and urine drug screening. Taking a societal cost perspective, we did an evaluation of cost-effectiveness with a wide range of willingness-to-pay values for a unit improvement in the probability of treatment response. We also calculated quality-adjusted life-years (QALYs). Efficacy was analysed in a modified-intention-to-treat population, including all participants who were randomly allocated but excluding those who had previously completed the intervention. This trial is registered with ISRCTN, number ISRCTN69313751. The trial is completed. FINDINGS Between June 7, 2013, and Dec 21, 2015, we randomly allocated 136 participants to the psychosocial intervention group and 137 to the control group. The trial database was locked on April 19, 2017. Three patients (one in the psychosocial intervention group and two in the control group) who were re-randomised in error were excluded from the analysis. 22 (16%) of 135 patients in the psychosocial intervention group had a treatment response, compared with nine (7%) of 135 in the control group (adjusted log odds 1·20 [95% CI 0·01-2·37]; p=0·048). The psychosocial intervention had a higher probability of being cost-effective than treatment as usual. There was a probability range of 47-87% for willingness-to-pay thresholds of £0-1000 for a unit improvement in the probability of treatment response. QALYs were higher in the psychosocial intervention group than in the control group (mean difference 0·048 [95% CI 0·016-0·080]; p=0·004) in adjusted analyses, with 60% and 67% probabilities of cost-effectiveness at the UK National Institute for Health and Care Excellence's willingness-to-pay thresholds of £20 000 and £30 000 per QALY, respectively. The number of adverse events was similar between groups, and no severe adverse events in either group were judged to be treatment related. One participant in the control group was hospitalised with drug-injection-related sepsis and died. INTERPRETATION In maintenance opioid agonist therapy, an adjunctive personalised psychosocial intervention in addition to standard therapy was efficacious and cost-effective compared with standard therapy alone at helping treatment-resistant patients abstain from using illicit and non-prescribed opioids and cocaine. FUNDING Indivior.
Collapse
Affiliation(s)
- John Marsden
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Lambeth Addictions, South London and Maudsley NHS Mental Health Foundation Trust, London, UK.
| | - Garry Stillwell
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Kirsty James
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James Shearer
- King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sarah Byford
- King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Jennifer Hellier
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Michael Kelleher
- Lambeth Addictions, South London and Maudsley NHS Mental Health Foundation Trust, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit at King's Health Partners, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Caroline Murphy
- King's Clinical Trials Unit at King's Health Partners, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Luke Mitcheson
- Lambeth Addictions, South London and Maudsley NHS Mental Health Foundation Trust, London, UK
| |
Collapse
|
8
|
Blanco C, Volkow ND. Management of opioid use disorder in the USA: present status and future directions. Lancet 2019; 393:1760-1772. [PMID: 30878228 DOI: 10.1016/s0140-6736(18)33078-2] [Citation(s) in RCA: 236] [Impact Index Per Article: 47.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 11/15/2018] [Accepted: 11/26/2018] [Indexed: 02/06/2023]
Abstract
Opioid use disorder is characterised by the persistent use of opioids despite the adverse consequences of its use. The disorder is associated with a range of mental and general medical comorbid disorders, and with increased mortality. Although genetics are important in opioid use disorder, younger age, male sex, and lower educational attainment level and income, increase the risk of opioid use disorder, as do certain psychiatric disorders (eg, other substance use disorders and mood disorders). The medications for opioid use disorder, which include methadone, buprenorphine, and extended-release naltrexone, significantly improve opioid use disorder outcomes. However, the effectiveness of medications for opioid use disorder is limited by problems at all levels of the care cascade, including diagnosis, entry into treatment, and retention in treatment. There is an urgent need for expanding the use of medications for opioid use disorder, including training of health-care professionals in the treatment and prevention of opioid use disorder, and for development of alternative medications and new models of care to expand capabilities for personalised interventions.
Collapse
Affiliation(s)
- Carlos Blanco
- National Institute on Drug Abuse, Bethesda, MD, USA.
| | | |
Collapse
|
9
|
Zhu Y, Evans EA, Mooney LJ, Saxon AJ, Kelleghan A, Yoo C, Hser YI. Correlates of Long-Term Opioid Abstinence After Randomization to Methadone Versus Buprenorphine/Naloxone in a Multi-Site Trial. J Neuroimmune Pharmacol 2018; 13:488-497. [PMID: 30094695 DOI: 10.1007/s11481-018-9801-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/30/2018] [Indexed: 11/25/2022]
Abstract
Opioid use disorder (OUD) is a chronic, relapsing condition with severe negative health consequences. Previous studies have reported that 5-year opioid abstinence is a good predictor of reduced likelihoods of relapse, but factors that shape long-term opioid abstinence are poorly understood. The present study is based on data from a prospective study of 699 adults with OUD who had been randomized to either methadone or buprenorphine/naloxone and who were followed for at least 5 years. During the 5 years prior to the participants' last follow-up interview, 232 (33.2%) had achieved 5-year abstinence from heroin. Of those 232, 145 (20.7% of the total) had remained abstinent from both heroin and other opioids (e.g., hydrocodone, oxycodone, other opioid analgesics, excluding methadone or buprenorphine). Compared to non-abstinent individuals, those in both categories of opioid abstinence had lower problem severity in health and social functioning at the final follow-up. Logistic regression results indicated that cocaine users and injection drug users were less likely to achieve 5-year heroin abstinence, whereas Hispanics (vs. whites) and those treated in clinics on the West Coast (vs. East) were less likely to achieve 5-year abstinence from heroin and other opioids. For both abstinence category groups, abstinence was positively associated with older age at first opioid use, lower impulsivity, longer duration of treatment for OUD, and greater social support. Reducing cocaine use and injection drug use and increasing social support and retention in treatment may help maintain long-term abstinence from opioids among individuals treated with agonist pharmacotherapy.
Collapse
Affiliation(s)
- Yuhui Zhu
- UCLA Integrated Substance Abuse Programs, University of California, Los Angeles, 11075 Santa Monica Blvd., Suite 200, Los Angeles, CA, 90025, USA
| | - Elizabeth A Evans
- University of Massachusetts Amherst, 311 Arnold House, 715 North Pleasant Street, Amherst, MA, 01003, USA
| | - Larissa J Mooney
- UCLA Integrated Substance Abuse Programs, University of California, Los Angeles, 11075 Santa Monica Blvd., Suite 200, Los Angeles, CA, 90025, USA.,Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
| | - Andrew J Saxon
- Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Room 116 ATC, Seattle, WA, 98108, USA
| | - Annamarie Kelleghan
- University of Southern California, SGM 501, 3620 South McClintock Ave., Los Angeles, CA, 90089-1061, USA
| | - Caroline Yoo
- UCLA Integrated Substance Abuse Programs, University of California, Los Angeles, 11075 Santa Monica Blvd., Suite 200, Los Angeles, CA, 90025, USA
| | - Yih-Ing Hser
- UCLA Integrated Substance Abuse Programs, University of California, Los Angeles, 11075 Santa Monica Blvd., Suite 200, Los Angeles, CA, 90025, USA.
| |
Collapse
|
10
|
Blum K, Han D, Modestino EJ, Saunders S, Roy AK, Jacobs W, Inaba DS, Baron D, Oscar-Berman M, Hauser M, Badgaiyan RD, Smith DE, Femino J, Gold MS. A Systematic, Intensive Statistical Investigation of Data from the Comprehensive Analysis of Reported Drugs (CARD) for Compliance and Illicit Opioid Abstinence in Substance Addiction Treatment with Buprenorphine/naloxone. Subst Use Misuse 2018; 53:220-229. [PMID: 29257919 DOI: 10.1080/10826084.2017.1400064] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Buprenorphine and naloxone (bup/nal), a combination partial mu receptor agonist and low-dose delta mu antagonist, is presently recommended and used to treat opioid-use disorder. However, a literature review revealed a paucity of research involving data from urine drug tests that looked at compliance and abstinence in one sample. METHOD Statistical analysis of data from the Comprehensive Analysis of Reported Drugs (CARD) was used to assess compliance and abstinence during treatment in a large cohort of bup/nal patients attending chemical-dependency programs from eastern USA in 2010 and 2011. RESULTS Part 1: Bup/nal was present in 93.4% of first (n = 1,282; p <.0001) and 92.4% of last (n = 1,268; p <.0001) urine samples. Concomitantly, unreported illicit drugs were present in 47.7% (n = 655, p =.0261) of samples. Patients who were compliant to the bup/nal prescription were more likely than noncompliant patients to be abstinent during treatment (p =.0012; odds ratio = 1.69 with 95% confidence interval (1.210, 2.354). Part 2: An analysis of all samples collected in 2011 revealed a significant improvement in both compliance (p < 2.2 × 10-16) and abstinence (p < 2.2 × 10-16) during treatment. Conclusion/Importance: While significant use of illicit opioids during treatment with bup/nal is present, improvements in abstinence and high compliance during maintenance-assisted therapy programs may ameliorate fears of diversion in comprehensive programs. Expanded clinical datasets, the treatment modality, location, and year of sampling are important covariates, for further studies. The potential for long-term antireward effects from bup/nal use requires consideration in future investigations.
Collapse
Affiliation(s)
- Kenneth Blum
- a Department of Psychiatry & McKnight Brain Institute , University of Florida College of Medicine , Gainesville , Florida , USA.,b Division of Addiction Services , Dominion Diagnostics, LLC , North Kingstown , Rhode Island , USA.,c Departments of Psychiatry & Behavioral Sciences , Keck School of Medicine of USC , Los Angeles , California , USA.,d Department of Psychology , Eötvös Loránd University, Institute of Psychology , Budapest , Hungary.,e Human Integrated Services Unit , University of Vermont Centre for Clinical & Translational Science, College of Medicine , Burlington , Vermont , USA.,f Division of Neuroscience Research & Addiction Therapy , Shores Treatment & Recovery Center , Port Saint Lucie , Florida , USA.,g Geneus Health , San Antonio , Texas , USA
| | - David Han
- h Department of Management Science and Statistics , University of Texas at San Antonio , Texas , USA
| | - Edward J Modestino
- i Department of Psychology , Curry College , Milton , Massachusetts , USA
| | - Scott Saunders
- b Division of Addiction Services , Dominion Diagnostics, LLC , North Kingstown , Rhode Island , USA
| | - A Kennison Roy
- j Behavioral Medical Corporation , Metairie , Louisiana , USA
| | - W Jacobs
- k Division of Addiction Medicine , Medical College of Georgia , Augusta , Georgia , USA
| | - Darryl S Inaba
- l Division of Alcohol & Drug Studies , University of Utah , Salt Lake City , Utah , USA
| | - David Baron
- c Departments of Psychiatry & Behavioral Sciences , Keck School of Medicine of USC , Los Angeles , California , USA
| | - Marlene Oscar-Berman
- n Department of Psychiatry, Neurology, Anatomy & Neurobiology , Boston University School of Medicine, & VA Boston Healthcare System , Boston , Massachusetts , USA
| | - Mary Hauser
- b Division of Addiction Services , Dominion Diagnostics, LLC , North Kingstown , Rhode Island , USA
| | - Rajendra D Badgaiyan
- m Department of Psychiatry , Icahn School of Medicine , New York , New York , USA
| | - David E Smith
- p Department of Pharmacology , University of San Francisco , San Francisco , California , USA
| | - John Femino
- b Division of Addiction Services , Dominion Diagnostics, LLC , North Kingstown , Rhode Island , USA
| | - Mark S Gold
- o Department of Psychiatry , Washington University School of Medicine , St. Louis , Missouri , USA
| |
Collapse
|
11
|
Abstract
OBJECTIVE Although counseling is a required part of office-based buprenorphine treatment of opioid use disorders, the nature of what constitutes appropriate counseling is unclear and controversial. The authors review the literature on the role, nature, and intensity of behavioral interventions in office-based buprenorphine treatment. METHOD The authors conducted a review of randomized controlled studies testing the efficacy of adding a behavioral intervention to buprenorphine maintenance treatment. RESULTS Four key studies showed no benefit from adding a behavioral intervention to buprenorphine plus medical management, and four studies indicated some benefit for specific behavioral interventions, primarily contingency management. The authors examined the findings from the negative trials in the context of six questions: 1) Is buprenorphine that effective? 2) Is medical management that effective? 3) Are behavioral interventions that ineffective in this population? 4) How has research design affected the results of studies of buprenorphine plus behavioral treatment? 5) What do we know about subgroups of patients who do and those who do not seem to benefit from behavioral interventions? 6) What should clinicians aim for in terms of treatment outcome in buprenorphine maintenance? CONCLUSIONS High-quality medical management may suffice for some patients, but there are few data regarding the types of individuals for whom medical management is sufficient. Physicians should consider a stepped-care model in which patients may begin with relatively nonintensive treatment, with increased intensity for patients who struggle early in treatment. Finally, with 6-month retention rates seldom exceeding 50% and poor outcomes following dropout, we must explore innovative strategies for enhancing retention in buprenorphine treatment.
Collapse
Affiliation(s)
- Kathleen M. Carroll
- Department of Psychiatry, Yale University School of Medicine, 950 Campbell Avenue, MIRECC 151D, West Haven, CT 06516, 203-932-5711 x 7403,
| | - Roger D. Weiss
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill St. Belmont, MA 02478, 617-855-2242, , Department of Psychiatry, Harvard Medical School, Boston, MA 02215
| |
Collapse
|
12
|
Cook R, Quinn B, Heinzerling K, Shoptaw S. Dropout in clinical trials of pharmacological treatment for methamphetamine dependence: the role of initial abstinence. Addiction 2017; 112:1077-1085. [PMID: 28107598 PMCID: PMC5984202 DOI: 10.1111/add.13765] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/09/2016] [Accepted: 01/13/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS High rates of loss to follow-up represent a significant challenge to clinical trials of pharmacological treatments for methamphetamine (MA) use disorder. We aimed to estimate and test the relationship between achieving and maintaining abstinence in the initial weeks of study participation and subsequent retention in such trials, hypothesizing that participants able to achieve early abstinence would be less likely to drop out. DESIGN Data from four randomized controlled trials (RCTs) of pharmacological treatments for MA use disorder were pooled and analyzed using a random-effects approach. SETTING All trials were conducted in the greater Los Angeles, CA, USA area. PARTICIPANTS A total of 440 participants were included; trials were conducted between 2004 and 2014. MEASUREMENTS Participants' ability to achieve a brief period of initial abstinence was measured as the number of MA-negative urine screens completed in the first 2 weeks of the trials. Outcomes were the likelihood of dropout, i.e. missing two consecutive weeks of scheduled urine drug screens, and the number of days participants were retained in the trials. FINDINGS Study participants achieved an average of three (of six possible) negative urine screens during the first 2 weeks of the trials, 51% dropped out and the average number of days retained was 60 (of 90 maximum). Each additional negative urine screen achieved during the first 2 weeks of the study reduced multiplicatively the odds of dropout by 41% [odds ratio (OR) = 0.59, 95% confidence interval (CI) = 0.53, 0.66]. Abstinence was also a significant predictor of retention time; the hazard ratio for non-completion was 0.75 per additional negative urine screen (95% CI = 0.71, 0.80). CONCLUSIONS Participants in randomized controlled trials of pharmacological treatments for methamphetamine use disorder who are able to achieve a brief period of early abstinence are retained longer in the trials and are less likely to drop out overall.
Collapse
Affiliation(s)
- Ryan Cook
- Department of Epidemiology, Los Angeles Fielding School of Public Health, University of California, Los Angeles, CA, USA,Departments of Family Medicine and Psychiatry and Biobehavioral Science, Los Angeles David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Brendan Quinn
- Departments of Family Medicine and Psychiatry and Biobehavioral Science, Los Angeles David Geffen School of Medicine, University of California, Los Angeles, CA, USA,Centre for Population Health, Burnet Institute, Melbourne, VIC, Australia
| | - Keith Heinzerling
- Departments of Family Medicine and Psychiatry and Biobehavioral Science, Los Angeles David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Steve Shoptaw
- Departments of Family Medicine and Psychiatry and Biobehavioral Science, Los Angeles David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| |
Collapse
|
13
|
Chatterjee A, Obando A, Strickland E, Nestler A, Harrington-Levey R, Williams T, LaCoursiere-Zucchero T. Shelter-Based Opioid Treatment: Increasing Access to Addiction Treatment in a Family Shelter. Am J Public Health 2017; 107:1092-1094. [PMID: 28520496 DOI: 10.2105/ajph.2017.303786] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Avik Chatterjee
- All of the authors are with the Boston Health Care for the Homeless Program, Boston, MA
| | - Aura Obando
- All of the authors are with the Boston Health Care for the Homeless Program, Boston, MA
| | - Erica Strickland
- All of the authors are with the Boston Health Care for the Homeless Program, Boston, MA
| | - Ariana Nestler
- All of the authors are with the Boston Health Care for the Homeless Program, Boston, MA
| | | | - Toni Williams
- All of the authors are with the Boston Health Care for the Homeless Program, Boston, MA
| | | |
Collapse
|
14
|
The Prescription Opioid Addiction Treatment Study: What have we learned. Drug Alcohol Depend 2017; 173 Suppl 1:S48-S54. [PMID: 28363320 PMCID: PMC6866670 DOI: 10.1016/j.drugalcdep.2016.12.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 12/16/2016] [Accepted: 12/17/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND The multi-site Prescription Opioid Addiction Treatment Study (POATS), conducted by the National Drug Abuse Treatment Clinical Trials Network, was the largest clinical trial yet conducted with patients dependent upon prescription opioids (N=653). In addition to main trial results, the study yielded numerous secondary analyses, and included a 3.5-year follow-up study, the first of its kind with this population. This paper reviews key findings from POATS and its follow-up study. METHODS The paper summarizes the POATS design, main outcomes, predictors of outcome, subgroup analyses, the predictive power of early treatment response, and the long-term follow-up study. RESULTS POATS examined combinations of buprenorphine-naloxone of varying duration and counseling of varying intensity. The primary outcome analysis showed no overall benefit to adding drug counseling to buprenorphine-naloxone and weekly medical management. Only 7% of patients achieved a successful outcome (abstinence or near-abstinence from opioids) during a 4-week taper and 8-week follow-up; by comparison, 49% of patients achieved success while subsequently stabilized on buprenorphine-naloxone. Long-term follow-up results were more encouraging, with higher abstinence rates than in the main trial. Patients receiving opioid agonist treatment at the time of follow-up were more likely to have better outcomes, though a sizeable number of patients succeeded without agonist treatment. Some patients initiated risky use patterns, including heroin use and drug injection. A limitation of the long-term follow-up study was the low follow-up rate. CONCLUSIONS POATS was the first large-scale study of the treatment of prescription opioid dependence; its findings can influence both treatment guidelines and future studies.
Collapse
|
15
|
Abstract
This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.
Collapse
Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
| |
Collapse
|
16
|
Effectiveness of adjunctive, personalised psychosocial intervention for non-response to opioid agonist treatment: Study protocol for a pragmatic randomised controlled trial. Contemp Clin Trials 2016; 53:36-43. [PMID: 27940188 DOI: 10.1016/j.cct.2016.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/25/2016] [Accepted: 12/03/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Opioid use disorder (OUD) is a debilitating and relapsing psychiatric disorder; opioid agonist therapy (OAT) is the front-line, evidence-supported treatment. A substantial number of patients relapse or continue to use heroin or other illicit drugs during OAT. There is considerable heterogeneity in the OAT-resistant sub-population, with many behavioural moderators of treatment response. We have developed a personalised psychosocial intervention (PSI) targeting these individuals. A formulation-guided assessment is linked to a toolkit of motivational, cognitive/behavioural and social support techniques. Change methods have been adapted from evidence-supported psychological therapies and are idiosyncratically tailored to the need and response. METHODS In this single-centre, 18-week, parallel group, pragmatic randomised clinical trial, we will determine the clinical and cost-effectiveness of the PSI as an adjunctive intervention during OAT, in comparison to opioid agonist treatment-as-usual. We plan to recruit 368 adults. The primary outcome measure is the proportion of participants categorised as 'responders' at the end of the intervention (defined as self-reported abstinence from heroin and cocaine with no positive biological drug tests during the 28days prior to the endpoint). Secondary outcomes include: percentage of days abstinent from heroin and cocaine in the 28days before follow-up; treatment retention; therapy compliance; health and social functioning; exploratory genetic biomarkers; and analyses of treatment moderation and mediation. CONCLUSIONS This pragmatic controlled trial determines the effectiveness and cost-effectiveness of a personalised PSI for non-responding patients during OAT. Our intervention applies motivational, cognitive/behavioural and social support techniques adapted from evidence-based therapies. Findings will inform stratified delivery of OAT.
Collapse
|
17
|
Marcovitz DE, McHugh RK, Volpe J, Votaw V, Connery HS. Predictors of early dropout in outpatient buprenorphine/naloxone treatment. Am J Addict 2016; 25:472-7. [PMID: 27442456 DOI: 10.1111/ajad.12414] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/08/2016] [Accepted: 07/09/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Identifying predictors of early drop out from outpatient treatment of opioid use disorder (OUD) with buprenorphine/naloxone (BN) may improve care for subgroups requiring more intensive engagement to achieve stabilization. However, previous research on predictors of dropout among this population has yielded mixed results. The aim of the present study was to elucidate these mixed findings by simultaneously evaluating a range of putative risk factors that may predict dropout in BN maintenance treatment. METHODS Outpatient medical records and weekly supervised urine toxicology results were retrospectively reviewed for patients at two community psychiatric clinics (n = 202): a private hospital clinic (n = 84) and a federally qualified health center (n = 118). A forward stepwise logistic regression was utilized to investigate the association between early dropout (i.e., discontinuing treatment or buprenorphine non-adherence within the first 3 months of clinic entry) and extracted sociodemographic, clinical, substance use, and treatment history variables. RESULTS Overall, 56 of 202 participants (27.7%) dropped out of treatment. The multivariable analysis indicated that age under 25 (B = 1.47, SEB = .52, p < .01) and opioid use in month 1 (B = 1.50, SEB = .41, p < .001) were significantly associated with early dropout; those with a history of suicide attempt were significantly less likely to drop out (B = -1.44, SEB = .67, p < .05). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Consistent with previous research, younger age and use of opioids during the first month of treatment predicted early dropout. Having a history of prior suicide attempt was associated with 3-month BN treatment retention, which has not been previously reported. (Am J Addict 2016;25:472-477).
Collapse
Affiliation(s)
- David E Marcovitz
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts.,Massachusetts General Hospital/McLean Adult Psychiatry Residency, Boston/Belmont, Massachusetts
| | - R Kathryn McHugh
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts.,McLean Hospital, Belmont, Massachusetts
| | - Julie Volpe
- Community Health Services, Hartford, Connecticut
| | | | - Hilary S Connery
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts.,McLean Hospital, Belmont, Massachusetts
| |
Collapse
|
18
|
Just J, Mücke M, Bleckwenn M. Dependence on Prescription Opioids. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:213-20. [PMID: 27120492 PMCID: PMC4857553 DOI: 10.3238/arztebl.2016.0213] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 12/09/2015] [Accepted: 12/09/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND The incidence of initial prescriptions of opioids for chronic non-cancer pain rose by 37% in Germany from 2000 to 2010. Prescribing practice does not always conform with the recommendations of current guidelines. In the USA, 8-12% of patients with chronic non-cancer pain are opioid-dependent. METHODS This review is based on publications retrieved by a selective PubMed search and on the German S3 guideline on the long-term use of opioids in non-cancer pain. RESULTS Patients must be informed and counseled about the effects and risks of opioids before these drugs are prescribed. All opioid prescriptions for patients with chronic non-cancer pain should be regularly reviewed. The risk of abuse is high in young adults (odds ratio [OR] = 6.74) and in those with a history of substance abuse (OR = 2.34). Any unusual medication-related behavior, e.g., loss of prescriptions or increasing the dose without prior discussion with the physician, calls for further assessment by the physician in conversation with the patient. Urine testing for drugs and their metabolites is helpful as well. The goal of treatment of opioid abuse is opioid abstinence by gradual reduction of the dose. If this is not possible on an outpatient basis, hospitalization for drug withdrawal or substitution-based addiction therapy can be offered. CONCLUSION Physicians who know the indications and risks of opioid therapy and the typical behavior of drug-dependent patients will be better able to identify patients at risk and to prevent dependence. Studies on the prevalence of opioid abuse and dependence in German patients with chronic pain can help provide better estimates of the current extent and implications of this problem in Germany.
Collapse
Affiliation(s)
- Johannes Just
- Institute of General Practice and Family Medicine, Universität Bonn
| | - Martin Mücke
- Institute of General Practice and Family Medicine, Universität Bonn
- Department of Palliative Medicine, University Hospital Bonn
- Center for Rare Diseases, University Hospital Bonn
| | - Markus Bleckwenn
- Institute of General Practice and Family Medicine, Universität Bonn
| |
Collapse
|
19
|
Abstract
OBJECTIVE Prescription opioid abuse and dependence have escalated rapidly in the United States over the past 20 years, leading to high rates of overdose deaths and a dramatic increase in the number of people seeking treatment for opioid dependence. The authors review the scope of the abuse and overdose epidemic, prescription practices, and the assessment, treatment, and prevention of prescription opioid misuse and dependence. METHOD The authors provide an overview of the literature from 2006 to the present, with the twin goals of highlighting advances in prevention and treatment and identifying remaining gaps in the science. RESULTS A number of policy and educational initiatives at the state and federal government level have been undertaken in the past 5 years to help providers and consumers, respectively, prescribe and use opioids more responsibly. Initial reports suggest that diversion and abuse levels have begun to plateau, likely as a result of these initiatives. While there is a large body of research suggesting that opioid substitution coupled with psychosocial interventions is the best treatment option for heroin dependence, there is limited research focusing specifically on the treatment of prescription opioid dependence. In particular, the treatment of chronic pain in individuals with prescription opioid use disorders is underexplored. CONCLUSIONS While policy and educational initiatives appear to be effective in decreasing prescription opioid abuse and misuse, research focusing on the development and evaluation of treatments specific to prescription opioid dependence and its common comorbidities (e.g., chronic pain, depression) is critically needed.
Collapse
Affiliation(s)
- Kathleen T Brady
- From the Addiction Sciences Division, Institute of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston; and the Ralph H. Johnson Veterans Affairs Medical Center, Charleston
| | - Jenna L McCauley
- From the Addiction Sciences Division, Institute of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston; and the Ralph H. Johnson Veterans Affairs Medical Center, Charleston
| | - Sudie E Back
- From the Addiction Sciences Division, Institute of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston; and the Ralph H. Johnson Veterans Affairs Medical Center, Charleston
| |
Collapse
|