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Qian G, Humphreys K, Goldhaber-Fiebert JD, Brandeau ML. Estimated effectiveness and cost-effectiveness of opioid use disorder treatment under proposed U.S. regulatory relaxations: A model-based analysis. Drug Alcohol Depend 2024; 256:111112. [PMID: 38335797 PMCID: PMC10940194 DOI: 10.1016/j.drugalcdep.2024.111112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 01/12/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024]
Abstract
AIM To assess the effectiveness and cost-effectiveness of buprenorphine and methadone treatment in the U.S. if exemptions expanding coverage for substance use disorder services via telehealth and allowing opioid treatment programs to supply a greater number of take-home doses of medications for opioid use disorder (OUD) continue (Notice of Proposed Rule Making, NPRM). DESIGN SETTING AND PARTICIPANTS Model-based analysis of buprenorphine and methadone treatment for a cohort of 100,000 individuals with OUD, varying treatment retention and overdose risk among individuals receiving and not receiving methadone treatment compared to the status quo (no NPRM). INTERVENTION Buprenorphine and methadone treatment under NPRM. MEASUREMENTS Fatal and nonfatal overdoses and deaths over five years, discounted lifetime per person QALYs and costs. FINDINGS For buprenorphine treatment under the status quo, 1.21 QALYs are gained at a cost of $19,200/QALY gained compared to no treatment; with 20% higher treatment retention, 1.28 QALYs are gained at a cost of $17,900/QALY gained compared to no treatment, and the strategy dominates the status quo. For methadone treatment under the status quo, 1.11 QALYs are gained at a cost of $17,900/QALY gained compared to no treatment. In all scenarios, methadone provision cost less than $20,000/QALY gained compared to no treatment, and less than $50,000/QALY gained compared to status quo methadone treatment. CONCLUSIONS Buprenorphine and methadone OUD treatment under NPRM are likely to be effective and cost-effective. Increases in overdose risk with take-home methadone would reduce health benefits. Clinical and technological strategies could mitigate this risk.
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Affiliation(s)
- Gary Qian
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA.
| | - Keith Humphreys
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | | | - Margaret L Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
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Greenwald MK, Sogbesan T, Moses TEH. Relationship between opioid cross-tolerance during buprenorphine stabilization and return to opioid use during buprenorphine dose tapering. Psychopharmacology (Berl) 2024:10.1007/s00213-024-06549-1. [PMID: 38326506 DOI: 10.1007/s00213-024-06549-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/31/2024] [Indexed: 02/09/2024]
Abstract
RATIONALE Opioid injection drug use (IDU) has been linked to a more severe pattern of use (e.g. tolerance, overdose risk) and shorter retention in treatment, which may undermine abstinence attempts. OBJECTIVES This secondary data analysis of four human laboratory studies investigated whether current opioid IDU modulates subjective abuse liability responses to high-dose hydromorphone during intermediate-dose buprenorphine stabilization (designed to suppress withdrawal but allow surmountable agonist effects), and whether hydromorphone response magnitude predicts latency of return to opioid use during buprenorphine dose-tapering. METHODS Regular heroin users not currently seeking treatment (n = 54; 29 current injectors, 25 non-injectors) were stabilized on 8-mg/day sublingual buprenorphine and assessed for subjective responses (e.g. 'liking', craving) to hydromorphone 24-mg intramuscular challenge (administered 16-hr post-buprenorphine) under randomized, double-blinded, controlled conditions. A subgroup (n = 35) subsequently completed a standardized 3-week outpatient buprenorphine dose-taper, paired with opioid-abstinent contingent reinforcement, and were assessed for return to opioid use based on thrice-weekly urinalysis and self-report. RESULTS During buprenorphine stabilization, IDU reported lower 'liking' of buprenorphine and post-hydromorphone peak 'liking', 'good effect' and 'high' compared to non-IDU. Less hydromorphone peak increase-from-baseline in 'liking' (which correlated with less hydromorphone-induced craving suppression) predicted significantly faster return to opioid use during buprenorphine dose-tapering. CONCLUSIONS In these buprenorphine-stabilized regular heroin users, IDU is associated with attenuated 'liking' response (more cross-tolerance) to buprenorphine and to high-dose hydromorphone challenge and, in turn, this cross-tolerance (but not IDU) predicts faster return to opioid use. Further research should examine mechanisms that link cross-tolerance to treatment response.
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Affiliation(s)
- Mark K Greenwald
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Tolan Park Medical Building, 3901 Chrysler Service Drive, Suite 2A, Detroit, MI, 48201, USA.
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Wang K, Shafique S, Xiao D, Walter SM, Liu Y, Piamjariyakul U, Xie C. Repeated measures analysis of opioid use disorder treatment on clinical opiate withdrawal scale in a randomized clinical trial: sex differences. J Addict Dis 2024; 42:33-44. [PMID: 36655851 DOI: 10.1080/10550887.2022.2131957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE Sex differences may exist in opioid use disorder (OUD) treatment. This study examined the treatment effects of buprenorphine/naloxone (BUP/NX) and methadone (MET) on the Clinical Opiate Withdrawal Scale (COWS) score in individuals with OUD and tested whether the associations differ by sex. METHOD We performed a secondary analysis of the data from the National Drug Abuse Treatment Clinical Trials Network (CTN) protocol-0027. A total of 1269 participants (861 males and 408 females) being aged 18 or older with OUD were randomly assigned to receive BUP/NX (n = 740) or MET (n = 529). The paired t test was initially used to compare the COWS scores between pre-dose and post-dose for BUP/NX and MET treatments, separately. The linear mixed model was used to examine the changes in COWS score adjusted for baseline demographic, substance use, and mental health disorders. The interaction of sex and treatment was detected and stratified analysis by sex was conducted. RESULTS The paired t test showed that both BUP/NX and MET treatments significantly reduced the COWS scores (p values <0.0001). BUP/NX revealed higher COWS scores than MET (p = 0.0008) and females demonstrated significantly higher COWS scores than males (p = 0.0169). Stratified by sex, BUP/NX compared with MET revealed higher COWS scores only in males (p = 0.0043), whereas baseline amphetamines use disorder and major depressive disorder were significantly associated with COWS scores in females (p = 0.0158 and 0.0422, respectively). CONCLUSIONS Both BUP/NX and MET are effective in decreasing opioid withdrawal symptoms via COWS scores, however, treatment plans for OUD by clinical providers should consider sex differences.
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Affiliation(s)
- Kesheng Wang
- Department of Family and Community Health, School of Nursing, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Saima Shafique
- Department of Epidemiology, School of Public Health, West Virginia University, Morgantown, WV, USA
| | - Danqing Xiao
- Department of STEM, School of Arts and Sciences, Regis College, Weston, MA, USA
- Neuroimaging Center, McLean Hospital, Belmont, MA, USA
| | - Suzy Mascaro Walter
- Department of Family and Community Health, School of Nursing, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Ying Liu
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN, USA
| | - Ubolrat Piamjariyakul
- School of Nursing, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Changchun Xie
- Division of Biostatistics and Bioinformatics, Department of Environmental Health, University of Cincinnati, Cincinnati, OH, USA
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Greenwald MK, Wiest KL, Haight BR, Laffont CM, Zhao Y. Examining the benefit of a higher maintenance dose of extended-release buprenorphine in opioid-injecting participants treated for opioid use disorder. Harm Reduct J 2023; 20:173. [PMID: 38042801 PMCID: PMC10693082 DOI: 10.1186/s12954-023-00906-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 11/17/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND BUP-XR (SUBLOCADE®) is the first buprenorphine extended-release subcutaneous injection approved in the USA for monthly treatment of moderate-to-severe opioid use disorder (OUD). Among patients with OUD, those who inject or use high doses of opioids likely require higher doses of buprenorphine to maximize treatment efficacy. The objective of this analysis was to compare the efficacy and safety of 100-mg versus 300-mg maintenance doses of BUP-XR in OUD patients who inject opioids. METHODS This was a secondary analysis of a randomized, double-blind, placebo-controlled study in which adults with moderate or severe OUD received monthly injections of BUP-XR (2 × 300-mg doses, then 4 × 100-mg or 300-mg maintenance doses) or placebo for 24 weeks. Abstinence was defined as opioid-negative urine drug screens combined with negative self-reports collected weekly. Each participant's percentage abstinence was calculated after the first, second, and third maintenance doses in opioid-injecting and non-injecting participants. The proportion of participants achieving opioid abstinence in each group was also calculated weekly. Treatment retention rate following the first maintenance dose was estimated for opioid-injecting participants with Kaplan-Meier method. Risk-adjusted comparisons were made via inverse propensity weighting using propensity scores. Buprenorphine plasma concentration-time profiles were compared between injecting and non-injecting participants. The percentages of participants reporting treatment-emergent adverse events were compared between maintenance dose groups within injecting and non-injecting participants separately. RESULTS BUP-XR 100-mg and 300-mg maintenance doses were equally effective in non-injecting participants. However, in opioid-injecting participants, the 300-mg maintenance dose delivered clinically meaningful improvements over the 100-mg maintenance dose for treatment retention and opioid abstinence. Exposure-response analyses confirmed that injecting participants would require higher buprenorphine plasma concentrations compared to non-injecting opioid participants to achieve similar efficacy in terms of opioid abstinence. Importantly, both 100- and 300-mg maintenance doses had comparable safety profiles, including hepatic safety events. CONCLUSIONS These analyses show clear benefits of the 300-mg maintenance dose in injecting participants, while no additional benefit was observed in non-injecting participants relative to the 100-mg maintenance dose. This is an important finding as opioid-injecting participants represent a high-risk and difficult-to-treat population. Optimal buprenorphine dosing in this population might facilitate harm reduction by improving abstinence and treatment retention. TRIAL REGISTRATION ClinicalTrials.gov, NCT02357901.
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Affiliation(s)
- Mark K Greenwald
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA.
| | | | | | | | - Yue Zhao
- Indivior, Inc., North Chesterfield, VA, USA
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Rudolph KE, Williams NT, Díaz I, Luo SX, Rotrosen J, Nunes EV. Optimally Choosing Medication Type for Patients With Opioid Use Disorder. Am J Epidemiol 2023; 192:748-756. [PMID: 36549900 PMCID: PMC10423632 DOI: 10.1093/aje/kwac217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 09/16/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Patients with opioid use disorder (OUD) tend to get assigned to one of 3 medications based on the treatment program to which the patient presents (e.g., opioid treatment programs tend to treat patients with methadone, while office-based practices tend to prescribe buprenorphine). It is possible that optimally matching patients with treatment type would reduce the risk of return to regular opioid use (RROU). We analyzed data from 3 comparative effectiveness trials from the US National Institute on Drug Abuse Clinical Trials Network (CTN0027, 2006-2010; CTN0030, 2006-2009; and CTN0051 2014-2017), in which patients with OUD (n = 1,459) were assigned to treatment with either injection extended-release naltrexone (XR-NTX), sublingual buprenorphine-naloxone (BUP-NX), or oral methadone. We learned an individualized rule by which to assign medication type such that risk of RROU during 12 weeks of treatment would be minimized, and then estimated the amount by which RROU risk could be reduced if the rule were applied. Applying our estimated treatment rule would reduce risk of RROU compared with treating everyone with methadone (relative risk (RR) = 0.79, 95% confidence interval (CI): 0.60, 0.97) or treating everyone with XR-NTX (RR = 0.71, 95% CI: 0.47, 0.96). Applying the estimated treatment rule would have resulted in a similar risk of RROU to that of with treating everyone with BUP-NX (RR = 0.92, 95% CI: 0.73, 1.11).
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Affiliation(s)
- Kara E Rudolph
- Correspondence to Dr. Kara Rudolph, 722 W. 168th Street, Room 522, New York, NY 10032 (e-mail: )
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Qian G, Rao I, Humphreys K, Owens DK, Brandeau ML. Cost-effectiveness of office-based buprenorphine treatment for opioid use disorder. Drug Alcohol Depend 2023; 243:109762. [PMID: 36621198 PMCID: PMC9852082 DOI: 10.1016/j.drugalcdep.2022.109762] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 12/31/2022]
Abstract
AIM To assess the effectiveness and cost-effectiveness of office-based buprenorphine treatment (OBBT) in the U.S. DESIGN SETTING AND PARTICIPANTS We performed a model-based analysis of buprenorphine treatment provided in a primary care setting for the U.S. population with OUD. INTERVENTION Buprenorphine treatment provided in a primary care setting. MEASUREMENTS Fatal and nonfatal overdoses and deaths over five years, discounted lifetime quality-adjusted life years (QALYs), costs. FINDINGS For a cohort of 100,000 untreated individuals who enter OBBT, approximately 9350 overdoses would be averted over five years; of these, approximately 900 would have been fatal. OBBT compared to no treatment would yield 1.07 incremental lifetime QALYs per person at an incremental cost of $17,000 per QALY gained when using a healthcare perspective. If OBBT is half as effective and twice as expensive as assumed in the base case, the incremental cost when using a healthcare perspective is $25,500 per QALY gained. Using a limited societal perspective that additionally includes patient costs and criminal justice costs, OBBT is cost-saving compared to no treatment even under pessimistic assumptions about efficacy and cost. CONCLUSIONS Expansion of OBBT would be highly cost-effective compared to no treatment when considered from a healthcare perspective, and cost-saving when reduced criminal justice costs are included. Given the continuing opioid crisis in the U.S., expansion of this care option should be a high priority.
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Affiliation(s)
- Gary Qian
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA.
| | - Isabelle Rao
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Keith Humphreys
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Douglas K Owens
- Department of Health Policy, School of Medicine, and Stanford Health Policy, Freeman-Spogli Institute for International Studies, Stanford University, Stanford, CA, USA
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Rudolph KE, Russell M, Luo SX, Rotrosen J, Nunes EV. Under-representation of key demographic groups in opioid use disorder trials. Drug Alcohol Depend Rep 2022; 4:100084. [PMID: 36187300 PMCID: PMC9524855 DOI: 10.1016/j.dadr.2022.100084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background The extent to which clinical trials of medications for opioid use disorder (MOUD) are representative or not is unknown. Some patient characteristics modify MOUD effectiveness; if these same characteristics differ in distribution between the trial population and usual-care population, this could contribute to lack of generalizability-a discrepancy between trial and usual-care effectiveness. Our objective was to identify interpretable, multidimensional subgroups who were prescribed MOUD in substance use treatment programs in the US but who were not represented or under-represented by clinical trial participants. Methods This was a secondary descriptive analysis of trial and real-world data. The trial data included twenty-seven US opioid treatment programs in the National Drug Abuse Treatment Clinical Trials Network, N = 2,199 patients. The real-world data included US substance use treatment programs that receive public funding, N = 740,015 patients. We characterized real-world patient populations who were non-represented and under-represented in the trial data in terms of sociodemographic and clinical characteristics that could modify MOUD effectiveness. Results We found that 10.7% of MOUD patients in TEDS-A were not represented in the three clinical trials. As expected, pregnant MOUD patients (n = 19,490) were not represented. Excluding pregnancy, education and marital status from the characteristics, 2.6% of MOUD patients were not represented. Patients aged 65 years and older (n = 11,204), and those 50-64 years who identified as other (non-White, non-Black, and non-Hispanic) race/ethnicity or multi-racial (n = 7,281) were under-represented. Conclusions Quantifying and characterizing non- or under-represented subgroups in trials can provide the data necessary to improve representation in future trials and address research-to-practice gaps.
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Affiliation(s)
- Kara E. Rudolph
- Department of Epidemiology, Columbia University, 722 W 168th St, Room 522, New York, NY 10032, United States,Corresponding author. Tel.: +12123422926
| | - Matthew Russell
- Department of Epidemiology, Columbia University, 722 W 168th St, Room 522, New York, NY 10032, United States
| | - Sean X. Luo
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, New York, United States
| | - John Rotrosen
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, United States
| | - Edward V. Nunes
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, New York, United States
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Andraka-Christou B, Clark MH, Atkins DN, del Pozo B. Criminal problem-solving and civil dependency court policies regarding medications for opioid use disorder. Subst Abuse 2022; 43:425-432. [PMID: 34236297 PMCID: PMC9518695 DOI: 10.1080/08897077.2021.1944958] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Criminal problem-solving courts and civil dependency courts often have participants with substance use disorder (SUD), including opioid use disorder (OUD). These courts refer participants to treatment and set treatment-related requirements for court participants to avoid incarceration or to regain custody of children. Medications for opioid use disorder (MOUD) are the most effective treatment for OUD but are underutilized by court system participants. Little is known about variation in court policies for different MOUDs. Also, more information is needed about types of policies for each MOUD, including whether participants may begin MOUD, continue previously begun MOUD, or complete the court program with MOUD. Methods: An online survey was distributed to criminal problem-solving and civil dependency judges in Florida in 2019 and 2020, yielding data from 58 judges (a 24% response rate). We used nonparametric statistics to test hypotheses with ordinal data. A Friedman's test for related samples or Cochran's Q was used to make within-group comparisons between policies and MOUDs. Results: We found considerable policy variation, with more permissive policies for naltrexone than buprenorphine or methadone, and more permissive policies for continuing MOUD than for initiating MOUD or completing a court program with MOUD. For each medication, less than one quarter of judges indicated their court always permits MOUD, with most indicating that MOUD is permitted sometimes or usually. Conclusion: Because respondents rarely chose "never" or "always" for any MOUD policy, most courts appear to be making MOUD decisions on a case-by-case basis. A clearer understanding of this decision-making process is needed. Some court participants may be required to discontinue MOUD before completing a court program, even if they were permitted to start or continue MOUD treatment. Discontinuation of MOUD without medical justification is contrary to the standard of care for individuals with OUD and increases their risk of overdose.
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Affiliation(s)
- Barbara Andraka-Christou
- Department of Health Management and Informatics, University of Central Florida, Orlando, FL, USA,Department of Internal Medicine (Joint Secondary Appointment), University of Central Florida, Orlando, FL, USA
| | - MH Clark
- Department of Learning Sciences and Educational Research, University of Central Florida, Orlando, FL, USA
| | - Danielle N. Atkins
- Department of Health Management and Informatics, University of Central Florida, Orlando, FL, USA
| | - Brandon del Pozo
- Warren Alpert Medical School, Brown University, Providence, RI, USA
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Archambault L, Bertrand K, Perreault M. Problematic Opioid Use: A Scoping Literature Review of Profiles. Subst Abuse 2022; 16:11782218221103581. [PMID: 35923179 PMCID: PMC9340351 DOI: 10.1177/11782218221103581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/06/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Problematic opioid use can be defined as opioid use behaviors leading to social, medical, or psychological consequences. In some instances, people presenting problematic opioid use can also meet criteria for an opioid use disorder. A growing body of literature highlights different types of people who use opioids, with contrasting characteristics and initiation patterns. In recent years, dynamic trends in opioid use have been documented and studies have demonstrated a shift in profiles. Methods: A scoping literature review was conducted to identify profiles of people presenting problematic opioid use, in order to support the development of tailored interventions and services. Results: Nine articles met the inclusion criteria. Five classifications emerge from the literature reviewed to distinguish types of people presenting problematic opioid use, according to: (1) the type of opioids used, (2) the route of opioid administration, (3) the level of quality of life, (4) patterns of other drugs used, and (5) dependence severity. While samples, concepts, and measurement tools vary between studies, the most salient finding might be the distinct profile of people presenting problematic use of pharmaceutical-type opioids. Discussion and Conclusions: This scoping review highlights that few studies address distinctive profiles of people presenting problematic opioid use. Geographical and chronological differences suggest that local timely assessments may be needed to tailor the service offer to specific needs. Scientific Significance: Future studies should focus on providing a deep understanding of distinct experiential perspectives and service needs, through exploratory quantitative and qualitative designs.
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Affiliation(s)
- Léonie Archambault
- Douglas Research Center and Université de Sherbrooke, Montréal, QC, Canada
| | - Karine Bertrand
- Institut universitaire sur les dépendances and Université de Sherbrooke, Longueuil, QC, Canada
| | - Michel Perreault
- Douglas Research Center and McGill University, Montréal, QC, Canada
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Frost MC, Lampert H, Tsui JI, Iles-Shih MD, Williams EC. The impact of methamphetamine/amphetamine use on receipt and outcomes of medications for opioid use disorder: a systematic review. Addict Sci Clin Pract 2021; 16:62. [PMID: 34635170 PMCID: PMC8504567 DOI: 10.1186/s13722-021-00266-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 09/10/2021] [Indexed: 01/01/2023] Open
Abstract
Background Methamphetamine/amphetamine use has sharply increased among people with opioid use disorder (OUD). It is therefore important to understand whether and how use of these substances may impact receipt of, and outcomes associated with, medications for OUD (MOUD). This systematic review identified studies that examined associations between methamphetamine/amphetamine use or use disorder and 3 classes of outcomes: (1) receipt of MOUD, (2) retention in MOUD, and (3) opioid abstinence during MOUD. Methods We searched 3 databases (PubMed/MEDLINE, PsycINFO, CINAHL Complete) from 1/1/2000 to 7/28/2020 using key words and subject headings, and hand-searched reference lists of included articles. English-language studies of people with documented OUD/opioid use that reported a quantitative association between methamphetamine/amphetamine use or use disorder and an outcome of interest were included. Study data were extracted using a standardized template, and risk of bias was assessed for each study. Screening, inclusion, data extraction and bias assessment were conducted independently by 2 authors. Study characteristics and findings were summarized for each class of outcomes. Results Thirty-nine studies met inclusion criteria. Studies generally found that methamphetamine/amphetamine use or use disorder was negatively associated with receiving methadone and buprenorphine; 2 studies suggested positive associations with receiving naltrexone. Studies generally found negative associations with retention; most studies finding no association had small samples, and these studies tended to examine shorter retention timeframes and describe provision of adjunctive services to address substance use. Studies generally found negative associations with opioid abstinence during treatment among patients receiving methadone or sustained-release naltrexone implants, though observed associations may have been confounded by other polysubstance use. Most studies examining opioid abstinence during other types of MOUD treatment had small samples. Conclusions Overall, existing research suggests people who use methamphetamine/amphetamines may have lower receipt of MOUD, retention in MOUD, and opioid abstinence during MOUD. Future research should examine how specific policies and treatment models impact MOUD outcomes for these patients, and seek to understand the perspectives of MOUD providers and people who use both opioids and methamphetamine/amphetamines. Efforts to improve MOUD care and overdose prevention strategies are needed for this population.
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Affiliation(s)
- Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, WA, 98195, Seattle, United States. .,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, United States.
| | - Hannah Lampert
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - Judith I Tsui
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - Matthew D Iles-Shih
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, WA, 98195, Seattle, United States.,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, United States
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12
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Crist RC, Vickers-Smith R, Kember RL, Rentsch CT, Xu H, Edelman EJ, Hartwell EE, Kampman KM, Kranzler HR. Analysis of genetic and clinical factors associated with buprenorphine response. Drug Alcohol Depend 2021; 227:109013. [PMID: 34488071 PMCID: PMC9328121 DOI: 10.1016/j.drugalcdep.2021.109013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 08/12/2021] [Accepted: 08/15/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Buprenorphine, approved for treating opioid use disorder (OUD), is not equally efficacious for all patients. Candidate gene studies have shown limited success in identifying genetic moderators of buprenorphine treatment response. METHODS We studied 1616 European-ancestry individuals enrolled in the Million Veteran Program, of whom 1609 had an ICD-9/10 code consistent with OUD, a 180-day buprenorphine treatment exposure, and genome-wide genotype data. We conducted a genome-wide association study (GWAS) of buprenorphine treatment response [defined as having no opioid-positive urine drug screens (UDS) following the first prescription]. We also examined correlates of buprenorphine treatment response in multivariable analyses. RESULTS Although no variants reached genome-wide significance, 6 loci were nominally significant (p < 1 × 10-5), four of which were located near previously characterized genes: rs756770 (ADAMTSL2), rs11782370 (SLC25A37), rs7205113 (CRISPLD2), and rs13169373 (LINC01947). A higher maximum daily buprenorphine dosage (aOR = 0.98; 95 %CI: 0.97, 0.995), greater number of UDS (aOR = 0.97; 95 %CI: 0.96, 0.99), and history of hepatitis C (HCV) infection (aOR = 0.71; 95 %CI: 0.57, 0.88) were associated with a reduced odds of buprenorphine response. Older age (aOR: 1.01; 95 %CI: 1.000, 1.02) was associated with increased odds of buprenorphine response. CONCLUSIONS This study had limited statistical power to detect genetic variants associated with a complex human phenotype like buprenorphine treatment response. Meta-analysis of multiple data sets is needed to ensure adequate statistical power for a GWAS of buprenorphine treatment response. The most robust phenotypic predictor of buprenorphine treatment response was intravenous drug use, a proxy for which was HCV infection.
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Affiliation(s)
- Richard C. Crist
- Mental Illness Research, Education and Clinical Center, Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104,Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104
| | - Rachel Vickers-Smith
- Mental Illness Research, Education and Clinical Center, Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104,Department of Epidemiology, University of Kentucky College of Public Health, Lexington, KY 40536,Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY 40536
| | - Rachel L. Kember
- Mental Illness Research, Education and Clinical Center, Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104,Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104
| | - Christopher T. Rentsch
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, 06516,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Heng Xu
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104
| | | | - Emily E. Hartwell
- Mental Illness Research, Education and Clinical Center, Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104,Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104
| | - Kyle M. Kampman
- Mental Illness Research, Education and Clinical Center, Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104,Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104
| | - Henry R. Kranzler
- Mental Illness Research, Education and Clinical Center, Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104,Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104,Corresponding Author: Henry R. Kranzler, M.D., Center for Studies of Addiction, University of Pennsylvania Perelman School of Medicine, 3535 Market St., Suite 500, Philadelphia, PA 19104, Phone: 215-746-1943,
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13
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Nwabueze C, Elom H, Liu S, Walter SM, Sha Z, Acevedo P, Liu Y, Su BB, Xu C, Piamjariyakul U, Wang K. Gender differences in the associations of multiple psychiatric and chronic conditions with major depressive disorder among patients with opioid use disorder. J Addict Dis 2021; 40:168-178. [PMID: 34328394 DOI: 10.1080/10550887.2021.1957639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE The study examined the associations of multiple psychiatric and chronic conditions with the self-reported history of major depressive disorder (MDD) among patients with opioid use disorder (OUD) and tested whether the associations differed by gender. METHODS We conducted a secondary data analysis of baseline data from a clinical trial including 1,646 participants with OUD, of which 465 had MDD. A variable cluster analysis was used to classify chronic medical and psychiatric conditions. Multivariable logistic regression analyses were used to estimate their associations with MDD in subjects with OUD. RESULTS Nine variables were divided into three clusters: cluster 1 included heart condition, hypertension, and liver problems; cluster 2 included gastrointestinal (GI) problems and head injury, and cluster 3 included anxiety disorder, bipolar disorder, and schizophrenia. The overall prevalence of MDD in participants with OUD was 28.3% (22.8% for males and 39.5% for females). Gender, anxiety disorder, schizophrenia, liver problems, heart condition, GI problems, and head injury were significantly associated with MDD. Gender-stratified analyses showed that bipolar disorder, liver problems and individuals with one chronic condition were associated with MDD only in males, whereas heart condition, hypertension, and GI problems were associated with MDD only in females. In addition, anxiety disorder, head injury, individuals with one or more than two psychiatric conditions, and individuals with more than two chronic conditions were associated with MDD regardless of gender. CONCLUSIONS Treatment plans in patients with OUD should not only address MDD but also co-morbid psychiatric and chronic medical conditions that occur with MDD.
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Affiliation(s)
- Christian Nwabueze
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN, USA
| | - Hilary Elom
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN, USA
| | - Sophia Liu
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Suzy Mascaro Walter
- Department of Family and Community Health, School of Nursing, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Zhanxin Sha
- School of Kinesiology and Nutrition, College of Education and Human Sciences, University of Southern Mississippi, Hattiesburg, MS, USA
| | - Priscila Acevedo
- Department of Health and Biomedical Sciences, College of Health Affairs, University of Texas Rio Grande Valley, Brownsville, TX, USA
| | - Ying Liu
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN, USA
| | - Brenda Bin Su
- Department of Health and Biomedical Sciences, College of Health Affairs, University of Texas Rio Grande Valley, Brownsville, TX, USA
| | - Chun Xu
- Department of Health and Biomedical Sciences, College of Health Affairs, University of Texas Rio Grande Valley, Brownsville, TX, USA
| | - Ubolrat Piamjariyakul
- School of Nursing, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Kesheng Wang
- Department of Family and Community Health, School of Nursing, Health Sciences Center, West Virginia University, Morgantown, WV, USA
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14
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Andraka-Christou B, Totaram R, Randall-Kosich O. Stigmatization of medications for opioid use disorder in 12-step support groups and participant responses. Subst Abus 2021; 43:415-424. [PMID: 34214400 DOI: 10.1080/08897077.2021.1944957] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: 12-step groups are the most common approach to managing opioid use disorder (OUD) in the U.S. Medications for OUD (MOUD) are the most effective tool for preventing opioid misuse and relapse. Previous research has identified stigma of MOUD in 12-step groups. Objectives: We sought to identify how MOUD stigma is operationalized in 12-step groups and to identify responses to stigma. Methods: We recruited individuals with both MOUD experience and 12-step group experience from three syringe exchange programs in the U.S. using snowball sampling. We conducted individual telephone semi-structured interviews during 2018 and 2019. We coded data in Dedoose software and conducted thematic analysis using iterative categorization. Results: We recruited 30 individuals meeting our inclusion criteria. The following stigma operationalization methods were identified: prohibiting people using MOUD from speaking at meetings; encouraging shortened duration of MOUD treatment; refusing to sponsor people using MOUD; and refusing to let people using MOUD claim recovery time. Responses to stigma included the following: feeling shame; feeling anger; shopping around for different groups, leaving the group, or forming a new group; not revealing MOUD utilization or only telling a sponsor; speaking out on behalf of MOUD; and using cognitive approaches to avoid stigma internalization. Cognitive approaches included believing that anti-MOUD stigma is contrary to 12-step principles; disregarding statements as inaccurate based on one's experience of MOUD benefits; and accepting that all groups of humans have some ignorant people. Conclusion: Healthcare systems should help address MOUD stigma experienced by patients in 12-step groups, such as by offering non-12-step alternative groups and encouraging MOUD healthcare providers to prepare patients for potential stigma they may face. Some stigma response options, like shopping around for different groups, may not be feasible in rural areas or for participants newer to recovery.
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Affiliation(s)
- Barbara Andraka-Christou
- Department of Health Management and Informatics, University of Central Florida, Orlando, FL, USA.,Department of Internal Medicine, University of Central Florida, Orlando, FL, USA
| | - Rachel Totaram
- Department of Health Management and Informatics, University of Central Florida, Orlando, FL, USA
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15
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Nunes EV, Scodes JM, Pavlicova M, Lee JD, Novo P, Campbell ANC, Rotrosen J. Sublingual Buprenorphine-Naloxone Compared With Injection Naltrexone for Opioid Use Disorder: Potential Utility of Patient Characteristics in Guiding Choice of Treatment. Am J Psychiatry 2021; 178:660-671. [PMID: 34170188 PMCID: PMC11061873 DOI: 10.1176/appi.ajp.2020.20060816] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Sublingual buprenorphine-naloxone and extended-release injection naltrexone are effective treatments, with distinct mechanisms, for opioid use disorder. The authors examined whether patients' demographic and clinical characteristics were associated with better response to one medication or the other. METHODS In a multisite 24-week randomized comparative-effectiveness trial of assignment to buprenorphine-naloxone (N=287) compared with extended-release naltrexone (N=283) comprising inpatients planning to initiate medication treatment for opioid use disorder, 50 demographic and clinical characteristics were examined as moderators of the effect of medication assignment on relapse to regular opioid use and failure to initiate medication. Moderator-by-medication interactions were estimated using logistic regression with correction for multiple testing. RESULTS In the intent-to-treat sample, patients who reported being homeless had a lower relapse rate if they were assigned to receive extended-release naltrexone (51.6%) compared with buprenorphine-naloxone (70.4%) (odds ratio=0.45, 95% CI=0.22, 0.90); patients who were not homeless had a higher relapse rate if they were assigned to extended-release naltrexone (70.9%) compared with buprenorphine-naloxone (53.1%) (odds ratio=2.15, 95% CI=1.44, 3.21). In the subsample of patients who initiated medication, the interaction was not significant, with a similar pattern of lower relapse with extended-release naltrexone (41.4%) compared with buprenorphine (68.6%) among homeless patients (odds ratio=0.32, 95% CI=0.15, 0.68) but less difference among those not homeless (extended-release naltrexone, 57.2%; buprenorphine, 52.0%; odds ratio=1.24, 95% CI=0.80, 1.90). For failure to initiate medication, moderators were stated preference for medication (failure was less likely if the patient was assigned to the medication preferred), parole and probation status (fewer failures with extended-release naltrexone for those on parole or probation), and presence of pain and timing of randomization (more failure with extended-release naltrexone for patients endorsing moderate to severe pain and randomized early while still undergoing medically managed withdrawal). CONCLUSIONS Among patients with opioid use disorder admitted to inpatient treatment, homelessness, parole and probation status, medication preference, and factors likely to influence tolerability of medication initiation may be important in matching patients to buprenorphine or extended-release naltrexone.
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Affiliation(s)
- Edward V Nunes
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen)
| | - Jennifer M Scodes
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen)
| | - Martina Pavlicova
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen)
| | - Joshua D Lee
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen)
| | - Patricia Novo
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen)
| | - Aimee N C Campbell
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen)
| | - John Rotrosen
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen)
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16
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Fairley M, Humphreys K, Joyce VR, Bounthavong M, Trafton J, Combs A, Oliva EM, Goldhaber-Fiebert JD, Asch SM, Brandeau ML, Owens DK. Cost-effectiveness of Treatments for Opioid Use Disorder. JAMA Psychiatry 2021; 78:767-777. [PMID: 33787832 PMCID: PMC8014209 DOI: 10.1001/jamapsychiatry.2021.0247] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Opioid use disorder (OUD) is a significant cause of morbidity and mortality in the US, yet many individuals with OUD do not receive treatment. OBJECTIVE To assess the cost-effectiveness of OUD treatments and association of these treatments with outcomes in the US. DESIGN AND SETTING This model-based cost-effectiveness analysis included a US population with OUD. INTERVENTIONS Medication-assisted treatment (MAT) with buprenorphine, methadone, or injectable extended-release naltrexone; psychotherapy (beyond standard counseling); overdose education and naloxone distribution (OEND); and contingency management (CM). MAIN OUTCOMES AND MEASURES Fatal and nonfatal overdoses and deaths throughout 5 years, discounted lifetime quality-adjusted life-years (QALYs), and costs. RESULTS In the base case, in the absence of treatment, 42 717 overdoses (4132 fatal, 38 585 nonfatal) and 12 660 deaths were estimated to occur in a cohort of 100 000 patients over 5 years, and 11.58 discounted lifetime QALYs were estimated to be experienced per person. An estimated reduction in overdoses was associated with MAT with methadone (10.7%), MAT with buprenorphine or naltrexone (22.0%), and when combined with CM and psychotherapy (range, 21.0%-31.4%). Estimated deceased deaths were associated with MAT with methadone (6%), MAT with buprenorphine or naltrexone (13.9%), and when combined with CM, OEND, and psychotherapy (16.9%). MAT yielded discounted gains of 1.02 to 1.07 QALYs per person. Including only health care sector costs, methadone cost $16 000/QALY gained compared with no treatment, followed by methadone with OEND ($22 000/QALY gained), then by buprenorphine with OEND and CM ($42 000/QALY gained), and then by buprenorphine with OEND, CM, and psychotherapy ($250 000/QALY gained). MAT with naltrexone was dominated by other treatment alternatives. When criminal justice costs were included, all forms of MAT (with buprenorphine, methadone, and naltrexone) were associated with cost savings compared with no treatment, yielding savings of $25 000 to $105 000 in lifetime costs per person. The largest cost savings were associated with methadone plus CM. Results were qualitatively unchanged over a wide range of sensitivity analyses. An analysis using demographic and cost data for Veterans Health Administration patients yielded similar findings. CONCLUSIONS AND RELEVANCE In this cost-effectiveness analysis, expanded access to MAT, combined with OEND and CM, was associated with cost-saving reductions in morbidity and mortality from OUD. Lack of widespread MAT availability limits access to a cost-saving medical intervention that reduces morbidity and mortality from OUD. Opioid overdoses in the US likely reached a record high in 2020 because of COVID-19 increasing substance use, exacerbating stress and social isolation, and interfering with opioid treatment. It is essential to understand the cost-effectiveness of alternative forms of MAT to treat OUD.
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Affiliation(s)
- Michael Fairley
- Department of Management Science and Engineering, Stanford University, Stanford, California
| | - Keith Humphreys
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Vilija R. Joyce
- Veterans Affairs Health Services Research and Development Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California
| | - Mark Bounthavong
- Veterans Affairs Health Services Research and Development Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California
| | - Jodie Trafton
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California,Veterans Affairs Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, VA Central Office, US Department of Veterans Affairs, Palo Alto, California
| | - Ann Combs
- Veterans Affairs Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, VA Central Office, US Department of Veterans Affairs, Palo Alto, California
| | - Elizabeth M. Oliva
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California
| | - Jeremy D. Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Steven M. Asch
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California,Department of Medicine, Stanford University, Stanford, California
| | - Margaret L. Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, California
| | - Douglas K. Owens
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California,Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California,Department of Medicine, Stanford University, Stanford, California
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17
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Fishman M, Vo HT, Burgower R, Ruggiero M, Rotrosen J, Lee J, Nunes E. Treatment Trajectories During and After a Medication Trial for Opioid Use Disorder: Moving from Research as Usual to Treatment as Usual. J Addict Med 2020; 14:331-6. [PMID: 31972765 DOI: 10.1097/ADM.0000000000000592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The effectiveness of treatment incorporating relapse prevention medications for opioid use disorder (OUD) is typically examined in research using rigidly predefined endpoints of success versus failure, usually over a single episode of care. But this perspective may not adequately portray the nonlinear trajectories typical of real-world treatment courses in this chronic, remitting, and relapsing disorder. METHODS This descriptive study examined 12-month treatment trajectories of n = 60 patients enrolled at a single site of a larger multisite randomized controlled trial examining the comparative effectiveness of buprenorphine versus extended-release naltrexone. While the parent study provided medication treatment through the research protocol for 6 months, this study documents treatment up to 12 months, including medications, provided through standard community resources (treatment as usual) outside of the protocol. RESULTS Some patients continued medications past the end of the study intervention, whereas others did not. Some patients initiated medications other than the one assigned by the study. Some patients switched from 1 medication to the other. Many patients returned to treatment after 1 or more periods of dropout and/or relapse. Patients utilized multiple episodes of bed-based care, including short-term acute residential and long-term residential treatment, and also recovery housing supports. Described trajectories are also depicted graphically. At 12 months, while rates of continuous treatment retention were low (8%), rates of cross-sectional treatment engagement including return to treatment after drop out were higher (35%). CONCLUSIONS This description of nonlinear treatment trajectories highlights the potential benefits of flexibility and optimism in the promotion of re-engagement, despite interim outcomes that might traditionally be considered "failure" endpoints.
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18
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Tsui JI, Akosile MA, Lapham GT, Boudreau DM, Johnson EA, Bobb JF, Binswanger IA, Yarborough BJH, Glass JE, Rossom RC, Murphy MT, Cunningham CO, Arnsten JH, Thakral M, Saxon AJ, Merrill JO, Samet JH, Bart GB, Campbell CI, Loree AM, Silva A, Stotts AL, Ahmedani B, Braciszewski JM, Hechter RC, Northrup TF, Horigian VE, Bradley KA. Prevalence and Medication Treatment of Opioid Use Disorder Among Primary Care Patients with Hepatitis C and HIV. J Gen Intern Med 2021; 36:930-937. [PMID: 33569735 PMCID: PMC8041979 DOI: 10.1007/s11606-020-06389-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 12/03/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hepatitis C and HIV are associated with opioid use disorders (OUD) and injection drug use. Medications for OUD can prevent the spread of HCV and HIV. OBJECTIVE To describe the prevalence of documented OUD, as well as receipt of office-based medication treatment, among primary care patients with HCV or HIV. DESIGN Retrospective observational cohort study using electronic health record and insurance data. PARTICIPANTS Adults ≥ 18 years with ≥ 2 visits to primary care during the study (2014-2016) at 6 healthcare systems across five states (CO, CA, OR, WA, and MN). MAIN MEASURES The primary outcome was the diagnosis of OUD; the secondary outcome was OUD treatment with buprenorphine or oral/injectable naltrexone. Prevalence of OUD and OUD treatment was calculated across four groups: HCV only; HIV only; HCV and HIV; and neither HCV nor HIV. In addition, adjusted odds ratios (AOR) of OUD treatment associated with HCV and HIV (separately) were estimated, adjusting for age, gender, race/ethnicity, and site. KEY RESULTS The sample included 1,368,604 persons, of whom 10,042 had HCV, 5821 HIV, and 422 both. The prevalence of diagnosed OUD varied across groups: 11.9% (95% CI: 11.3%, 12.5%) for those with HCV; 1.6% (1.3%, 2.0%) for those with HIV; 8.8% (6.2%, 11.9%) for those with both; and 0.92% (0.91%, 0.94%) among those with neither. Among those with diagnosed OUD, the prevalence of OUD medication treatment was 20.9%, 16.0%, 10.8%, and 22.3%, for those with HCV, HIV, both, and neither, respectively. HCV was not associated with OUD treatment (AOR = 1.03; 0.88, 1.21), whereas patients with HIV had a lower probability of OUD treatment (AOR = 0.43; 0.26, 0.72). CONCLUSIONS Among patients receiving primary care, those diagnosed with HCV and HIV were more likely to have documented OUD than those without. Patients with HIV were less likely to have documented medication treatment for OUD.
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Affiliation(s)
- Judith I Tsui
- University of Washington/Harborview Medical Center, Seattle, USA
| | - Mary A Akosile
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Eric A Johnson
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Ingrid A Binswanger
- Kaiser Permanente Colorado, Colorado Permanente Medical Group, and the University of Colorado School of Medicine, Aurora, USA
| | | | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Rebecca C Rossom
- HealthPartners Institute, University of Minnesota, Bloomington, USA
| | - Mark T Murphy
- MultiCare Institute for Research and Innovation, MultiCare Health System WA, Seattle, USA
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine, Montefiore Medical Center, New York City, USA
| | - Julia H Arnsten
- Albert Einstein College of Medicine, Montefiore Medical Center, New York City, USA
| | - Manu Thakral
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, USA
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System/University of Washington School of Medicine, Seattle, USA
| | - Joseph O Merrill
- University of Washington/Harborview Medical Center, Seattle, USA
| | | | - Gavin B Bart
- Hennepin Healthcare, University of Minnesota, Minneapolis, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, USA
| | - Amy M Loree
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
| | - Angela Silva
- MultiCare Institute for Research and Innovation, MultiCare Health System WA, Seattle, USA
| | - Angela L Stotts
- Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, USA
| | - Brian Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
| | - Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
- Department of Psychiatry, Henry Ford Health System, Detroit, USA
| | - Rulin C Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Oakland, USA
| | - Thomas F Northrup
- Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, USA
| | - Viviana E Horigian
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Florida, USA
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA.
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19
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Zhao L, Cheng C, Bouchard L. Medication-Assisted Treatment for Opioid Use Disorder in Pregnancy: Practical Applications and Clinical Impact. Obstet Gynecol Surv 2020; 75:175-89. [PMID: 32232496 DOI: 10.1097/OGX.0000000000000744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Opioid use disorder is increasingly common in the United States and affects many pregnancies. Given the rise in pregnancies complicated by opioid use, providers should understand the diagnosis and management of opioid use disorder in pregnancy. Objective This article focuses on screening for opioid misuse, selecting appropriate treatment for patients, initiating medication-assisted treatment in the inpatient setting, and providing appropriate peripartum care. Evidence Acquisition A PubMed search was undertaken using the following search terms: "opioid use disorder", "pregnancy," "medication assisted treatment," "buprenorphine," "methadone," "heroin," "addiction," "neonatal abstinence syndrome," and "detoxification." The search was limited to the English language publications, with most being published after 2000. Results All women should be screened for opioid use disorder during pregnancy. Opioid use has profound effects on the mother and infant. Medication-assisted treatment is the standard of care for pregnant women with opioid use disorder. Patients will require a multidisciplinary approach to management in the intrapartum and postpartum period. Conclusions Conclusions Opioid use disorder is a common, chronic condition with significant implications during pregnancy. Recognition and appropriate treatment of this disorder can optimize maternal and fetal outcomes. Conclusions Obstetricians are increasingly being challenged to manage pregnancies complicated by opioid use disorder and should be proficient in providing safe and effective care.
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20
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Lake S, St Pierre M. The relationship between cannabis use and patient outcomes in medication-based treatment of opioid use disorder: A systematic review. Clin Psychol Rev 2020; 82:101939. [PMID: 33130527 DOI: 10.1016/j.cpr.2020.101939] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 10/14/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
Despite high rates of cannabis use during medication-based treatment of opioid use disorder (MOUD), uncertainty remains around how cannabis influences treatment outcomes. We sought to investigate the relationship between cannabis use during MOUD and a number of patient outcomes. We searched seven databases for original peer-reviewed studies documenting the relationship between cannabis use and at least one primary outcome (opioid use, treatment adherence, or treatment retention) among patients enrolled in methadone-, buprenorphine-, or naltrexone-based therapy for OUD. In total, 41 articles (including 23 methadone, 7 buprenorphine, 6 naltrexone, and 5 mixed modalities) were included in this review. For each primary outcome area, there was a small number of studies that produced findings suggestive of a supportive or detrimental role of concurrent cannabis use, but the majority of studies reported that cannabis use was not statistically significantly associated with the outcome. No studies of naltrexone treatment demonstrated significantly worse outcomes for cannabis users. We identified methodological shortcomings and future research priorities, including exploring the potential role of adjunct cannabis use for improving opioid craving and withdrawal during MOUD. While monitoring for cannabis use may help guide clinicians towards an improved treatment plan, cannabis use is unlikely to independently threaten treatment outcomes.
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Affiliation(s)
- Stephanie Lake
- British Columbia Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada.
| | - Michelle St Pierre
- Department of Psychology, University of British Columbia, 3187 University Way, Kelowna, BC V1V 1V7, Canada
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21
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Abstract
Background: The U.S. opioid epidemic has caused substantial harm for over 20 years. Policy interventions have had limited impact and sometimes backfired. Experts recommend a systems modeling approach to address the complexities of opioid policymaking.Objectives: Develop a system dynamics simulation model that reflects the complexities and can anticipate intended and unintended intervention effects.Methods: The model was developed from literature review and data gathering. Its outputs, starting in 1990, were compared against 12 historical time series. Four illustrative interventions were simulated for 2020-2030: reducing prescription dosage by 20%, cutting diversion by 30%, increasing addiction treatment from 45% to 65%, and increasing lay naloxone use from 4% to 20%. Sensitivity testing was performed to determine effects of uncertainties. No human subjects were studied.Results: The model fits historical data well with error percentage averaging 9% across 201 data points. Interventions to reduce dosage and diversion reduce the number of persons with opioid use disorder (PWOUD) by 11% and 16%, respectively, but each of these interventions reduces overdoses by only 1%. Boosting treatment reduces overdoses by 3% but increases PWOUD by 1%. Expanding naloxone reduces overdose deaths by 12% but increases PWOUD by 2% and overdoses by 3%. Combining all four interventions reduces PWOUD by 24%, overdoses by 4%, and deaths by 18%. Uncertainties may affect these numerical results, but policy findings are unchanged.Conclusion: No single intervention significantly reduces both PWOUD and overdose deaths, but a combination strategy can do so. Entering the 2020s, only protective measures like naloxone expansion could significantly reduce overdose deaths.
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Affiliation(s)
- Jack Homer
- Homer Consulting, Barrytown, New York, USA
| | - Wayne Wakeland
- Systems Science Graduate Program, Portland State University, Portland, Oregon, USA
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22
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Carroll KM, Weiss RD. The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review. Focus (Am Psychiatr Publ) 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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
(Reprinted with permission from Am J Psychiatry 2017;174:738-747).
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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
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23
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Homayra F, Hongdilokkul N, Piske M, Pearce LA, Zhou H, Min JE, Krebs E, Nosyk B. Determinants of selection into buprenorphine/naloxone among people initiating opioid agonist treatment in British Columbia. Drug Alcohol Depend 2020; 207:107798. [PMID: 31927163 DOI: 10.1016/j.drugalcdep.2019.107798] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Studies assessing the comparative effectiveness of methadone versus buprenorphine/naloxone for opioid use disorder in real-world settings are rare - challenged by structural differences in delivery across settings and factors influencing treatment selection. We identified determinants of selection into buprenorphine/naloxone and quantified contributions of individual and provider-level covariates in a setting delivering both medications within the same healthcare settings. METHODS Utilizing linked health administrative datasets, we conducted a retrospective cohort study of people with opioid use disorder (PWOUD) receiving opioid agonist treatment (OAT) in British Columbia, Canada, from 2008-2017. Determinants of buprenorphine/naloxone selection were identified using a generalized linear mixed model with random intercept terms for providers and individuals. We determined the influence of individual demographics, clinical history, measures of provider experience and preference, and dates of key policy changes. RESULTS A total of 39,605 individuals experienced 178,976 OAT episodes (methadone:139,439(77.9 %);buprenorphine/naloxone:39,537(22.1 %)). Male sex, less OAT experience, younger age, mental health conditions and chronic pain were associated with higher odds of buprenorphine/naloxone prescription. For providers, higher client-attachment, more complex OAT case-mixes, and higher buprenorphine/naloxone prescribing-preference were also associated with higher odds of buprenorphine/naloxone prescription. Observed individual-level covariates explained 9.7 % of variance in odds of buprenorphine/naloxone selection, while observed provider-level covariates explained 20.0 %. Controlling for covariates, residual unmeasured between-individual variance accounted for 18.5 % of the explained variation in the odds of buprenorphine/naloxone selection, while unmeasured between-provider variance accounted for 28.4 %. CONCLUSION Provider characteristics were more influential in selection of buprenorphine/naloxone over methadone informing subsequent analyses of comparative effectiveness of these regimens.
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Affiliation(s)
- F Homayra
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - N Hongdilokkul
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - M Piske
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - L A Pearce
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - H Zhou
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - J E Min
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - E Krebs
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - B Nosyk
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 9706, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
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24
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Pro G, Utter J, Cram J, Baldwin J. Racial/Ethnic and Gender Differences in Associations of Medication-Assisted Therapy and Reduced Opioid Use between Outpatient Treatment Admission and Discharge. J Psychoactive Drugs 2020; 52:186-194. [PMID: 32005084 DOI: 10.1080/02791072.2020.1717685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Medication-assisted therapy (MAT) for opioid use disorders is an effective treatment strategy. Racial/ethnic and gender disparities in MAT utilization have been documented, but less is known about disparities in MAT outcomes. We used the Treatment Episodes Dataset-Discharges (TEDS-D; 2015- 2017) to identify outpatient treatment episodes with heroin or illicit opioids indicated at admission (n = 232,547). We used multivariate logistic regression to model the association between MAT and a reduction in opioid use between treatment admission and discharge. We explored moderation by race/ethnicity and gender by including an interaction term. We identified a strong moderating effect of race/ethnicity and gender. American Indian/Alaska Native (AI/AN) women demonstrated the strongest association between MAT (versus no MAT) and a reduction in opioid use (aOR = 6.05, 95% CI = 4.81- 7.61), while White men demonstrated the weakest association (aOR = 2.78, CI = 2.70- 2.87). Our findings could inform changes in clinical MAT settings that are based on harm reduction and the incremental transition from illicit opioids to medication-assistance among a diverse opioid use disorder population.
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Affiliation(s)
- George Pro
- Center for Health Equity Research, Northern Arizona University , Flagstaff, AZ, USA
| | - Jeff Utter
- Department of Family Medicine, University of Colorado , Denver, CO, USA
| | - Jessica Cram
- Department of Counseling Supervising and Education, Capella University , Minneapolis, MN, USA
| | - Julie Baldwin
- Center for Health Equity Research, Northern Arizona University , Flagstaff, AZ, USA.,Department of Health Sciences, Northern Arizona University , Flagstaff, AZ, USA
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25
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Dennis BB, Sanger N, Bawor M, Naji L, Plater C, Worster A, Woo J, Bhalerao A, Baptist-Mohseni N, Hillmer A, Rice D, Corace K, Hutton B, Tugwell P, Thabane L, Samaan Z. A call for consensus in defining efficacy in clinical trials for opioid addiction: combined results from a systematic review and qualitative study in patients receiving pharmacological assisted therapy for opioid use disorder. Trials 2020; 21:30. [PMID: 31907000 PMCID: PMC6945391 DOI: 10.1186/s13063-019-3995-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 12/13/2019] [Indexed: 11/23/2022] Open
Abstract
Background Given the complex nature of opioid addiction treatment and the rising number of available opioid substitution and antagonist therapies (OSAT), there is no ‘gold standard’ measure of treatment effectiveness, and each successive trial measures a different set of outcomes which reflect success in arbitrary or opportune terms. We sought to describe the variation in current outcomes employed across clinical trials for opioid addiction, as well as determine whether a discrepancy exists between the treatment targets that patients consider important and how treatment effectiveness is measured in the literature. Methods We searched nine commonly used databases (e.g., EMBASE, MEDLINE) from inception to August 1, 2015. Outcomes used across trials were extracted and categorized according to previously established domains. To evaluate patient-reported goals of treatment, semi-structured interviews were conducted with 18 adults undergoing methadone treatment. Results We identified 60 trials eligible for inclusion. Once outcomes were categorized into eight broad domains (e.g., abstinence/substance abuse), we identified 21 specific outcomes with furthermore 53 subdomains and 118 measurements. Continued opioid use and treatment retention were the most commonly reported measures (46%, n = 28). The majority of patients agreed that abstinence from opioids was a primary goal in their treatment, although they also stressed goals under-reported in clinical trials. Conclusions There is inconsistency in the measures used to evaluate the effectiveness of OSATs. Individual and population level decision making is being guided by a standard of effect considered useful to researchers yet in direct conflict with what patients deem important. Trial registration PROSPERO, CRD42013006507.
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Affiliation(s)
- Brittany B Dennis
- McMaster University Internal Medicine Residency Program, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Nitika Sanger
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Monica Bawor
- McMaster University Internal Medicine Residency Program, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Leen Naji
- Department of Family Medicine Residency Program, Michael G. Degroote School of Medicine, McMaster University, Hamilton, Canada
| | - Carolyn Plater
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Andrew Worster
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, Hamilton General Hospital, Hamilton, Canada
| | - Julia Woo
- University of Toronto Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Anuja Bhalerao
- University of Toronto Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Natasha Baptist-Mohseni
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Alannah Hillmer
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Danielle Rice
- Faculty of Science, Department of Psychology, McGill University, Montreal, Canada.,Center for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kim Corace
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,University of Ottawa Institute of Mental Health Research, Ottawa, ON, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tugwell
- WHO Collaborating Centre for Knowledge Translation and Health Technology Assessment in Health Equity, Bruyère Research Institute, Ottawa, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Centre for Evaluation of Medicine, Hamilton, Canada.,System Linked Research Unit, Hamilton, Canada
| | - Zainab Samaan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada. .,Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada. .,Population Genomics Program, Chanchlani Research Center, McMaster University, Hamilton, Canada.
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26
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Abstract
PURPOSE OF REVIEW Recent HIV outbreaks have occurred as a result of the current US opioid epidemic. Providing medications for opioid use disorder (MOUD) with methadone, buprenorphine, and extended-release naltrexone is essential to achieving optimal HIV treatment outcomes including viral suppression and retention in treatment. This review describes the pharmacology of MOUD with specific attention to interactions with antiretroviral therapy, and to the effect of MOUD on HIV treatment outcomes. RECENT FINDINGS Methadone and buprenorphine both improve HIV viral suppression, adherence to antiretroviral therapy, and overall mortality for persons with opioid use disorder (OUD). Extended-release naltrexone has been most extensively studied in persons with HIV leaving incarcerated settings, and improves HIV viral suppression in that context. Strategies that integrate MOUD and HIV treatment are crucial to optimize viral suppression. The differing pharmacokinetic and delivery characteristics of these MOUD offer diverse options. Given the chronic and relapsing nature of both HIV and OUD, long-term approaches are required.
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Affiliation(s)
- Laura Fanucchi
- Division of Infectious Disease, University of Kentucky College of Medicine, 740 South Limestone, K512, Lexington, KY, 40536, USA. .,Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, USA.
| | - Sandra A Springer
- Department of Internal Medicine, Section of Infectious Disease, Yale School of Medicine, New Haven, CT, USA.,Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA
| | - P Todd Korthuis
- Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA
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27
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Zortea M, Ramalho L, Alves RL, Alves CFDS, Braulio G, Torres ILDS, Fregni F, Caumo W. Transcranial Direct Current Stimulation to Improve the Dysfunction of Descending Pain Modulatory System Related to Opioids in Chronic Non-cancer Pain: An Integrative Review of Neurobiology and Meta-Analysis. Front Neurosci 2019; 13:1218. [PMID: 31803005 PMCID: PMC6876542 DOI: 10.3389/fnins.2019.01218] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 10/29/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Opioid long-term therapy can produce tolerance, opioid-induced hyperalgesia (OIH), and it induces dysfunction in pain descending pain inhibitory system (DPIS). Objectives: This integrative review with meta-analysis aimed: (i) To discuss the potential mechanisms involved in analgesic tolerance and opioid-induced hyperalgesia (OIH). (ii) To examine how the opioid can affect the function of DPIS. (ii) To show evidence about the tDCS as an approach to treat acute and chronic pain. (iii) To discuss the effect of tDCS on DPIS and how it can counter-regulate the OIH. (iv) To draw perspectives for the future about the tDCS effects as an approach to improve the dysfunction in the DPIS in chronic non-cancer pain. Methods: Relevant published randomized clinical trials (RCT) comparing active (irrespective of the stimulation protocol) to sham tDCS for treating chronic non-cancer pain were identified, and risk of bias was assessed. We searched trials in PubMed, EMBASE and Cochrane trials databases. tDCS protocols accepted were application in areas of the primary motor cortex (M1), dorsolateral prefrontal cortex (DLPFC), or occipital area. Results: Fifty-nine studies were fully reviewed, and 24 with moderate to the high-quality methodology were included. tDCS improved chronic pain with a moderate effect size [pooled standardized mean difference; -0.66; 95% confidence interval (CI) -0.91 to -0.41]. On average, active protocols led to 27.26% less pain at the end of treatment compared to sham [95% CI; 15.89-32.90%]. Protocol varied in terms of anodal or cathodal stimulation, areas of stimulation (M1 and DLPFC the most common), number of sessions (from 5 to 20) and current intensity (from 1 to 2 mA). The time of application was 20 min in 92% of protocols. Conclusion: In comparison with sham stimulation, tDCS demonstrated a superior effect in reducing chronic pain conditions. They give perspectives that the top-down neuromodulator effects of tDCS are a promising approach to improve management in refractory chronic not-cancer related pain and to enhance dysfunctional neuronal circuitries involved in the DPIS and other pain dimensions and improve pain control with a therapeutic opioid-free. However, further studies are needed to determine individualized protocols according to a biopsychosocial perspective.
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Affiliation(s)
- Maxciel Zortea
- Post-graduation Program in Medicine: Medical Sciences, Universidade Federal do Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil.,Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Leticia Ramalho
- Post-graduation Program in Medicine: Medical Sciences, Universidade Federal do Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil.,Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Rael Lopes Alves
- Post-graduation Program in Medicine: Medical Sciences, Universidade Federal do Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil.,Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Camila Fernanda da Silveira Alves
- Post-graduation Program in Medicine: Medical Sciences, Universidade Federal do Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil.,Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Gilberto Braulio
- Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,Service of Anesthesia and Perioperative Medicine, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Iraci Lucena da Silva Torres
- Department of Pharmacology, Institute of Health Sciences (ICBS), Universidade Federal do Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil.,Pharmacology of Pain and Neuromodulation: Pre-clinical Investigations Research Group, Universidade Federal do Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil
| | - Felipe Fregni
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States
| | - Wolnei Caumo
- Post-graduation Program in Medicine: Medical Sciences, Universidade Federal do Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil.,Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,Pain Treatment and Palliative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
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Randall-kosich O, Andraka-christou B, Totaram R, Alamo J, Nadig M. Comparing Reasons for Starting and Stopping Methadone, Buprenorphine, and Naltrexone Treatment Among a Sample of White Individuals With Opioid Use Disorder. J Addict Med 2020; 14:e44-52. [DOI: 10.1097/adm.0000000000000584] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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29
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Andraka-christou B, Gabriel M, Madeira J, Silverman RD. Court personnel attitudes towards medication-assisted treatment: A state-wide survey. J Subst Abuse Treat 2019; 104:72-82. [DOI: 10.1016/j.jsat.2019.06.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 01/21/2023]
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30
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Montgomery L, Burlew AK, Haeny AM, Jones CA. A systematic scoping review of research on Black participants in the National Drug Abuse Treatment Clinical Trials Network. Psychol Addict Behav 2019; 34:117-127. [PMID: 31246072 DOI: 10.1037/adb0000483] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Black individuals experience a disproportionate burden of substance-related disabilities and premature death relative to other racial/ethnic groups, highlighting the need for additional research. The National Drug Abuse Treatment Clinical Trials Network (CTN), a research platform for multisite behavioral, pharmacological, and integrated trials designed to evaluate the effectiveness of substance use treatments in community settings with diversified patient populations, provides a wealth of research knowledge on substance use. Although CTN trials have enrolled over 5,000 Black individuals since its inception in 2000, there has been no synthesis of the findings, discussion of the implications, or suggestions for future research for Black individuals. Members of the Minority Interest Group of the CTN conducted a scoping review of published research on Black participants in CTN trials. Studies were included if the sample was more than 75% Black and/or specific findings pertaining to Black participants were reported. The review yielded 50 articles, with studies that mostly focused on baseline characteristics, followed by substance use treatment outcomes, HIV/risky sex behaviors, retention, comorbid conditions and measurement issues. This review highlighted the importance of several issues that are critical to understanding and treating substance misuse among Black people, such as the characteristics of Black people entering treatment, measurement equivalence, and engaging/retaining adolescents and young adults in treatment. There is still a continued need to identify the most effective treatments for Black individuals who use substances. The CTN offers several untapped opportunities to further advance research on Black individuals who use substances (e.g., secondary analyses of publicly available data). (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Korownyk C, Perry D, Ton J, Kolber MR, Garrison S, Thomas B, Allan GM, Dugré N, Finley CR, Ting R, Yang PR, Vandermeer B, Lindblad AJ. Opioid use disorder in primary care: PEER umbrella systematic review of systematic reviews. Can Fam Physician 2019; 65:e194-e206. [PMID: 31088885 PMCID: PMC6516704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To summarize the best available evidence regarding various topics related to primary care management of opioid use disorder (OUD). DATA SOURCES MEDLINE, Cochrane Library, Google, and the references of included studies and relevant guidelines. STUDY SELECTION Published systematic reviews and newer randomized controlled trials from the past 5 to 10 years that investigated patient-oriented outcomes related to managing OUD in primary care, diagnosis, pharmacotherapies (including buprenorphine, methadone, and naltrexone), tapering strategies, psychosocial interventions, prescribing practices, and management of comorbidities. SYNTHESIS From 8626 articles, 39 systematic reviews and an additional 26 randomized controlled trials were included. New meta-analyses were performed where possible. One cohort study suggests 1 case-finding tool might be reasonable to assist with diagnosis (positive likelihood ratio of 10.3). Meta-analysis demonstrated that retention in treatment improves when buprenorphine or methadone are used (64% to 73% vs 22% to 39% for control), when OUD is treated in primary care (86% vs 67% in specialty care, risk ratio [RR] of 1.25, 95% CI 1.07 to 1.47), and when counseling is added to pharmacotherapy (74% vs 62% for controls, RR = 1.20, 95% CI 1.06 to 1.36). Retention was also improved with naltrexone (33% vs 25% for controls, RR = 1.35, 95% CI 1.11 to 1.64) and reduced with medication-related contingency management (eg, loss of take-home doses as a punitive measure; 68% vs 77% for no contingency, RR = 0.86, 95% CI 0.76 to 0.99). CONCLUSION There is reasonable evidence that patients with OUD should be managed in the primary care setting. Diagnostic criteria for OUD remain elusive, with 1 reasonable case-finding tool. Methadone and buprenorphine improve treatment retention, while medication-related contingency methods could worsen retention. Counseling is beneficial when added to pharmacotherapy.
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Affiliation(s)
- Christina Korownyk
- Family physician and Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton.
| | - Danielle Perry
- Nurse and Clinical Evidence Expert at the Alberta College of Family Physicians in Edmonton
| | - Joey Ton
- Pharmacist and Clinical Evidence Expert at the College of Family Physicians of Canada in Mississauga, Ont
| | - Michael R Kolber
- Family physician and Professor in the Department of Family Medicine at the University of Alberta
| | - Scott Garrison
- Family physician and Associate Professor in the Department of Family Medicine at the University of Alberta
| | - Betsy Thomas
- Pharmacist; Project Manager, Education and Knowledge Translation at the Alberta College of Family Physicians; and Assistant Adjunct Professor in the Department of Family Medicine at the University of Alberta
| | - G Michael Allan
- Family physician, Director of Programs and Practice Support at the College of Family Physicians of Canada, and Professor in the Department of Family Medicine at the University of Alberta
| | - Nicolas Dugré
- Pharmacist at the CIUSSS du Nord-de-l'Ile-de-Montréal and Clinical Associate Professor in the Faculty of Pharmacy at the University of Montreal in Quebec
| | | | - Rhonda Ting
- Doctoral student in the Faculty of Pharmacy and Pharmaceutical Sciences at the University of Alberta
| | | | - Ben Vandermeer
- Research Associate at the Alberta Research Centre for Health Evidence
| | - Adrienne J Lindblad
- Pharmacist and Knowledge Translation and Evidence Coordinator at the Alberta College of Family Physicians and Associate Clinical Professor in the Department of Family Medicine at the University of Alberta
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Lv Y, Hu RR, Jing M, Zhao TY, Wu N, Song R, Li J, Hu G. Selective dopamine D3 receptor antagonist YQA14 inhibits morphine-induced behavioral sensitization in wild type, but not in dopamine D3 receptor knockout mice. Acta Pharmacol Sin 2019; 40:583-8. [PMID: 30224637 DOI: 10.1038/s41401-018-0153-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/17/2018] [Indexed: 12/15/2022] Open
Abstract
Increasing preclinical evidence demonstrates that dopamine D3 receptor (D3R) antagonists are a potential option for the treatment of drug addiction. The reinstatement of the addiction can be triggered by environmental stimuli that acquire motivational salience through repeated associations with the drug's effects. YQA14 is a novel D3R antagonist that has exhibited pharmacotherapeutic efficacy in reducing cocaine and amphetamine reward and relapse to drug seeking in mice. In this study we investigated the effects of YQA14 on morphine-induced context-specific locomotor sensitization in mice. We showed that repeated injection of YQA14 (6.25-25 mg/kg every day ip) prior to morphine (10 mg/kg every day sc) not only inhibited the acquisition, but also significantly attenuated the expression of morphine-induced locomotor sensitization. Furthermore, in the expression phase, one single injection of YQA14 (6.25-25 mg/kg, ip) dose-dependently inhibited the expression of morphine-induced behavioral sensitization. Moreover, YQA14 inhibited the expression of morphine-induced behavioral sensitization in wild mice (WT), but not in D3R knockout (D3R-/-) mice in the expression phase. In addition, D3R-/- mice also displayed the reduction in the expression phase compared with WT mice. In summary, this study demonstrates that blockade or knockout of the D3R inhibits morphine-induced behavior sensitization, suggesting that D3R plays an important role in the pathogenesis and etiology of morphine addiction, and it might be a potential target for clinical management of opioid addiction.
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Abstract
Opioid use disorder (OUD) is epidemic in the United States. In addition to medical, economic, and social impairments, risk of overdose fatality is high. In 2017, there were 14,958 deaths from natural or semisynthetic opioids, 15,958 from heroin, and 29,406 from synthetic opioids, such as fentanyl. Psychosocial interventions do not add substantial efficacy to medical OUD treatments, and thus making evidence-based OUD treatments more accessible is urgent. However, considerable diversion of oral and transmucosal opioid maintenance medications has been documented. Delivery systems that reduce risks of nonadherence through diversion or altered self-administration may increase buprenorphine's effectiveness for clinical stabilization via increased treatment exposure. The article presents findings from multisite efficacy studies of two subcutaneous depot buprenorphine formulations and a long-acting implant. Novel delivery systems show promise in providing improved outcomes through intermediate- and long-acting exposure to medication while reducing the risk of medication nonadherence, diversion, and accidental exposure.
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Affiliation(s)
- Richard N Rosenthal
- Department of Psychiatry and Behavioral Health, Health Sciences Center, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
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Abstract
BACKGROUND Premature discharge is a pervasive problem in methadone maintenance treatment (MMT), and is associated with numerous adverse outcomes. Although a number of demographic variables have consistently been found to impact MMT retention, method of payment has received considerably less attention. A notable limitation of prior work is that most studies classify all patients who leave treatment early, irrespective of reason, as treatment dropouts and fail to account for specific reasons. OBJECTIVE This study sought to determine whether method of payment for MMT services was associated with differential reasons for premature discharge. METHODS The sample was comprised of 4158 patients prematurely discharged from 33 MMT facilities located throughout the U.S. from 2009 to 2012. Patients were classified into two groups based on their method of payment: self-pay and insurance (largely Medicaid). Patients were studied through retrospective electronic chart review. RESULTS Binary logistic regression indicated that insurance patients who were prematurely discharged were significantly more likely to be discharged due to a program-initiated reason (administrative), while self-pay patients were more likely to be discharged due to a patient-initiated reason (against medical advice) after controlling for significant intake demographic and clinical covariates. CONCLUSIONS Further research is needed to determine whether insurance patients may require different supports in place compared to self-pay patients in order to improve compliance with program guidelines (e.g. behavioral contracts providing a detailed description of rules both at admission and throughout treatment with an emphasis on the potential consequences of noncompliance), and whether self-pay patients may benefit from motivational incentives and interventions to remain engaged in treatment.
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Affiliation(s)
- Steven L Proctor
- a Albizu University-Miami Campus, Institutional Center for Scientific Research, Miami, FL, USA
| | | | - Ronnie Lee
- c Department of Psychology , Albizu University-Miami Campus , Miami , FL , USA
| | - Albert M Kopak
- d Department of Criminology and Criminal Justice , Western Carolina University, Cullowhee, NC, USA
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Proctor SL, Birch A, Herschman PL. Medication Treatment With Methadone or Buprenorphine: Differential Reasons for Premature Discharge. J Addict Med 2019; 13:113-8. [PMID: 30199427 DOI: 10.1097/ADM.0000000000000456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Medication treatment with methadone or buprenorphine has shown demonstrated effectiveness for opioid dependence; while premature discharge is associated with adverse outcomes. Specific reasons for premature discharge generally fall into 2 broad categories (ie, patient- and program-initiated). Previous studies have typically failed to distinguish between different types of discharge reasons among patients who leave treatment early. This study sought to determine whether type of medication was associated with differential discharge reasons among medication treatment patients who were prematurely discharged. METHODS Data were derived from electronic health records for 5486 patients prematurely discharged from 41 for-profit licensed opioid treatment programs in the United States from 2012 to 2013. All patients were treated with methadone or buprenorphine. Patients were studied through retrospective chart review until premature discharge. RESULTS Buprenorphine patients who left treatment prematurely were 2.18 times (95% confidence interval [CI] 1.89-2.53) more likely to be discharged against medical advice relative to methadone patients after controlling for intake differences. Methadone patients were 1.76 times (95% CI 1.47-2.10) more likely to be administratively discharged after adjustment for covariates. CONCLUSIONS Further research is warranted to determine whether individually-tailored strategies may improve retention for certain patients based on medication. Ongoing review of program rules and policies may benefit methadone patients, who are nearly twice as likely to be discharged for an administrative, program-initiated reason. Strategies including contingency management, motivational incentives, and psychoeducation regarding the advantages of retention may benefit buprenorphine patients who are over 2 times more likely to leave treatment early due to a patient-initiated reason.
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Krawczyk N, Picher CE, Feder KA, Saloner B. Only One In Twenty Justice-Referred Adults In Specialty Treatment For Opioid Use Receive Methadone Or Buprenorphine. Health Aff (Millwood) 2018; 36:2046-2053. [PMID: 29200340 DOI: 10.1377/hlthaff.2017.0890] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
People in the US criminal justice system experience high rates of opioid use disorder, overdose, and other adverse outcomes. Expanding treatment is a key strategy for addressing the opioid epidemic, but little is known about whether the criminal justice system refers people to the highest standard of treatment: the use of the opioid agonist therapies methadone or buprenorphine. We used 2014 data from the national Treatment Episode Data Set to examine the use of agonist treatment among justice-involved people referred to specialty treatment for opioid use disorder. Only 4.6 percent of justice-referred clients received agonist treatment, compared to 40.9 percent of those referred by other sources. Of all criminal justice sources, courts and diversionary programs were least likely to refer people to agonist treatment. Our findings suggest that an opportunity is being missed to promote effective, evidence-based care for justice-involved people who seek treatment for opioid use disorder.
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Affiliation(s)
- Noa Krawczyk
- Noa Krawczyk ( ) is a PhD student in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Caroline E Picher
- Caroline E. Picher is a policy analyst at the National Governors Association Center for Best Practices, in Washington, DC. At the time this study was developed, she was a master of public health student in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health
| | - Kenneth A Feder
- Kenneth A. Feder is a PhD student in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health
| | - Brendan Saloner
- Brendan Saloner is an assistant professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health
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Abstract
Drawing from existing opioid prescribing guidelines, this article describes how medical providers can reduce the risk of overdose. Through primary prevention, providers can prevent initial exposure and associated risks by educating patients, using risk stratification, minimizing opioid dose and duration, and avoiding coprescribing with sedatives. Secondary prevention efforts include monitoring patients with urine toxicology and prescription monitoring programs, and screening for opioid use disorders. Tertiary prevention includes treating opioid use disorders and providing naloxone to prevent overdose death. Specific preventive strategies may be required for those with psychiatric disorders or substance use disorders, adolescents, the elderly, and pregnant women.
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Affiliation(s)
- Stephanie Lee Peglow
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, 825 Fairfax Avenue Suite 710, Norfolk, VA 23507, USA.
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, 2550 South Parker Road, Suite 200, Aurora, CO 80014, USA; Division of General Internal Medicine, Department of Medicine, University of Colorado, 12631 East 17th Avenue, Academic Office One, Campus Box B180, Aurora, CO 80045, USA
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Parker MA, Streck JM, Sigmon SC. Associations between opioid and nicotine dependence in nationally representative samples of United States adult daily smokers. Drug Alcohol Depend 2018; 186:167-70. [PMID: 29579724 DOI: 10.1016/j.drugalcdep.2018.01.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/24/2018] [Accepted: 01/28/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Smoking prevalence among adults with opioid dependence far exceeds that of the general population, and cessation outcomes in this group are one-fourth that of smokers without a substance use disorder. Understanding the reasons underlying these poor outcomes is critical for developing more effective smoking interventions in this group. Elevated baseline severity of nicotine dependence is associated with lower rates of smoking cessation over time. We examined whether nicotine dependence severity among smokers may vary as a function of opioid dependence status using nationally representative samples of adult smokers. METHODS Data were derived from multiple years of the National Survey on Drug Use and Health (NSDUH, 2006-2014; n = 58,971). Nicotine dependence was measured by the Nicotine Dependence Syndrome Scale (NDSS) and the first item (i.e., time to first cigarette) of the Fagerström Test for Nicotine Dependence (FTND). Opioid dependence was assessed using the Diagnostic and Statistical Manual of Mental Disorders criteria. RESULTS Opioid-dependent smokers exhibited greater severity of nicotine dependence compared to non-opioid dependent smokers, as evidenced by higher mean NDSS scores (p < 0.05). On both NDSS and FTND measures of nicotine dependence, opioid-dependent smokers were also approximately twice as likely to be dependent on nicotine than those not dependent on opioids (p's < 0.05). CONCLUSIONS Opioid dependence is associated with increased severity and prevalence of nicotine dependence among smokers. Considering the disproportionate societal and economic burdens of smoking and smoking-related consequences in this vulnerable population, continued investigations are needed to better understand opioid-dependent individuals' poor cessation outcomes.
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Rieb LM, Norman WV, Martin RE, Berkowitz J, Wood E, Milloy MJ, McNeil R. Linking opioid-induced hyperalgesia and withdrawal-associated injury site pain: a case report. Pain Rep 2018; 3:e648. [PMID: 29922741 DOI: 10.1097/PR9.0000000000000648] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 03/07/2018] [Accepted: 03/08/2018] [Indexed: 02/07/2023] Open
Abstract
Introduction and objectives: Understanding the details of one individual's experience with pain, opioid use and withdrawal may generate insights into possible relationships between opioid-induced hyperalgesia and withdrawal-associated injury site pain (WISP). Methods: This case study was extracted from a mixed methods study that characterized WISP. In 2014, the individual was recruited from a primary care clinic that prescribes opioid agonist therapy. In an interview, she completed a 35-item survey and elaborated on her own experience. Follow-up contact was made in June of 2017. Results: This 34-year-old white woman had several twisting injuries of her right knee between ages 13 and 15. The pain resolved each time in a few days, and she was pain free for 15 years. Around age 30, she initiated illicit oxycodone recreationally (not for pain) and developed an opioid use disorder. On detoxification, she experienced severe knee pain for 6 weeks that resolved postdetoxification but returned after subsequent oxycodone use and withdrawal episodes along with generalized skin sensitivity. This experience of WISP became a barrier to opioid cessation. Although nonsteroidal anti-inflammatories and gabapentin relieved WISP and methadone therapy assisted her opioid use disorder, an eventual change to sublingual buprenorphine/naloxone provided superior control of both. Conclusion: This case report illustrates that both opioid use and withdrawal can reactivate injury site pain, which can increase with dose escalation and repeated withdrawal events. The timing, trajectory, and neuropathic features of WISP reported here are consistent with those previously reported for the development of opioid-induced hyperalgesia, possibly linking these phenomena.
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Vadivelu N, Kai AM, Kodumudi G, Haddad D, Kodumudi V, Kuruvilla N, Kaye AD, Urman RD. Recommendations for Substance Abuse and Pain Control in Patients with Chronic Pain. Curr Pain Headache Rep 2018; 22:25. [DOI: 10.1007/s11916-018-0679-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Witkiewitz K, Vowles KE. Alcohol and Opioid Use, Co-Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review. Alcohol Clin Exp Res 2018; 42:478-488. [PMID: 29314075 PMCID: PMC5832605 DOI: 10.1111/acer.13594] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/29/2017] [Indexed: 12/20/2022]
Abstract
The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.
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Affiliation(s)
- Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, NM
| | - Kevin E Vowles
- Department of Psychology, University of New Mexico, Albuquerque, NM
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Pouget ER, Fong C, Rosenblum A. Racial/Ethnic Differences in Prevalence Trends for Heroin use and Non-Medical use of Prescription Opioids Among Entrants to Opioid Treatment Programs, 2005-2016. Subst Use Misuse 2018; 53:290-300. [PMID: 28854060 DOI: 10.1080/10826084.2017.1334070] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Recent data suggest an increase in use of heroin and non-medical use of prescription opioids (POs) in the United States, but it is unclear if these trends are consistent across racial/ethnic groups. In a nationwide prevalence study, 69,140 patients newly admitted to an opioid treatment program (OTP) completed a brief self-administered survey of past month heroin use and PO misuse from January 2005 through September 2016. We calculated heroin use and PO misuse prevalence rates, and prevalence rate ratios of Black and Latino OTP entrants compared to White entrants over time. Initially, Black and Latino respondents reported much higher prevalence of heroin use and much lower prevalence of PO misuse than White respondents. Heroin use increased among White respondents, while it decreased among Black respondents, resulting in rates that were no longer significantly different. PO misuse prevalence decreased among White respondents while it increased among Black respondents, but remained significantly higher among White respondents. Heroin use decreased and PO misuse increased among Latino respondents during the late 2000s, but these trends largely reversed in more recent years. Among OTP entrants, racially/ethnically disparate rates of heroin use, and to a lesser extent, of PO misuse have become more similar over time. These trends were stronger when analysis was restricted to OTP entrants who either had no previous OTP history or were younger. To understand potential impacts of interventions to deter PO misuse and to maximize the effectiveness of OTPs it is important to consider potential changes in opioid use across racial/ethnic groups.
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Affiliation(s)
- Enrique R Pouget
- a Center for Policing Equity at John Jay College of Criminal Justice , New York , New York , USA
| | - Chunki Fong
- b National Development and Research Institutes, Inc. , New York , New York , USA
| | - Andrew Rosenblum
- b National Development and Research Institutes, Inc. , New York , New York , USA
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Morrison KB, Brunelle C, Campbell MA, Christie TK, Hildebrand J. Diversity in the Needs and Outcomes of Low-Threshold/High-Tolerance Methadone Maintenance Therapy Clients. Canadian Journal of Addiction 2017; 8:26-33. [DOI: 10.1097/cxa.0000000000000002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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McHugh RK, Votaw VR, Sugarman DE, Greenfield SF. Sex and gender differences in substance use disorders. Clin Psychol Rev 2017; 66:12-23. [PMID: 29174306 DOI: 10.1016/j.cpr.2017.10.012] [Citation(s) in RCA: 437] [Impact Index Per Article: 62.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/26/2017] [Accepted: 10/30/2017] [Indexed: 12/18/2022]
Abstract
The gender gap in substance use disorders (SUDs), characterized by greater prevalence in men, is narrowing, highlighting the importance of understanding sex and gender differences in SUD etiology and maintenance. In this critical review, we provide an overview of sex/gender differences in the biology, epidemiology and treatment of SUDs. Biological sex differences are evident across an array of systems, including brain structure and function, endocrine function, and metabolic function. Gender (i.e., environmentally and socioculturally defined roles for men and women) also contributes to the initiation and course of substance use and SUDs. Adverse medical, psychiatric, and functional consequences associated with SUDs are often more severe in women. However, men and women do not substantively differ with respect to SUD treatment outcomes. Although several trends are beginning to emerge in the literature, findings on sex and gender differences in SUDs are complicated by the interacting contributions of biological and environmental factors. Future research is needed to further elucidate sex and gender differences, especially focusing on hormonal factors in SUD course and treatment outcomes; research translating findings between animal and human models; and gender differences in understudied populations, such as those with co-occurring psychiatric disorders and gender-specific populations, such as pregnant women.
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Affiliation(s)
- R Kathryn McHugh
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, United States; Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA 02155, United States.
| | - Victoria R Votaw
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, United States
| | - Dawn E Sugarman
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, United States; Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA 02155, United States
| | - Shelly F Greenfield
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, United States; Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA 02155, United States
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You ZB, Gao JT, Bi GH, He Y, Boateng C, Cao J, Gardner EL, Newman AH, Xi ZX. The novel dopamine D3 receptor antagonists/partial agonists CAB2-015 and BAK4-54 inhibit oxycodone-taking and oxycodone-seeking behavior in rats. Neuropharmacology 2017; 126:190-199. [PMID: 28888944 DOI: 10.1016/j.neuropharm.2017.09.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/02/2017] [Accepted: 09/05/2017] [Indexed: 12/30/2022]
Abstract
The use of prescription opioid analgesics, particularly oxycodone, has dramatically increased, and parallels escalated opioid abuse and drug-related deaths worldwide. Understanding the molecular mechanisms underlying the development of opioid dependence and expanding treatment options to counter prescription opioid abuse has become a critical public health matter. In the present study, we first evaluated the reinforcing effects of oxycodone in a rat model of self-administration and then explored the potential utility of two novel high affinity dopamine D3 receptor (D3R) antagonists/partial agonists, CAB2-015 and BAK4-54, for treatment of prescription opioid abuse and dependence. We found that rats acquired oxycodone self-administration rapidly within a range of unit doses that was similar to that for heroin, confirming that oxycodone has significant abuse potential. Strikingly, pretreatment with either CAB2-015 or BAK4-54 (0.4-10 mg/kg, i.p.) dose-dependently decreased oxycodone self-administration, and shifted the oxycodone dose-response curve downward. Repeated pretreatment with CAB2-015 or BAK4-54 (0.4-4 mg/kg) facilitated extinction and inhibited oxycodone-induced reinstatement of drug-seeking behavior. In addition, pretreatment with CAB2-015 or BAK4-54 (4-10 mg/kg) also dose-dependently decreased oxycodone-enhanced locomotor activity, but only CAB2-015 decreased oral sucrose self-administration. These data suggest that D3R antagonists may be suitable alternatives or adjunctive to opioid-based medications currently used clinically in treating opioid addiction and that the D3R-selective ligands (CAB2-015 or BAK4-54) provide new lead molecules for development.
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Affiliation(s)
- Zhi-Bing You
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD 21224, USA
| | - Jun-Tao Gao
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD 21224, USA
| | - Guo-Hua Bi
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD 21224, USA
| | - Yi He
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD 21224, USA
| | - Comfort Boateng
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD 21224, USA
| | - Jianjing Cao
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD 21224, USA
| | - Eliot L Gardner
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD 21224, USA
| | - Amy Hauck Newman
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD 21224, USA.
| | - Zheng-Xiong Xi
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD 21224, USA.
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Marie-Claire C, Jourdaine C, Lépine JP, Bellivier F, Bloch V, Vorspan F. Pharmacoepigenomics of opiates and methadone maintenance treatment: current data and perspectives. Pharmacogenomics 2017; 18:1359-1372. [DOI: 10.2217/pgs-2017-0040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Current treatments of opioid addiction include primarily maintenance medications such as methadone. Chronic exposure to opiate and/or long-lasting maintenance treatment induce modulations of gene expression in brain and peripheral tissues. There is increasing evidence that epigenetic modifications underlie these modulations. This review summarizes published results on opioid-induced epigenetic changes in animal models and in patients. The epigenetic modifications observed with other drugs of abuse often used by opiate abusers are also outlined. Specific methadone maintenance treatment induced epigenetic modifications at different treatment stages may be combined with the ones resulting from patients’ substance use history. Therefore, research comparing groups of addicts with similar history and substances use disorders but contrasting for well-characterized treatment phenotypes should be encouraged.
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Affiliation(s)
- Cynthia Marie-Claire
- Variabilité de réponse aux psychotropes, INSERMU1144/Faculté de Pharmacie de Paris/Université Paris Descartes/Université ParisDiderot/Université Sorbonne Paris Cité, Paris, France
| | - Clément Jourdaine
- AP-HP, GH Saint-Louis – Lariboisière – F. Widal, Pôle de Psychiatrie et de Médecine Addictologique, 75475 Paris cedex 10, France
| | - Jean-Pierre Lépine
- AP-HP, GH Saint-Louis – Lariboisière – F. Widal, Pôle de Psychiatrie et de Médecine Addictologique, 75475 Paris cedex 10, France
| | - Frank Bellivier
- Variabilité de réponse aux psychotropes, INSERMU1144/Faculté de Pharmacie de Paris/Université Paris Descartes/Université ParisDiderot/Université Sorbonne Paris Cité, Paris, France
- AP-HP, GH Saint-Louis – Lariboisière – F. Widal, Pôle de Psychiatrie et de Médecine Addictologique, 75475 Paris cedex 10, France
| | - Vanessa Bloch
- Variabilité de réponse aux psychotropes, INSERMU1144/Faculté de Pharmacie de Paris/Université Paris Descartes/Université ParisDiderot/Université Sorbonne Paris Cité, Paris, France
| | - Florence Vorspan
- Variabilité de réponse aux psychotropes, INSERMU1144/Faculté de Pharmacie de Paris/Université Paris Descartes/Université ParisDiderot/Université Sorbonne Paris Cité, Paris, France
- AP-HP, GH Saint-Louis – Lariboisière – F. Widal, Pôle de Psychiatrie et de Médecine Addictologique, 75475 Paris cedex 10, France
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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.
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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
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Broad K, Colon-Rivera HA, Haque L. Opioid agonist therapy. Can Fam Physician 2017; 63:509-510. [PMID: 28701435 PMCID: PMC5507220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Abstract
Opioid abuse among pregnant women has reached epidemic proportions and has influenced maternal and child health policy at the federal, state, and local levels. As a result, we review the current state of opioid use in pregnancy and evaluate recent legislative and health policy initiatives designed to combat opioid addiction in pregnancy. We emphasize the importance of safe and responsible opioid-prescribing practices, expanding the availability and accessibility of medication-assisted treatment and standardizing care for neonates at risk of neonatal abstinence syndrome. Efforts to penalize pregnant women and negative consequences for disclosing substance use to health care providers are harmful and may prevent women from seeking prenatal care and other beneficial health care services during pregnancy. Instead, health care providers should advocate for health policy informed by scientific research and evidence-based practice to reduce the burden of prenatal opioid abuse and optimize outcomes for mothers and their neonates.
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Weiss RD, Rao V. The Prescription Opioid Addiction Treatment Study: What have we learned. Drug Alcohol Depend 2017; 173 Suppl 1:S48-54. [PMID: 28363320 DOI: 10.1016/j.drugalcdep.2016.12.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [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.
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