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Lee DC, Schlienz NJ, Herrmann ES, Martin EL, Leoutsakos J, Budney AJ, Smith MT, Tompkins DA, Hampson AJ, Vandrey R. Randomized controlled trial of zolpidem as a pharmacotherapy for cannabis use disorder. J Subst Use Addict Treat 2024; 156:209180. [PMID: 37802317 DOI: 10.1016/j.josat.2023.209180] [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] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/07/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Sleep disturbance is commonly reported among individuals meeting criteria for cannabis use disorder (CUD), and people who use cannabis frequently report sleep disturbance as a contributor to failed quit attempts. The purpose of this study was to measure sleep in individuals enrolled in treatment for CUD, and to determine whether use of hypnotic medication during treatment increased abstinence rates. METHOD The study enrolled 127 adults seeking treatment for CUD in a 12-week clinical trial and randomized to receive extended-release zolpidem (zolpidem-XR) or placebo. All participants received computerized behavioral therapy and abstinence-based contingency management. The study conducted in-home ambulatory polysomnography (PSG) assessments at baseline and during treatment to objectively measure sleep. Self-report measures of recent sleep, Insomnia Severity Index (ISI), and drug use (Timeline Follow-Back) were collected at each study visit, and the study confirmed self-reported abstinence via quantitative urine drug testing. RESULT Participants randomized to placebo, but not zolpidem-XR exhibited significant sleep disturbance during week 1 of treatment. Sleep disturbance emerged in the zolpidem-XR group after study medication was stopped at the end of treatment. Though participants assigned to the zolpidem-XR condition had qualitatively greater rates of abstinence compared with placebo (27 % versus 15 % negative at end of treatment), the difference was not statistically significant. Treatment retention was poor (about 50 % drop out in both groups) and medication adherence was a challenge without the use of contingent incentives. CONCLUSION Results from this randomized controlled trial suggest that zolpidem-XR can attenuate abstinence-induced sleep disturbance early in treatment for CUD, but that sleep problems are likely to emerge after the medication is stopped. Further research should identify alternative pharmacotherapies and behavioral treatments for CUD and elucidate the role of sleep disturbance in the development and maintenance of CUD.
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Affiliation(s)
- Dustin C Lee
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Nicolas J Schlienz
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Evan S Herrmann
- Division of Therapeutics and Medical Consequences, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Erin L Martin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jeannie Leoutsakos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Alan J Budney
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Michael T Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - D Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Aidan J Hampson
- Division of Therapeutics and Medical Consequences, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Ryan Vandrey
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Hay KR, Jardot J, Huhn AS, Tompkins DA. Substance Use in the Performing Artist with Chronic Pain. Med Probl Perform Art 2022; 37:24-29. [PMID: 35234802 PMCID: PMC9795469 DOI: 10.21091/mppa.2022.1003] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 11/29/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To evaluate how performing artists (PAs) with chronic pain may differ on measures of substance use compared to non-PA controls. METHODS 157 participants reporting chronic pain (89 PAs, 68 non-PA controls) completed an online cross-sectional survey. Participants were assessed for self-reported current pain severity using the Brief Pain Inventory Short-Form, opioid misuse risk using the Screener and Opioid Assessment for Patients with Pain-Revised, opioid withdrawal using the Subjective Opiate Withdrawal Scale, and symptoms of opioid use disorder (OUD) using a modified version of the DSM-V checklist. RESULTS PAs had lower pain severity (p <0.05, t=2.196, df=155) and lower pain interference (p <0.05, t=2.194) than non-PA controls. 24% of PAs and 13% of controls reported using opioids within the past month. Among PAs, the number of days using opioids in the past month was positively associated with hours spent practicing per week (r=0.508, p <0.05). PAs (66%) were more likely to endorse current alcohol use than controls (44.1%, t= -2.136, X2=7.72, p <0.01). Importantly, PAs (19%) were more likely than controls (3%) to endorse symptoms of at least mild OUD (X2(3)=11.3, p <0.01) and higher ratings of opioid misuse risk (t=-2.166, p <0.05). Past month opioid withdrawal was also greater in PAs than controls (t=-2.136, p <0.05), and 5.6% of PAs and 1.5% of controls reported at least one prior incidence incident of opioid overdose in their lifetime (X2 =1.80, NS). CONCLUSIONS Among persons with chronic pain, PAs may have higher risk for opioid-related consequences, including OUD, and should be screened during health care encounters.
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Affiliation(s)
| | | | | | - D Andrew Tompkins
- Zuckerberg San Francisco General Hospital, 1001 Potrero Ave., Ward 95, San Francisco, CA 94110, USA. Tel 628-206-3645.
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Meacham MC, Nobles AL, Tompkins DA, Thrul J. "I got a bunch of weed to help me through the withdrawals": Naturalistic cannabis use reported in online opioid and opioid recovery community discussion forums. PLoS One 2022; 17:e0263583. [PMID: 35134074 PMCID: PMC8824349 DOI: 10.1371/journal.pone.0263583] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 01/21/2022] [Indexed: 11/23/2022] Open
Abstract
A growing body of research has reported on the potential opioid-sparing effects of cannabis and cannabinoids, but less is known about specific mechanisms. The present research examines cannabis-related posts in two large online communities on the Reddit platform (“subreddits”) to compare mentions of naturalistic cannabis use by persons self-identifying as actively using opioids versus persons in recovery. We extracted all posts mentioning cannabis-related keywords (e.g., “weed”, “cannabis”, “marijuana”) from December 2015 through August 2019 from an opioid use subreddit and an opioid recovery subreddit. To investigate how cannabis is discussed at-scale, we identified and compared the most frequent phrases in cannabis-related posts in each subreddit using term-frequency-inverse document frequency (TF-IDF) weighting. To contextualize these findings, we also conducted a qualitative content analysis of 200 random posts (100 from each subreddit). Cannabis-related posts were about twice as prevalent in the recovery subreddit (n = 908; 5.4% of 16,791 posts) than in the active opioid use subreddit (n = 4,224; 2.6% of 159,994 posts, p < .001). The most frequent phrases from the recovery subreddit referred to time without using opioids and the possibility of using cannabis as a “treatment.” The most frequent phrases from the opioid subreddit referred to concurrent use of cannabis and opioids. The most common motivations for using cannabis were to manage opioid withdrawal symptoms in the recovery subreddit, often in conjunction with anti-anxiety and GI-distress “comfort meds,” and to enhance the “high” when used in combination with opioids in the opioid subreddit. Despite limitations in generalizability from pseudonymous online posts, this examination of reports of naturalistic cannabis use in relation to opioid use identified withdrawal symptom management as a common motivation. Future research is warranted with more structured assessments that examines the role of cannabis and cannabinoids in addressing both somatic and affective symptoms of opioid withdrawal.
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Affiliation(s)
- Meredith C. Meacham
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, United States of America
- * E-mail:
| | - Alicia L. Nobles
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, United States of America
| | - D. Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, United States of America
| | - Johannes Thrul
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States of America
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
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Pro G, Tompkins DA, Azari S, Zaller N. National trends in testing for hepatitis C virus in licensed opioid treatment programs: Differences by facility ownership and state medicaid expansion status. Drug Alcohol Depend 2021; 228:109092. [PMID: 34571287 DOI: 10.1016/j.drugalcdep.2021.109092] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/26/2021] [Accepted: 08/07/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The recent surge in hepatitis C virus (HCV) prevalence is primarily due to increased injection drug use. Opioid treatment programs (OTPs) are a major source of treatment for people at risk for HCV and are ideal settings for on-site HCV testing. The purpose of this national study was to identify state- and facility-level factors associated with HCV testing availability. METHODS We used the National Survey of Substance Abuse Treatment Services (2019) to identify OTPs in the US (n = 1679). We used multilevel logistic regression to test for an association between HCV testing and state Medicaid expansion status, and assessed whether the association depended on private or non-profit OTP ownership, adjusted for state racial/ethnic minority populations, poverty, Medicaid access to HCV treatment, and HCV, opioid use disorder, and overdose rates. RESULTS Two-thirds of OTPs offered HCV testing. Medicaid expansion (versus non-expansion) was associated with a higher odds of HCV testing within OTPs owned by non-profits (adjusted odds ratio=1.99, 95% CI=1.02-3.91, p = 0.04). Nearly all non-profit OTPs that were in expansion states had predicted probabilities that were higher than the national average. CONCLUSION HCV testing was highest in non-profit OTPs in expansion states. This is concerning given the increasing dominance of private OTPs in the marketplace. Payment structures and reimbursement are likely factors driving the low rate of HCV testing in private facilities and could be addressed with health policies aimed at eliminating HCV. Expanding support for non-profit OTPs also has the potential to strengthen testing rates and improve health.
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Affiliation(s)
- George Pro
- Health Behavior and Health Education, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301W. Markham, Little Rock, AR 72205, USA; Southern Public Health and Criminal Justice Research Center, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301W. Markham, Little Rock, AR 72205, USA.
| | - D Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, UCSF School of Medicine, 1001 Potrero Ave., San Francisco, CA 94110, USA.
| | - Soraya Azari
- Department of Medicine, UCSF School of Medicine, 1001 Potrero Ave., San Francisco, CA 94110, USA.
| | - Nickolas Zaller
- Health Behavior and Health Education, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301W. Markham, Little Rock, AR 72205, USA; Southern Public Health and Criminal Justice Research Center, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301W. Markham, Little Rock, AR 72205, USA.
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Agin-Liebes G, Huhn AS, Strain EC, Bigelow GE, Smith MT, Edwards RR, Gruber VA, Tompkins DA. Methadone maintenance patients lack analgesic response to a cumulative intravenous dose of 32 mg of hydromorphone. Drug Alcohol Depend 2021; 226:108869. [PMID: 34216862 PMCID: PMC9559787 DOI: 10.1016/j.drugalcdep.2021.108869] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/10/2021] [Accepted: 06/17/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Acute pain management in patients with opioid use disorder who are maintained on methadone presents unique challenges due to high levels of opioid tolerance in this population. This randomized controlled study assessed the analgesic and abuse liability effects of escalating doses of acute intravenous (IV) hydromorphone versus placebo utilizing a validated experimental pain paradigm, quantitative sensory testing (QST). METHODS Individuals (N = 8) without chronic pain were maintained on 80-100 mg/day of oral methadone. Participants received four IV, escalating/incremental doses of hydromorphone over 270 min (32 mg total) or four placebo doses within a session test day. Test sessions were scheduled at least one week apart. QST and abuse liability measures were administered at baseline and after each injection. RESULTS No significant differences between the hydromorphone and placebo control conditions on analgesic indices for any QST outcomes were detected. Similarly, no differences on safety or abuse liability indices were detected despite the high doses of hydromorphone utilized. Few adverse events were detected, and those reported were mild in severity. CONCLUSIONS The findings demonstrate that methadone-maintained individuals are highly insensitive to the analgesic effects of high-dose IV hydromorphone and may require very high doses of opioids, more efficacious opioids, or combined non-opioid analgesic strategies to achieve adequate analgesia.
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Affiliation(s)
- Gabrielle Agin-Liebes
- University of California, San Francisco, Department of Psychiatry and Behavioral Sciences, 401 Parnassus Ave, San Francisco, CA, 94143, USA; Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Ward 95, San Francisco, CA, 94110, USA.
| | - Andrew S. Huhn
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Eric C. Strain
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - George E. Bigelow
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Michael T. Smith
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Robert R. Edwards
- Harvard Medical School, Brigham and Women’s Hospital, Department of Anesthesiology, Perioperative, and Pain Medicine, 75 Francis St, Boston, MA, 02115, USA
| | - Valerie A. Gruber
- University of California, San Francisco, Department of Psychiatry and Behavioral Sciences, 401 Parnassus Ave, San Francisco, CA, 94143, USA,Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Ward 95, San Francisco, CA, 94110, USA
| | - D. Andrew Tompkins
- University of California, San Francisco, Department of Psychiatry and Behavioral Sciences, 401 Parnassus Ave, San Francisco, CA, 94143, USA,Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Ward 95, San Francisco, CA, 94110, USA,Corresponding author at: Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Ward 95, San Francisco, CA USA 94110. Tele: 628-206-3645.
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Smith MT, Remeniuk B, Finan PH, Speed TJ, Tompkins DA, Robinson M, Gonzalez K, Bjurstrom MF, Irwin MR. Sex differences in measures of central sensitization and pain sensitivity to experimental sleep disruption: implications for sex differences in chronic pain. Sleep 2020; 42:5146314. [PMID: 30371854 DOI: 10.1093/sleep/zsy209] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Indexed: 01/11/2023] Open
Abstract
Study Objectives Females demonstrate heightened central sensitization (CS), a risk factor for chronic pain characterized by enhanced responsivity of central nervous system nociceptors to normal or subthreshold input. Sleep disruption increases pain sensitivity, but sex has rarely been evaluated as a moderator and few experiments have measured CS. We evaluated whether two nights of sleep disruption alter CS measures of secondary hyperalgesia and mechanical temporal summation in a sex-dependent manner. We also evaluated differences in measures of pain sensitivity. Methods Seventy-nine healthy adults (female n = 46) participated in a randomized crossover experiment comparing two consecutive nights of eight pseudorandomly distributed forced awakenings (FA [-200 min sleep time]) against two nights of undisturbed sleep (US). We conducted sensory testing the mornings following Night 2; the heat-capsaicin pain model was used to induce secondary hyperalgesia. Results FA reduced total sleep time (REM and NREM Stage 3) more profoundly in males. We observed divergent, sex-dependent effects of FA on secondary hyperalgesia and temporal summation. FA significantly increased secondary hyperalgesia in males and significantly increased temporal summation in females. Sex differences were not attributable to differential sleep loss in males. FA also significantly reduced heat-pain threshold and cold pressor pain tolerance, independently of sex. Conclusions Sleep disruption enhances different pain facilitatory measures of CS in males and females suggesting that sleep disturbance may increase risk for chronic pain in males and females via distinct pathways. Findings have implications for understanding sex differences in chronic pain and investigating sleep in chronic pain prevention efforts.
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Affiliation(s)
- Michael T Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Bethany Remeniuk
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Patrick H Finan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Traci J Speed
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - D Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD.,Department of Psychiatry, UCSF School of Medicine, San Francisco, CA
| | - Mercedes Robinson
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Kaylin Gonzalez
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Martin F Bjurstrom
- Department of Psychiatry and Behavioral Sciences, Cousins Center for Psychoneuroimmunology, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA
| | - Michael R Irwin
- Department of Psychiatry and Behavioral Sciences, Cousins Center for Psychoneuroimmunology, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA
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Ghazzawi A, Suhail-Sindhu S, Casoy F, Libby N, McIntosh CA, Adelson S, Ashley K, Drescher J, Goldenberg D, Hung K, Lothwell LE, Mattson MR, McAfee SG, Schwartz A, Tompkins DA, Yarbrough E, Barber ME. Religious faith and transgender identities: The Dear Abby project. Journal of Gay & Lesbian Mental Health 2020. [DOI: 10.1080/19359705.2019.1706682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Alhasan Ghazzawi
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Maimonides Medical Center, New York, New York, USA
| | - Selena Suhail-Sindhu
- Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Flávio Casoy
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- New York State Office of Mental Health, New York, New York, USA
| | - Naomi Libby
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Yale Child Study Center, New Haven, Connecticut, USA
| | - Christopher A. McIntosh
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Michael Garron Hospital, Toronto, Canada
| | - Stewart Adelson
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Columbia University, College of Physicians and Surgeons, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Kenneth Ashley
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jack Drescher
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Columbia University, College of Physicians and Surgeons, New York, New York, USA
- Postdoctoral Program in Psychotherapy and Psychoanalysis, New York University, New York, New York, USA
| | - David Goldenberg
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Kenneth Hung
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lorraine E. Lothwell
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Marlin R. Mattson
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Scot G. McAfee
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- SUNY Downstate Medical Center, New York, New York, USA
| | - Alan Schwartz
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- William Alanson White Institute, New York, New York, USA
| | - D. Andrew Tompkins
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Department of Psychiatry, University of California, San Francisco, California, USA
| | - Eric Yarbrough
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Gay Men’s Health Crisis (GMHC), New York, New York, USA
| | - Mary E. Barber
- The Group for the Advancement of Psychiatry, LGBT Committee, West Harrison, New York, USA
- Columbia University, College of Physicians and Surgeons, New York, New York, USA
- Union Theological Seminary, New York, New York, USA
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Huhn AS, Tompkins DA, Campbell CM, Dunn KE. Individuals with Chronic Pain Who Misuse Prescription Opioids Report Sex-Based Differences in Pain and Opioid Withdrawal. Pain Med 2019; 20:1942-1947. [PMID: 30690594 PMCID: PMC6784741 DOI: 10.1093/pm/pny295] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Individuals with chronic pain who misuse prescription opioids are at high risk for developing opioid use disorder and/or succumbing to opioid overdose. The current study conducted a survey to evaluate sex-based differences in pain catastrophizing, opioid withdrawal, and current pain in persons with co-occurring chronic pain and opioid misuse. We hypothesized that women with chronic pain who misused prescription opioids would self-report higher pain ratings compared with men and that the relationship between pain catastrophizing and self-reported current pain would be moderated by symptoms of opioid withdrawal in women only. Design Survey assessment of the relationship between pain and opioid misuse. Setting Online via Amazon Mechanical Turk. Participants Persons with ongoing chronic pain who also misused prescription opioids on one or more days in the last 30 days were eligible (N = 181). Methods Participants completed demographic and standardized assessments including the Brief Pain Inventory (BPI), Pain Catastrophizing Scale (PCS), and Subjective Opiate Withdrawal Scale (SOWS). Results Women reported higher levels of current (P < 0.001), average (P < 0.001), and worst (P = .002) pain in the last 24 hours compared with men. Women also endorsed higher scores on the PCS (P = 0.006) and marginally higher past-30-day SOWS ratings (P = 0.068) compared with men. SOWS ratings moderated the relationship between PCS and BPI Worst Pain in women (ΔR2 < 0.127, ΔF(1, 78) = 12.39, P = 0.001), but not in men (ΔR2 < 0.000, ΔF(1, 98) = 0.003, P = 0.954). Conclusions These data suggest a strong relationship between opioid withdrawal, pain catastrophizing, and the experience of pain in women with chronic pain who misuse opioids.
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Affiliation(s)
- Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - D Andrew Tompkins
- Department of Psychiatry, UCSF School of Medicine, San Francisco, California, USA
| | - Claudia M Campbell
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Bergeria CL, Huhn AS, Tompkins DA, Bigelow GE, Strain EC, Dunn KE. The relationship between pupil diameter and other measures of opioid withdrawal during naloxone precipitated withdrawal. Drug Alcohol Depend 2019; 202:111-114. [PMID: 31336328 PMCID: PMC6745696 DOI: 10.1016/j.drugalcdep.2019.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 01/16/2019] [Revised: 04/29/2019] [Accepted: 05/03/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Understanding mechanisms of physiological opioid withdrawal symptoms can inform treatment strategies. This secondary analysis evaluated the association between mydriasis (dilated pupils), a commonly-assessed opioid withdrawal metric, with self- and observer-rated opioid withdrawal severity. METHOD Ninety-five participants with opioid physical dependence were stabilized with morphine before receiving an injection of the opioid antagonist naloxone to precipitate withdrawal. Pupil diameter, the Subjective Opiate Withdrawal Scale (SOWS), and the Clinical Opiate Withdrawal Scale (COWS) were collected at baseline and in 15-minute intervals for 120 min following naloxone administration. Pearson product-moment correlations and linear regressions characterized the relationships between pupil measurements (baseline and peak naloxone-induced) and self- and observer-rated measures of withdrawal. Repeated-measures ANOVAs tested whether self and observer-rated withdrawal severity corresponded to unique patterns in pupil changes. RESULTS Baseline pupil diameter significantly correlated with SOWS and COWS peak scores. Peak naloxone-induced pupil diameter significantly correlated with SOWS scores only. Peak changes in pupil from baseline did not correspond to peak changes in self- and observer-rated withdrawal scales. CONCLUSIONS This study suggests that pupil diameter measurements were more closely associated with acute opioid withdrawal severity than changes in pupil diameter. Prospective research examining the mechanisms underlying the relationship between pupil diameter and opioid withdrawal severity are warranted.
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Affiliation(s)
- Cecilia L Bergeria
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - D Andrew Tompkins
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - George E Bigelow
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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10
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Huhn AS, Sweeney MM, Brooner RK, Kidorf MS, Tompkins DA, Ayaz H, Dunn KE. Prefrontal cortex response to drug cues, craving, and current depressive symptoms are associated with treatment outcomes in methadone-maintained patients. Neuropsychopharmacology 2019; 44:826-833. [PMID: 30375498 PMCID: PMC6372589 DOI: 10.1038/s41386-018-0252-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: 07/30/2018] [Revised: 10/13/2018] [Accepted: 10/17/2018] [Indexed: 12/31/2022]
Abstract
Methadone maintenance is an effective treatment for opioid use disorder, yet many methadone-maintained patients (MMPs) continue to struggle with chronic relapse. The current study evaluated whether functional near-infrared spectroscopy (fNIRS) could identify prefrontal cortex (PFC) markers of ongoing opioid use in MMPs, and whether clinical measures of depression and self-report measures of craving would also be associated with opioid use. MMPs (n = 29) underwent a drug cue reactivity paradigm during fNIRS measurements of PFC reactivity. Self-reported opioid craving (measured by a visual analog scale; 0-100) was collected before and after drug cue reactivity, and depressive symptoms were assessed via the 17-item Hamilton Depression Rating Scale (HAM-D). Hierarchical regression and partial correlations were used to evaluate associations between weekly urine drug screens over a 90-day follow-up period and fNIRS, craving, and HAM-D assessments. Neural response to drug cues in the left lateral PFC, controlling for age, sex, and days in treatment was significantly associated with percent opioid-negative urine screens during follow-up (∆F1, 24 = 13.19, p = 0.001, ∆R2 = 0.30), and correctly classified 86% of MMPs as either using opioids, or abstaining from opioids (χ2(4) = 16.28, p = 0.003). Baseline craving (p < 0.001) and HAM-D assessment (p < 0.01) were also associated with percent opioid-negative urine screens. Combining fNIRS results, baseline craving scores, and HAM-D scores created a robust predictive model (∆F3, 22 = 16.75, p < 0.001, ∆R2 = 0.59). These data provide preliminary evidence that the fNIRS technology may have value as an objective measure of treatment outcomes within outpatient methadone clinics. Depressive symptoms and drug craving were also correlated with opioid use in MMPs.
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Affiliation(s)
- Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA.
| | - Mary M Sweeney
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
| | - Robert K Brooner
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
| | - Michael S Kidorf
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
| | - D Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
- Department of Psychiatry, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Hasan Ayaz
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, USA
- Department of Family and Community Health, University of Pennsylvania, Philadelphia, PA, USA
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
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Jarvis BP, Holtyn AF, Subramaniam S, Tompkins DA, Oga EA, Bigelow G, Silverman K. Extended-release injectable naltrexone (XR-NTX): a response to clinical issues raised by Brewer & Streel. Addiction 2019; 114:189-190. [PMID: 30345640 DOI: 10.1111/add.14462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 10/01/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Brantley P Jarvis
- Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - August F Holtyn
- Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shrinidhi Subramaniam
- Department of Psychology and Child Development, California State University, Stanislaus, Turlock, CA, USA
| | - D Andrew Tompkins
- Department of Psychiatry, University of California San Francisco School of Medicine Ringgold standard institution, San Francisco, CA, USA
| | - Emmanuel A Oga
- Center for Applied Public Health Research, RTI International, Rockville, MD, USA
| | - George Bigelow
- Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenneth Silverman
- Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Satre DD, Borsari B, Tompkins DA, Ramo D. Psychiatric Disorders and Comorbid Cannabis Use: When Should We Be Concerned and What Can We Do About It? J Clin Psychiatry 2018; 79. [PMID: 30256546 DOI: 10.4088/jcp.18ac12268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Derek D Satre
- Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Ave, Box 0984, San Francisco, CA 94143. .,Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco, California, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Brian Borsari
- Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco, California, USA.,San Francisco Veterans Administration Health Care System, San Francisco, California, USA
| | - D Andrew Tompkins
- Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco, California, USA.,Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Danielle Ramo
- Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco, California, USA
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13
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Jarvis BP, Holtyn AF, Subramaniam S, Tompkins DA, Oga EA, Bigelow GE, Silverman K. Extended-release injectable naltrexone for opioid use disorder: a systematic review. Addiction 2018; 113:1188-1209. [PMID: 29396985 PMCID: PMC5993595 DOI: 10.1111/add.14180] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [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: 07/21/2017] [Revised: 09/18/2017] [Accepted: 01/26/2018] [Indexed: 12/14/2022]
Abstract
AIMS To review systematically the published literature on extended-release naltrexone (XR-NTX, Vivitrol® ), marketed as a once-per-month injection product to treat opioid use disorder. We addressed the following questions: (1) how successful is induction on XR-NTX; (2) what are adherence rates to XR-NTX; and (3) does XR-NTX decrease opioid use? Factors associated with these outcomes as well as overdose rates were examined. METHODS We searched PubMed and used Google Scholar for forward citation searches of peer-reviewed papers from January 2006 to June 2017. Studies that included individuals seeking treatment for opioid use disorder who were offered XR-NTX were included. RESULTS We identified and included 34 studies. Pooled estimates showed that XR-NTX induction success was lower in studies that included individuals that required opioid detoxification [62.6%, 95% confidence interval (CI) = 54.5-70.0%] compared with studies that included individuals already detoxified from opioids (85.0%, 95% CI = 78.0-90.1%); 44.2% (95% CI = 33.1-55.9%) of individuals took all scheduled injections of XR-NTX, which were usually six or fewer. Adherence was higher in prospective investigational studies (i.e. studies conducted in a research context according to a study protocol) compared to retrospective studies of medical records taken from routine care (6-month rates: 46.7%, 95% CI = 34.5-59.2% versus 10.5%, 95% CI = 4.6-22.4%, respectively). Compared with referral to treatment, XR-NTX reduced opioid use in adults under criminal justice supervision and when administered to inmates before release. XR-NTX reduced opioid use compared with placebo in Russian adults, but this effect was confounded by differential retention between study groups. XR-NTX showed similar efficacy to buprenorphine when randomization occurred after detoxification, but was inferior to buprenorphine when randomization occurred prior to detoxification. CONCLUSIONS Many individuals intending to start extended-release naltrexone (XR-NTX) do not and most who do start XR-NTX discontinue treatment prematurely, two factors that limit its clinical utility significantly. XR-NTX appears to decrease opioid use but there are few experimental demonstrations of this effect.
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Affiliation(s)
- Brantley P. Jarvis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine,Public Health Research and Translational Science, Battelle Memorial Institute
| | - August F. Holtyn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Shrinidhi Subramaniam
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - D. Andrew Tompkins
- Department of Psychiatry, University of California, San Francisco School of Medicine
| | - Emmanuel A. Oga
- Public Health Research and Translational Science, Battelle Memorial Institute
| | - George E. Bigelow
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Kenneth Silverman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
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Bisaga A, Mannelli P, Yu M, Nangia N, Graham CE, Tompkins DA, Kosten TR, Akerman SC, Silverman BL, Sullivan MA. Outpatient transition to extended-release injectable naltrexone for patients with opioid use disorder: A phase 3 randomized trial. Drug Alcohol Depend 2018; 187:171-178. [PMID: 29674251 DOI: 10.1016/j.drugalcdep.2018.02.023] [Citation(s) in RCA: 26] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Injectable extended-release naltrexone (XR-NTX), approved to prevent relapse to opioid dependence, requires initial abstinence. This multisite outpatient clinical trial examined the efficacy and safety of low-dose oral naltrexone (NTX), combined with a brief buprenorphine (BUP) taper and standing ancillary medications, for detoxification and induction onto XR-NTX. METHODS Patients (N = 378) were randomized, stratified by primary short-acting opioid-of-use, to one of three regimens: NTX + BUP; NTX + placebo BUP (PBO-B); placebo NTX (PBO-N) + PBO-B. Patients received 7 days of ascending NTX or placebo, concurrent with a 3-day BUP or placebo taper, and ancillary medications in an outpatient setting. Daily psychoeducational counseling was provided. On Day 8, patients passing a naloxone challenge received XR-NTX. RESULTS Rates of transition to XR-NTX were comparable across groups: NTX/BUP (46.0%) vs. NTX/PBO-B (40.5%) vs. PBO-N/PBO-B (46.0%). Thus, the study did not meet its primary endpoint. Adverse events, reported by 32.5% of all patients, were mild to moderate in severity and consistent with opioid withdrawal. A first, second, and third XR-NTX injection was received by 44.4%, 29.9%, and 22.5% of patients, respectively. Compared with the PBO-N/PBO-B group, the NTX/BUP group demonstrated higher opioid abstinence during the transition and lower post-XR-NTX subjective opioid withdrawal scores. CONCLUSIONS A 7-day detoxification protocol with NTX alone or NTX + BUP provided similar rates of induction to XR-NTX as placebo. For those inducted onto XR-NTX, management of opioid withdrawal symptoms prior to induction was achieved in a structured outpatient setting using a well-tolerated, fixed-dose ancillary medication regimen common to all three groups.
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Affiliation(s)
- Adam Bisaga
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, 1051 Riverside Dr., Unit #120, New York, NY, 10032, USA.
| | - Paolo Mannelli
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 2213 Elba Street, Suite 156, DUMC 3074, Durham, NC, 27705, USA
| | - Miao Yu
- Alkermes, Inc., 852 Winter Street, Waltham, MA, 02451, USA
| | | | | | - D Andrew Tompkins
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
| | - Thomas R Kosten
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | | | | | - Maria A Sullivan
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, 1051 Riverside Dr., Unit #120, New York, NY, 10032, USA; Alkermes, Inc., 852 Winter Street, Waltham, MA, 02451, USA
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Dunn KE, Tompkins DA, Strain EC. Tramadol Extended-Release and Opioid Withdrawal Management-Legal Implications-Reply. JAMA Psychiatry 2018; 75:215. [PMID: 29282473 DOI: 10.1001/jamapsychiatry.2017.3827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kelly E Dunn
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - D Andrew Tompkins
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Psychiatry, University of California, San Francisco School of Medicine, San Francisco
| | - Eric C Strain
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Tompkins DA, Huhn AS, Johnson PS, Smith MT, Strain EC, Edwards RR, Johnson MW. To take or not to take: the association between perceived addiction risk, expected analgesic response and likelihood of trying novel pain relievers in self-identified chronic pain patients. Addiction 2018; 113:67-79. [PMID: 28645137 PMCID: PMC5725253 DOI: 10.1111/add.13922] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 11/17/2016] [Revised: 03/31/2017] [Accepted: 06/19/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND AIMS Probability discounting refers to the effect of outcome uncertainty on decision making. Using probability discounting, we examined the degree to which self-identified chronic pain patients (CPP) were likely to try a novel analgesic medication given increasing addiction risk. We postulated that propensity for opioid misuse, trait impulsivity and previous opioid experience would be associated positively with likelihood of risky medication use. DESIGN This cross-sectional on-line study determined state/trait associations with addiction-related medication decisions in CPP. SETTING US-based CPP participated via Amazon Mechanical Turk; data were collected and analyzed in Baltimore, Maryland. PARTICIPANTS A total of 263 CPP (70.6% female) participated in the study from 12-13 December 2014. MEASUREMENTS CPP responded to the Benefit versus Addiction Risk Questionnaire (BARQ) assessing likelihood of taking a hypothetical once-daily oral analgesic medication as a function of two factors: risk of addiction (0-50%) and duration of expected complete pain relief (3, 30 or 365 days). The primary outcome was the BARQ, quantified as area under the curve (AUC). Grouping of CPP at high or low risk for opioid misuse was based on the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). Predictors included previous experience with opioids, as well as various measures of chronic pain and mental health. FINDINGS Across hypothetical addiction risk assessed in the BARQ, the likelihood of taking a novel analgesic medication was elevated significantly in patients with high (≥18; n = 137) versus low (<18; n = 126) SOAPP-R scores [P < 0.001; 3-day: Cohen's d = 0.66, 95% confidence interval (CI) = 0.63, 0.69; 30-day: d = 0.74, 95% CI = 0.71, 0.78; 365-day: d = 0.75, 95% CI = 0.72, 0.79]. CONCLUSIONS In the United States, self-identified chronic pain patients (CPP) at higher risk for opioid misuse were more likely to report willingness to try a novel analgesic despite increasing addiction risk than CPP with low risk of opioid misuse.
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Affiliation(s)
- D. Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew S. Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Patrick S. Johnson
- Department of Psychology, California State University - Chico, Chico, CA, USA
| | - Michael T. Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric C. Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert R. Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
| | - Matthew W. Johnson
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Huhn AS, Tompkins DA, Dunn KE. The relationship between treatment accessibility and preference amongst out-of-treatment individuals who engage in non-medical prescription opioid use. Drug Alcohol Depend 2017; 180:279-285. [PMID: 28942031 PMCID: PMC5648596 DOI: 10.1016/j.drugalcdep.2017.08.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [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: 05/25/2017] [Revised: 08/17/2017] [Accepted: 08/18/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Relatively little is known regarding the perception of medication-assisted treatments (MATs) and other treatment options amongst individuals that engage in non-medical prescription opioid use. This study surveyed out-of-treatment individuals that misuse opioids to better understand how perceived access to treatment shapes treatment preference. METHODS Participants (n=357) were out-of-treatment adults registered as workers on the Amazon Mechanical Turk platform who reported current non-medical prescription opioid use. Participants were surveyed regarding demographics, insurance status, attitudes toward opioid use disorder (OUD) treatments, and self-reported symptoms of OUD. RESULTS Participants who were male, did not have health insurance, and knew that counseling-type services were locally available were most likely to first attempt counseling/detox treatments (χ2(6)=30.19, p<0.001). Participants who met criteria for severe OUD, used heroin in the last 30days, knew their insurance covered MAT, and knew of locally available MAT providers were most likely to first attempt MAT (χ2(4)=26.85, p<0.001). Participants with insurance and who knew of locally available physicians were most likely to attempt physician visits without the expressed purpose of MAT (χ2(3)=24.75, p<0.001). CONCLUSION Out-of-treatment opioid users were particularly interested in counseling-based services and medical care that could be attained from a primary-care physician. Results suggest that insurance coverage and perceived access to OUD treatment modalities influences where out-of-treatment opioid users might first seek treatment; understanding the factors that shape treatment preference is critical in designing early interventions to effectively reach this population.
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Abstract
IMPORTANCE Opioid use disorder (OUD) is a significant public health problem. Supervised withdrawal (ie, detoxification) from opioids using clonidine or buprenorphine hydrochloride is a widely used treatment. OBJECTIVE To evaluate whether tramadol hydrochloride extended-release (ER), an approved analgesic with opioid and nonopioid mechanisms of action and low abuse potential, is effective for use in supervised withdrawal settings. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial was conducted in a residential research setting with 103 participants with OUD. Participants' treatment was stabilized with morphine, 30 mg, administered subcutaneously 4 times daily. A 7-day taper using clonidine (n = 36), tramadol ER (n = 36), or buprenorphine (n = 31) was then instituted, and patients were crossed-over to double-blind placebo during a post-taper period. The study was conducted from October 25, 2010, to June 23, 2015. MAIN OUTCOMES AND MEASURES Retention, withdrawal symptom management, concomitant medication utilization, and naltrexone induction. Results were analyzed over time and using area under the curve for the intention-to-treat and completer groups. RESULTS Of the 103 participants, 88 (85.4%) were men and 43 (41.7%) were white; mean (SD) age was 28.9 (10.4) years. Buprenorphine participants (28 [90.3%]) were significantly more likely to be retained at the end of the taper compared with clonidine participants (22 [61.1%]); tramadol ER retention was intermediate and did not differ significantly from that of the other groups (26 [72.2%]; χ2 = 8.5, P = .01). Time-course analyses of withdrawal revealed significant effects of phase (taper, post taper) for the Clinical Opiate Withdrawal Scale (COWS) score (taper mean, 5.19 [SE, .26]; post-taper mean, 3.97 [SE, .23]; F2,170 = 3.6, P = .03) and Subjective Opiate Withdrawal Scale (SOWS) score (taper mean,8.81 [SE, .40]; post-taper mean, 4.14 [SE, .30]; F2,170 = 15.7, P < .001), but no group effects or group × phase interactions. Analyses of area under the curve of SOWS total scores showed significant reductions (F2,159 = 17.7, P < .001) in withdrawal severity between the taper and post-taper periods for clonidine (taper mean, 13.1; post-taper mean, 3.2; P < .001) and tramadol ER (taper mean, 7.4; post-taper mean, 2.8; P = .03), but not buprenorphine (taper mean, 6.4; post-taper mean, 7.4). Use of concomitant medication increased significantly (F2,159 = 30.7, P < .001) from stabilization to taper in the clonidine (stabilization mean, 0.64 [SE, .05]; taper mean, 1.54 [SE, .10]; P < .001) and tramadol ER (stabilization mean, 0.53 [SE, .05]; taper mean, 1.19 [SE, .09]; P = .003) groups and from stabilization to post taper in the buprenorphine group (stabilization mean, 0.46 [SE, .05] post-taper mean, 1.17 [SE, .09]; P = .006), suggesting higher withdrawal for those groups during those periods. Naltrexone initiation was voluntary and the percentage of participants choosing naltrexone therapy within the clonidine (8 [22.2%]), tramadol ER (7 [19.4%]), or buprenorphine (3 [9.7%]) groups did not differ significantly (χ2 = 2.5, P = .29). CONCLUSIONS AND RELEVANCE The results of this trial suggest that tramadol ER is more effective than clonidine and comparable to buprenorphine in reducing opioid withdrawal symptoms during a residential tapering program. Data support further examination of tramadol ER as a method to manage opioid withdrawal symptoms. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT01188421.
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Affiliation(s)
- Kelly E. Dunn
- Behavioral Pharmacology Research Unit, Department of
Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore,
Maryland
| | - D. Andrew Tompkins
- Behavioral Pharmacology Research Unit, Department of
Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore,
Maryland
| | - George E. Bigelow
- Behavioral Pharmacology Research Unit, Department of
Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore,
Maryland
| | - Eric C. Strain
- Behavioral Pharmacology Research Unit, Department of
Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore,
Maryland
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Tompkins DA, Hobelmann JG, Compton P. Providing chronic pain management in the "Fifth Vital Sign" Era: Historical and treatment perspectives on a modern-day medical dilemma. Drug Alcohol Depend 2017; 173 Suppl 1:S11-S21. [PMID: 28363315 PMCID: PMC5771233 DOI: 10.1016/j.drugalcdep.2016.12.002] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 12/29/2016] [Accepted: 12/31/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Over 100 million Americans are living with chronic pain, and pain is the most common reason that patients seek medical attention. Despite the prevalence of pain, the practice of pain management and the scientific discipline of pain research are relatively new fields compared to the rest of medicine - contributing to a twenty-first century dilemma for health care providers asked to relieve suffering in the "Fifth Vital Sign" era. METHODS This manuscript provides a narrative review of the basic mechanisms of chronic pain and history of chronic pain management in the United States - including the various regulatory, health system and provider factors that contributed to the decline of multidisciplinary pain treatment in favor of the predominant opioid treatment strategy seen today. Multiple non-opioid pain treatment strategies are then outlined. The manuscript concludes with three key questions to help guide future research at the intersection of pain and addiction. CONCLUSIONS The assessment and treatment of chronic pain will continue to be one of the most common functions of a health care provider. To move beyond an over reliance on opioid medications, the addiction and pain research communities must unite with chronic pain patients to increase the evidence base supporting non-opioid analgesic strategies.
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Affiliation(s)
- D. Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Corresponding author. Behavioral Pharmacology Research Unit, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - J. Greg Hobelmann
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peggy Compton
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia PA, USA.
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Drescher J, Schwartz A, Casoy F, McIntosh CA, Hurley B, Ashley K, Barber M, Goldenberg D, Herbert SE, Lothwell LE, Mattson MR, McAfee SG, Pula J, Rosario V, Tompkins DA. The Growing Regulation of Conversion Therapy. ACTA ACUST UNITED AC 2016. [DOI: 10.30770/2572-1852-102.2.7] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Conversion therapies are any treatments, including individual talk therapy, behavioral (e.g. aversive stimuli), group therapy or milieu (e.g. “retreats or inpatient treatments” relying on all of the above methods) treatments, which attempt to change an individual's sexual orientation from homosexual to heterosexual. However, these practices have been repudiated by major mental health organizations because of increasing evidence that they are ineffective and may cause harm to patients and their families who fail to change. At present, California, New Jersey, Oregon, Illinois, Vermont, Washington, D.C., and the Canadian Province of Ontario have passed legislation banning conversion therapy for minors and an increasing number of U.S. States are considering similar bans. In April 2015, the Obama administration also called for a ban on conversion therapies for minors.
The growing trend toward banning conversion therapies creates challenges for licensing boards and ethics committees, most of which are unfamiliar with the issues raised by complaints against conversion therapists. This paper reviews the history of conversion therapy practices as well as clinical, ethical and research issues they raise. With this information, state licensing boards, ethics committees and other regulatory bodies will be better able to adjudicate complaints from members of the public who have been exposed to conversion therapies.
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Drescher J, Schwartz A, Casoy F, McIntosh CA, Hurley B, Ashley K, Barber M, Goldenberg D, Herbert SE, Lothwell LE, Mattson MR, McAfee SG, Pula J, Rosario V, Tompkins DA. The Growing Regulation of Conversion Therapy. J Med Regul 2016; 102:7-12. [PMID: 27754500 PMCID: PMC5040471] [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] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Conversion therapies are any treatments, including individual talk therapy, behavioral (e.g. aversive stimuli), group therapy or milieu (e.g. "retreats or inpatient treatments" relying on all of the above methods) treatments, which attempt to change an individual's sexual orientation from homosexual to heterosexual. However these practices have been repudiated by major mental health organizations because of increasing evidence that they are ineffective and may cause harm to patients and their families who fail to change. At present, California, New Jersey, Oregon, Illinois, Washington, DC, and the Canadian Province of Ontario have passed legislation banning conversion therapy for minors and an increasing number of US States are considering similar bans. In April 2015, the Obama administration also called for a ban on conversion therapies for minors. The growing trend toward banning conversion therapies creates challenges for licensing boards and ethics committees, most of which are unfamiliar with the issues raised by complaints against conversion therapists. This paper reviews the history of conversion therapy practices as well as clinical, ethical and research issues they raise. With this information, state licensing boards, ethics committees and other regulatory bodies will be better able to adjudicate complaints from members of the public who have been exposed to conversion therapies.
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Affiliation(s)
- Jack Drescher
- Clinical Professor of Psychiatry, New York Medical College, and Adjunct Professor, New York University
| | - Alan Schwartz
- Supervisor of Psychotherapy, William Alanson White Institute, New York
| | - Flávio Casoy
- Medical Director of Admissions, Rockland Psychiatric Center-Office of Mental Health, and Clinical Instructor in Psychiatry, Columbia University
| | - Christopher A McIntosh
- Head, Adult Gender Identity Clinic, Centre for Addiction and Mental Health, and Assistant Professor, University of Toronto
| | - Brian Hurley
- Robert Wood Johnson Foundation Clinical Scholar, David Geffen School of Medicine of the University of California, Los Angeles
| | - Kenneth Ashley
- Assistant Professor of Psychiatry-Clinician/Educator Track, Icahn School of Medicine at Mount Sinai, New York
| | - Mary Barber
- Clinical Director, Rockland Psychiatric Center-Office of Mental Health, and Associate Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons
| | - David Goldenberg
- Assistant Professor of Clinical Psychiatry, Weill Cornell Medical College, and Faculty, New York Psychoanalytic Institute
| | - Sarah E Herbert
- Clinical Associate Professor, Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine
| | - Lorraine E Lothwell
- Medical Director, Child & Adolescent Psychiatry Outpatient Clinic, Harlem Hospital, and Assistant Clinical Professor of Psychiatry, Columbia University Department of Psychiatry
| | - Marlin R Mattson
- Professor Emeritus of Clinical Psychiatry, Weill Cornell Medical College
| | - Scot G McAfee
- Interim Chair and Residency Training Director, Psychiatry, Maimonides Medical Center, and Assistant Professor of Clinical Psychiatry, New York Medical College
| | - Jack Pula
- Assistant Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons
| | - Vernon Rosario
- Associate Clinical Professor, University of California, Los Angeles
| | - D Andrew Tompkins
- Assistant Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
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22
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Dunn KE, Finan PH, Tompkins DA, Fingerhood M, Strain EC. Characterizing pain and associated coping strategies in methadone and buprenorphine-maintained patients. Drug Alcohol Depend 2015; 157:143-9. [PMID: 26518253 PMCID: PMC4663104 DOI: 10.1016/j.drugalcdep.2015.10.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [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: 08/21/2015] [Revised: 10/13/2015] [Accepted: 10/13/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic pain is common among patients receiving opioid maintenance treatment (OMT) for opioid use disorder. To aid development of treatment recommendations for coexisting pain and opioid use disorder, it is necessary to characterize pain treatment needs and assess whether needs differ as a function of OMT medication. METHODS A point-prevalence survey assessing pain and engagement in coping strategies was administered to 179 methadone and buprenorphine-maintained patients. RESULTS Forty-two percent of participants were categorized as having chronic pain. Methadone patients had greater severity of pain relative to buprenorphine patients, though both groups reported high levels of interference with daily activities, and participants with pain attended the emergency room more frequently relative to participants without pain. Only 2 coping strategies were being utilized by more than 50% of participants (over-the-counter medication, prayer). CONCLUSIONS Results indicate that pain among OMT patients is common, severe, and of significant impairment. Methadone patients reported greater severity pain, particularly worse pain in the past 24h, though interference from pain in daily activities did not vary as a function of OMT. Most participants with pain were utilizing few evidenced-based pain coping strategies. Increasing OMT patient access to additional pain treatment strategies is an opportunity for immediate intervention, and similarities across OMT type suggest interventions do not need to be customized to methadone vs. buprenorphine patients.
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Affiliation(s)
- Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Patrick H Finan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - D Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael Fingerhood
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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23
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Liao C, Zhang D, Mungo C, Tompkins DA, Zeidan AM. Is diabetes mellitus associated with increased incidence and disease-specific mortality in endometrial cancer? A systematic review and meta-analysis of cohort studies. Gynecol Oncol 2014; 135:163-71. [PMID: 25072931 DOI: 10.1016/j.ygyno.2014.07.095] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [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: 06/24/2014] [Accepted: 07/22/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the association between diabetes mellitus (DM) and the incidence and disease-specific mortality of endometrial cancer (EC). METHODS MEDLINE, EMBASE and conference abstracts of the 2011-2013 Annual Meetings of Society of Gynecological Oncology were searched for reports of original cohort studies that enrolled diabetic and non-diabetic women who were free of EC at baseline to compare the incidence and disease-specific mortality of EC by DM status. The included reports were examined for demographic characteristics of study populations, study design, effect measures and risk of bias. Statistical heterogeneity was evaluated with Chi-square test of the Cochrane Q statistics at the 0.05 significance level and I(2) statistic. Publication bias was assessed by visual examination of a funnel plot and the Egger's test for small-study effects. RESULTS Twenty-nine cohort studies (17 prospective, 12 retrospective) were eligible for this review, 23 of which reported EC incidence, five reported disease-specific mortality and one reported both. For incidence of EC among women with versus without DM, the summary relative risk (RR) was 1.89 (95%CI, 1.46-2.45; p<0.001) and the summary incidence rate ratio was 1.61 (95%CI, 1.51-1.71; p<0.001). The pooled RR of disease-specific mortality was 1.32 (95%CI, 1.10-1.60; p=0.003), while results in the studies reporting standardized mortality ratios were inconsistent. There remains considerable amount of clinical and methodological heterogeneity among the included studies; moreover, the hazard ratios for incident EC showed significant statistical heterogeneity and therefore were not quantitatively synthesized. CONCLUSIONS There is consistent evidence for an independent association between DM and an increased risk of incident EC, while the association between DM and EC-specific mortality remains uncertain. Further studies with better considerations for selection bias, information bias and confounding will further facilitate causal inference involving DM and EC.
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Affiliation(s)
- Caiyun Liao
- The Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Dongyu Zhang
- The Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Chemtai Mungo
- The Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - D Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine Behavioral Pharmacology Research Unit, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University, and Yale Cancer Center, New Haven, CT, USA.
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24
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Umbricht A, DeFulio A, Winstanley EL, Tompkins DA, Peirce J, Mintzer MZ, Strain EC, Bigelow GE. Topiramate for cocaine dependence during methadone maintenance treatment: a randomized controlled trial. Drug Alcohol Depend 2014; 140:92-100. [PMID: 24814607 PMCID: PMC4431633 DOI: 10.1016/j.drugalcdep.2014.03.033] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [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: 04/24/2013] [Revised: 03/18/2014] [Accepted: 03/30/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Dual dependence on opiate and cocaine occurs in about 60% of patients admitted to methadone maintenance and negatively impacts prognosis (Kosten et al. 2003. Drug Alcohol Depend. 70, 315). Topiramate (TOP) is an antiepileptic drug that may have utility in the treatment of cocaine dependence because it enhances the GABAergic system, antagonizes the glutamatergic system, and has been identified by NIDA as one of only a few medications providing a "positive signal" warranting further clinical investigation. (Vocci and Ling, 2005. Pharmacol. Ther. 108, 94). METHOD In this double-blind controlled clinical trial, cocaine dependent methadone maintenance patients (N=171) were randomly assigned to one of four groups. Under a factorial design, participants received either TOP or placebo, and monetary voucher incentives that were either contingent (CM) or non-contingent (Non-CM) on drug abstinence. TOP participants were inducted onto TOP over 7 weeks, stabilized for 8 weeks at 300 mg daily then tapered over 3 weeks. Voucher incentives were supplied for 12 weeks, starting during the fourth week of TOP induction. Primary outcome measures were cocaine abstinence (Y/N) as measured by thrice weekly urinalysis and analyzed using Generalized Estimating Equations (GEE) and treatment retention. All analyses were intent to treat and included the 12-week evaluation phase of combined TOP/P treatment and voucher intervention period. RESULTS There was no significant difference in cocaine abstinence between the TOP vs. P conditions nor between the CM vs. Non-CM conditions. There was no significant TOP/CM interaction. Retention was not significantly different between the groups. CONCLUSION Topiramate is not efficacious for increasing cocaine abstinence in methadone patients.
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Affiliation(s)
- Annie Umbricht
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA.
| | - Anthony DeFulio
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - Erin L Winstanley
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - D Andrew Tompkins
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - Jessica Peirce
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - Miriam Z Mintzer
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - Eric C Strain
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - George E Bigelow
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
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25
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Tompkins DA, Smith MT, Mintzer MZ, Campbell CM, Strain EC. A double blind, within subject comparison of spontaneous opioid withdrawal from buprenorphine versus morphine. J Pharmacol Exp Ther 2013; 348:217-26. [PMID: 24227768 DOI: 10.1124/jpet.113.209478] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Preliminary evidence suggests that there is minimal withdrawal after the cessation of chronically administered buprenorphine and that opioid withdrawal symptoms are delayed compared with those of other opioids. The present study compared the time course and magnitude of buprenorphine withdrawal with a prototypical μ-opioid agonist, morphine. Healthy, out-of-treatment opioid-dependent residential volunteers (N = 7) were stabilized on either buprenorphine (32 mg/day i.m.) or morphine (120 mg/day i.m.) administered in four divided doses for 9 days. They then underwent an 18-day period of spontaneous withdrawal, during which four double-blind i.m. placebo injections were administered daily. Stabilization and spontaneous withdrawal were assessed for the second opioid using the same time course. Opioid withdrawal measures were collected eight times daily. Morphine withdrawal symptoms were significantly (P < 0.05) greater than those of buprenorphine withdrawal as measured by mean peak ratings of Clinical Opiate Withdrawal Scale (COWS), Subjective Opiate Withdrawal Scale (SOWS), all subscales of the Profile of Mood States (POMS), sick and pain (0-100) Visual Analog Scales, systolic and diastolic blood pressure, heart rate, respiratory rate, and pupil dilation. Peak ratings on COWS and SOWS occurred on day 2 of morphine withdrawal and were significantly greater than on day 2 of buprenorphine withdrawal. Subjective reports of morphine withdrawal resolved on average by day 7. There was minimal evidence of buprenorphine withdrawal on any measure. In conclusion, spontaneous withdrawal from high-dose buprenorphine appears subjectively and objectively milder compared with that of morphine for at least 18 days after drug cessation.
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Affiliation(s)
- D Andrew Tompkins
- Behavioral Pharmacology Research Unit (D.A.T., E.C.S., M.Z.M.) and Behavioral Sleep Medicine Program (M.T.S.), Department of Psychiatry and Behavioral Sciences (C.M.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland
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26
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Antoine DG, Strain EC, Tompkins DA, Bigelow GE. Opioid abusers' ability to differentiate an opioid from placebo in laboratory challenge testing. Drug Alcohol Depend 2013; 132:369-72. [PMID: 23369645 PMCID: PMC3911782 DOI: 10.1016/j.drugalcdep.2013.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 12/30/2012] [Accepted: 01/01/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Abuse liability assessments influence drug development, federal regulation, and clinical care. One suggested procedure to reduce variability of assessments is a qualification phase, which assesses whether study applicants adequately distinguish active drug from placebo; applicants failing to make this distinction are disqualified. The present analyses assessed differences between qualification phase qualifiers and non-qualifiers. METHODS Data were collected from 23 completers of the qualification phase of an abuse liability study. Opioid abusing participants received 30 mg oxycodone and placebo orally on separate days, and were characterized as qualifiers (vs. non-qualifiers) if their peak visual analog scale liking rating for oxycodone was at least 20 points higher than placebo's peak rating. Groups were compared on demographic characteristics, drug history, and physiologic, subject and observer ratings. RESULTS 61% of participants were qualifiers and 39% were non-qualifiers. Groups had similar demographic characteristics, drug use histories, and pupillary constriction responses. However, unlike qualifiers, non-qualifiers had an exaggerated placebo response for the liking score (p=0.03) and an attenuated oxycodone response for the liking score (p<0.0001). Non-qualifiers' failure to differentiate oxycodone versus placebo was evident for subject and observer ratings. CONCLUSION Different subjective responses to identical stimuli support the use of a qualification phase in abuse liability assessments. Further research should explore objective measures that may better account for these differences, determine optimal qualification criteria, and explore the developmental course of drug use. This study also documents certain opioid abusers fail to differentiate 30 mg of oxycodone from placebo, a phenomenon deserving further study.
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Affiliation(s)
- Denis G Antoine
- Johns Hopkins University School of Medicine, Bayview Campus, Behavioral Pharmacology Research Unit, 5510 Nathan Shock Drive, Baltimore, MD 21224, United States.
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27
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Byne W, Bradley SJ, Coleman E, Eyler AE, Green R, Menvielle EJ, Meyer-Bahlburg HFL, Pleak RR, Tompkins DA. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Arch Sex Behav 2012; 41:759-96. [PMID: 22736225 DOI: 10.1007/s10508-012-9975-x] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA's position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.
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Affiliation(s)
- William Byne
- Department of Psychiatry, JJ Peters VA Medical Center, Bronx, NY, USA.
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28
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Affiliation(s)
- William Byne
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA
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29
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Abstract
Opioids have become the unequivocal therapy of choice in treating many varieties of chronic pain. With the increased prescription of opioids, some unintended consequences have occurred. After prolonged opioid exposure, opioid-induced hyperalgesia (OIH), the paradoxical effect that opioid therapy may in fact enhance or aggravate preexisting pain, may occur. Over the past several decades, an increasing number of laboratory and clinical reports have suggested lowered pain thresholds and heightened atypical pain unrelated to the original perceived pain sensations as hallmarks of OIH. However, not all evidence supports the clinical importance of OIH, and some question whether the phenomenon exists at all. Here, we present a nonexhaustive, brief review of the recent literature. OIH will be reviewed in terms of preclinical and clinical evidence for and against its existence; recommendations for clinical evaluation and intervention also will be discussed.
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Affiliation(s)
- D Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21231, USA.
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30
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Tompkins DA, Bigelow GE, Harrison JA, Johnson RE, Fudala PJ, Strain EC. Concurrent validation of the Clinical Opiate Withdrawal Scale (COWS) and single-item indices against the Clinical Institute Narcotic Assessment (CINA) opioid withdrawal instrument. Drug Alcohol Depend 2009; 105:154-9. [PMID: 19647958 PMCID: PMC2774236 DOI: 10.1016/j.drugalcdep.2009.07.001] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [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: 04/10/2009] [Revised: 06/25/2009] [Accepted: 07/01/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The Clinical Opiate Withdrawal Scale (COWS) is an 11-item clinician-administered scale assessing opioid withdrawal. Though commonly used in clinical practice, it has not been systematically validated. The present study validated the COWS in comparison to the validated Clinical Institute Narcotic Assessment (CINA) scale. METHOD Opioid-dependent volunteers were enrolled in a residential trial and stabilized on morphine 30 mg given subcutaneously four times daily. Subjects then underwent double-blind, randomized challenges of intramuscularly administered placebo and naloxone (0.4 mg) on separate days, during which the COWS, CINA, and visual analog scale (VAS) assessments were concurrently obtained. Subjects completing both challenges were included (N=46). Correlations between mean peak COWS and CINA scores as well as self-report VAS questions were calculated. RESULTS Mean peak COWS and CINA scores of 7.6 and 24.4, respectively, occurred on average 30 min post-injection of naloxone. Mean COWS and CINA scores 30 min after placebo injection were 1.3 and 18.9, respectively. The Pearson's correlation coefficient for peak COWS and CINA scores during the naloxone challenge session was 0.85 (p<0.001). Peak COWS scores also correlated well with peak VAS self-report scores of bad drug effect (r=0.57, p<0.001) and feeling sick (r=0.57, p<0.001), providing additional evidence of concurrent validity. Placebo was not associated with any significant elevation of COWS, CINA, or VAS scores, indicating discriminant validity. Cronbach's alpha for the COWS was 0.78, indicating good internal consistency (reliability). DISCUSSION COWS, CINA, and certain VAS items are all valid measurement tools for acute opiate withdrawal.
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Affiliation(s)
- D. Andrew Tompkins
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Behavioral Pharmacology Research Unit, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - George E. Bigelow
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Behavioral Pharmacology Research Unit, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - Joseph A. Harrison
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Behavioral Pharmacology Research Unit, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - Rolley E. Johnson
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Behavioral Pharmacology Research Unit, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA,Reckitt Benckiser Pharmaceuticals Inc., Richmond, VA, 23235, USA
| | - Paul J. Fudala
- Reckitt Benckiser Pharmaceuticals Inc., Richmond, VA, 23235, USA
| | - Eric C. Strain
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Behavioral Pharmacology Research Unit, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
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31
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Gerbino-Rosen G, Roofeh D, Tompkins DA, Feryo D, Nusser L, Kranzler H, Napolitano B, Frederickson A, Henderson I, Rhinewine J, Kumra S. Hematological adverse events in clozapine-treated children and adolescents. J Am Acad Child Adolesc Psychiatry 2005; 44:1024-31. [PMID: 16175107 DOI: 10.1097/01.chi.0000171904.23947.54] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To retrospectively examine rates of hematological adverse events (HAEs) in psychiatrically ill, hospitalized children treated with clozapine. METHOD Clozapine treatment was administered in an open-label fashion using a flexible titration schedule, and data from weekly complete blood counts was obtained. The rate of neutropenia and agranulocytosis (HAEs) development was determined for 172 eligible patients (mean age at clozapine initiation, 15.03 +/- 2.13 years) with a median observation period of 8 months. RESULTS Neutropenia (absolute neutrophil count <1,500/mm) developed in 23 (13%) patients and agranulocytosis (absolute neutrophil count <500/mm) in one (0.6%) patient. The cumulative probability of developing an initial HAE at 1 year of clozapine treatment was 16.1% (95% confidence interval 9.7%-22.5%). Eleven (48%) of 24 patients who developed an HAE were successfully rechallenged on clozapine. Eight (5%) of 172 patients from this sample eventually discontinued clozapine because of an HAE (one agranulocytosis, seven neutropenia). CONCLUSIONS The occurrence of HAEs is a significant risk associated with the administration of clozapine. However, in this sample, few children actually discontinued therapy because of an HAE and the incidence of agranulocytosis does not appear higher than what has been reported in the adult literature.
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Affiliation(s)
- Ginny Gerbino-Rosen
- Bronx Children's Psychiatric Center, Division of Child and Adolescent Psychiatry, Department of Psychiatry, Albert Einstein College of Medicine, Bronx, NY, USA
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Wei Y, Chen J, Rosas G, Tompkins DA, Holt PA, Rao R. Phenotypic screening of mutations in Pmr1, the yeast secretory pathway Ca2+/Mn2+-ATPase, reveals residues critical for ion selectivity and transport. J Biol Chem 2000; 275:23927-32. [PMID: 10801855 DOI: 10.1074/jbc.m002618200] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [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: 11/06/2022] Open
Abstract
Thirty-five mutations were generated in the yeast secretory pathway/Golgi ion pump, Pmr1, targeting oxygen-containing side chains within the predicted transmembrane segments M4, M5, M6, M7, and M8, likely to be involved in coordination of Ca(2+) and Mn(2+) ions. Mutants were expressed in low copy number in a yeast strain devoid of endogenous Ca(2+) pumps and screened for loss of Ca(2+) and Mn(2+) transport on the basis of hypersensitivity to 1, 2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid (BAPTA) and Mn(2+) toxicity, respectively. Three classes of mutants were found: mutants indistinguishable from wild type (Class 1), mutants indistinguishable from the pmr1 null strain (Class 2), and mutants with differential sensitivity to BAPTA and Mn(2+) toxicity (Class 3). We show that Class 1 mutants retain normal/near normal properties, including (45)Ca transport, Golgi localization, and polypeptide conformation. In contrast, Class 2 mutants lacked any detectable (45)Ca transport; of these, a subset also showed defects in trafficking and protein folding, indicative of structural problems. Two residues identified as Class 2 mutants in this screen, Asn(774) and Asp(778) in M6, also play critical roles in related ion pumps and are therefore likely to be common architectural components of the cation-binding site. Class 3 mutants appear to have altered selectivity for Ca(2+) and Mn(2+) ions, as exemplified by mutant Q783A in M6. These results demonstrate the utility of phenotypic screening in the identification of residues critical for ion transport and selectivity in cation pumps.
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Affiliation(s)
- Y Wei
- Department of Physiology, The Johns Hopkins University School of Medicine, Baltimore Maryland 21205, USA
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