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Wenzel K, Thomas J, Carrano J, Stidham J, Fishman M. A pilot randomized controlled trial of medication adherence therapy: Psychosocial leverage using a significant other (MAT-PLUS) for individuals on extended-release naltrexone. J Subst Use Addict Treat 2024:209366. [PMID: 38636807 DOI: 10.1016/j.josat.2024.209366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 03/24/2024] [Accepted: 04/07/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Extended-release naltrexone (XR-NTX) is an important treatment option for individuals with opioid use disorder (OUD) and/or alcohol use disorder (AUD). However, problems with retention are a major barrier to its overall effectiveness, and interventions to improve adherence are underdeveloped. The purpose of this study was to pilot test the MAT-PLUS intervention, which combines assertive outreach and involvement of a treatment significant other (TSO) to improve adherence to XR-NTX. METHODS Adults (N = 41) seeking treatment for OUD and/or AUD with XR-NTX were recruited from an inpatient addiction treatment center and randomized to the MAT-PLUS intervention or treatment as usual (TAU) for 16-weeks. TSOs (N = 19) of individuals in the MAT-PLUS condition were also enrolled. The primary outcome was the number of XR-NTX doses received and relapse to regular heavy use (opioid or alcohol) was a secondary outcome. RESULTS Participants in the MAT-PLUS group received 3.4 doses compared to 2.5 in TAU, which was significant after controlling for SUD diagnosis (p < 0.05). Rates of receipts of all prescribed doses were 61.1 % in MAT-PLUS compared to 30.4 % in TAU, giving an NNT of 3.3. Relapse rates and days of heavy use did not vary by treatment group. CONCLUSIONS This study demonstrates preliminary efficacy of the MAT-PLUS intervention for XR-NTX adherence. This study was limited by its small sample size and future research should broaden the intervention to apply across medications for SUD in larger samples. Family support with an emphasis on medication adherence has strong potential for improving addiction treatment outcomes.
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Affiliation(s)
- Kevin Wenzel
- Maryland Treatment Centers, 3800 Frederick Ave, Baltimore, MD 21229, United States of America.
| | - Julia Thomas
- Maryland Treatment Centers, 3800 Frederick Ave, Baltimore, MD 21229, United States of America
| | - Jennifer Carrano
- Maryland Treatment Centers, 3800 Frederick Ave, Baltimore, MD 21229, United States of America
| | - Jennifer Stidham
- Maryland Treatment Centers, 3800 Frederick Ave, Baltimore, MD 21229, United States of America; Wayne State University, 5057 Woodward, Suite 7908, Detroit, MI 4820, United States of America
| | - Marc Fishman
- Maryland Treatment Centers, 3800 Frederick Ave, Baltimore, MD 21229, United States of America; Johns Hopkins University School of Medicine Dept of Psychiatry and Behavioral Sciences, 600 North Wolfe Street, Baltimore, MD 21287, United States of America
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Fishman M, Wenzel K, Gauthier P, Borodovsky J, Murray O, Subramaniam G, Levy S, Fredyma E, McLeman B, Marsch LA. Engagement, initiation, and retention in medication treatment for opioid use disorder among young adults: A narrative review of challenges and opportunities. J Subst Use Addict Treat 2024:209352. [PMID: 38494051 DOI: 10.1016/j.josat.2024.209352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/24/2024] [Accepted: 03/06/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Opioid Use Disorder (OUD) is a catastrophic public health problem for young adults (YAs) and their families. While medication for OUD (MOUD) is safe, effective, and recognized as the standard of care, its' uptake and success have been limited in YAs compared to older adults. METHODS This narrative review summarizes the existing literature and highlights select studies regarding barriers to YA MOUD, potential explanations for those barriers, and strategies to overcome them. RESULTS Barriers are prominent along the entire cascade of care, including: treatment engagement and entry, MOUD initiation, and MOUD retention. Hypothesized explanations for barriers include: developmental vulnerability, inadequate treatment system capacity, stigma against MOUD, among others. Interventions to address barriers include: promotion of family involvement, increasing provider capacity, integration of MOUD into primary care, assertive outreach, and others. CONCLUSIONS Integrating an adapted version of family coaching from the Community Reinforcement Approach and Family Training (CRAFT) and other models into YA MOUD treatment serves as an example of an emerging novel practice that holds promise for broadening the funnel of engagement in treatment and initiation of MOUD, and enhancing treatment outcomes. This and other developmentally-informed approaches should be evaluated as part of a high-priority clinical and research agenda for improving OUD treatment for YAs.
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Affiliation(s)
- Marc Fishman
- Maryland Treatment Centers, 3800 Frederick Avenue, Baltimore, MD 21229, USA; Johns Hopkins University School of Medicine, Dept of Psychiatry, 3800 Frederick Avenue, Baltimore, MD 21229, USA.
| | - Kevin Wenzel
- Maryland Treatment Centers, 3800 Frederick Avenue, Baltimore, MD 21229, USA
| | - Phoebe Gauthier
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH 03766, USA
| | - Jacob Borodovsky
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH 03766, USA
| | - Owen Murray
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH 03766, USA
| | - Geetha Subramaniam
- Center for Clinical Trials Network, National Institute on Drug Abuse, 301 North Stonestreet Ave, Bethesda, MD 20892, USA
| | - Sharon Levy
- Boston Children's Hospital, Division of Addiction Medicine, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Emma Fredyma
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH 03766, USA
| | - Bethany McLeman
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH 03766, USA
| | - Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Suite 315, Lebanon, NH 03766, USA
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Hogue A, Satcher MF, Drazdowski TK, Hagaman A, Hibbard PF, Sheidow AJ, Coetzer-Liversage A, Mitchell SG, Watson DP, Wilson KJ, Muench F, Fishman M, Wenzel K, de Martell SC, Stein LAR. Linkage facilitation services for opioid use disorder: Taxonomy of facilitation practitioners, goals, and activities. J Subst Use Addict Treat 2024; 157:209217. [PMID: 37981242 PMCID: PMC10922806 DOI: 10.1016/j.josat.2023.209217] [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: 03/03/2023] [Revised: 07/14/2023] [Accepted: 11/13/2023] [Indexed: 11/21/2023]
Abstract
INTRODUCTION This article proposes a taxonomy of linkage facilitation services used to help persons with opioid use disorder access treatment and recovery resources. Linkage facilitation may be especially valuable for persons receiving medication for opioid use disorder (MOUD) given the considerable barriers to treatment access and initiation that have been identified. The science of linkage facilitation currently lacks both consistent communication about linkage facilitation practices and a conceptual framework for guiding research. METHODS To address this gap, this article presents a taxonomy derived from expert consensus that organizes the array of practitioners, goals, and activities associated with linkage services for OUD and related needs. Expert panelists first independently reviewed research reports and policy guidelines summarizing the science and practice of linkage facilitation for substance use disorders generally and OUD specifically, then met several times to vet the conceptual scheme and content of the taxonomy until they reached a final consensus. RESULTS The derived taxonomy contains eight domains: facilitator identity, facilitator lived experience, linkage client, facilitator-client relationship, linkage activity, linkage method, linkage connectivity, and linkage goal. For each domain, the article defines basic domain categories, highlights research and practice themes in substance use and OUD care, and introduces innovations in linkage facilitation being tested in one of two NIDA-funded research networks: Justice Community Opioid Innovation Network (JCOIN) or Consortium on Addiction Recovery Science (CoARS). CONCLUSIONS To accelerate consistent application of this taxonomy to diverse research and practice settings, the article concludes by naming several considerations for linkage facilitation workforce training and implementation.
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Affiliation(s)
- Aaron Hogue
- Partnership to End Addiction, 711 Third Avenue, 5th floor, New York, NY 10017, United States of America.
| | - Milan F Satcher
- Dartmouth Health and Geisel School of Medicine at Dartmouth College, United States of America
| | | | - Angela Hagaman
- East Tennessee State University, United States of America
| | | | | | | | | | | | | | - Frederick Muench
- Partnership to End Addiction, 711 Third Avenue, 5th floor, New York, NY 10017, United States of America
| | - Marc Fishman
- Maryland Treatment Centers, United States of America
| | - Kevin Wenzel
- Maryland Treatment Centers, United States of America
| | | | - L A R Stein
- Department of Psychology, University of Rhode Island, United States of America; Department of Behavioral & Social Sciences, Brown University, United States of America; Department of Behavioral Healthcare, Developmental Disabilities & Hospitals, RI, United States of America
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Gopaldas M, Wenzel K, Campbell ANC, Jalali A, Fishman M, Rotrosen J, Nunes EV, Murphy SM. Impact of Medication-Based Treatment on Health Care Utilization Among Individuals With Opioid Use Disorder. Psychiatr Serv 2023; 74:1227-1233. [PMID: 37337675 PMCID: PMC10730760 DOI: 10.1176/appi.ps.20220549] [Citation(s) in RCA: 1] [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] [Indexed: 06/21/2023]
Abstract
OBJECTIVE This study evaluated the association between medication for opioid use disorder (MOUD) and health care utilization over time among a sample of treatment-seeking individuals with opioid use disorder. In contrast to previous studies, this study used a novel measure of MOUD adherence, more comprehensive utilization data, and analyses that controlled for detailed individual and social determinants of health. METHODS This study was a secondary analysis of a comparative effectiveness trial (N=570) of extended-release naltrexone versus buprenorphine-naloxone. The outcome of interest was usage of nonstudy acute care, inpatient and outpatient addiction services, and other outpatient services across 36 weeks of assessment. Adherence (percentage of days taking MOUD) was defined as low (<20%), medium (≥20% but <80%), or high (≥80%). A two-part model evaluated the probability of utilizing a resource and the quantity (utilization days) of the resource consumed. A time-varying approach was used to examine the effect of adherence in a given month on utilization in the same month, with analyses controlling for a wide range of person-level characteristics. RESULTS Participants with high adherence (vs. low) were significantly less likely to use inpatient addiction (p<0.001) and acute care (p<0.001) services and significantly more likely to engage in outpatient addiction (p=0.045) and other outpatient (p=0.042) services. CONCLUSIONS These findings reinforce the understanding that greater MOUD adherence is associated with reduced usage of high-cost health services and increased usage of outpatient care. The results further suggest the need for enhanced access to MOUD and for interventions that improve adherence.
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Affiliation(s)
- Manesh Gopaldas
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Kevin Wenzel
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Aimee N C Campbell
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Ali Jalali
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Marc Fishman
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - John Rotrosen
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Edward V Nunes
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Sean M Murphy
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
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Benner JD, Cohen SM, Hollenbaugh JA, Fishman M. Fentanyl-induced respiratory depression in rodents is inhibited by bioabsorbable, subcutaneous naltrexone implants at 3.5 months. Addict Biol 2023; 28:e13350. [PMID: 38017645 DOI: 10.1111/adb.13350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/24/2023] [Accepted: 09/28/2023] [Indexed: 11/30/2023]
Abstract
The aim of this study is to determine if extended-release, bioabsorbable, subcutaneous naltrexone (NTX) implants inhibit respiratory depression after an IV injection of fentanyl. Bioabsorbable implants fabricated from two different release-controlling polymers, poly-D-L-lactide (PDLLA) and polycaprolactone (PCL), alone (placebo) or containing NTX, were subcutaneously implanted in Sprague Dawley rats. After 3.5 months of implantation, the rodents were administered an IV bolus of fentanyl through the tail vein. The placebo implant rats received a dose of 4 micrograms (mcg) - (10 mcg/kg/dose), while the NTX implanted animals received a dose of 8 mcg (20 mcg/kg/dose). The minimum active dose of fentanyl that caused a > 50 ± 2% depression in the respiration rate in the placebo implanted rodents was 4 mcg. The respiration rate of the placebo implanted rats dropped from 208 ± 14 breaths/minute at predose, to 84 ± 12 breaths/minute (p = 0.0003) at 2 min. In contrast, all NTX implanted animals easily tolerated twice the dose of 8 mcg of fentanyl without any significant reduction in respiration rate. The mean respiration rate = increased from 164 ± 22 breaths/minute at predose to 178 ± 17 breaths/minute (p = 0.24) at 2 min. The mean plasma concentrations of NTX, 3.5 months after implantation, ranged from 7.4 (±1.1) ng/mL to 80.3 (±37.5) ng/mL. Bioabsorbable implants containing NTX effectively blocked fentanyl-induced respiratory depression in rodents as compared with placebo implants, 3.5 months after implantation.
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Affiliation(s)
- Jeffrey D Benner
- The Drug Delivery Company, LLC dba Akyso, Salisbury, MD (JDB and SMC), LabCorp Drug Development Greenfield, IN (JAH), The Department of Psychiatry, Johns Hopkins School of Medicine and Maryland Treatment Centers, Baltimore, Maryland, USA
| | - Steven M Cohen
- The Drug Delivery Company, LLC dba Akyso, Salisbury, MD (JDB and SMC), LabCorp Drug Development Greenfield, IN (JAH), The Department of Psychiatry, Johns Hopkins School of Medicine and Maryland Treatment Centers, Baltimore, Maryland, USA
| | - Joseph A Hollenbaugh
- The Drug Delivery Company, LLC dba Akyso, Salisbury, MD (JDB and SMC), LabCorp Drug Development Greenfield, IN (JAH), The Department of Psychiatry, Johns Hopkins School of Medicine and Maryland Treatment Centers, Baltimore, Maryland, USA
| | - Marc Fishman
- The Drug Delivery Company, LLC dba Akyso, Salisbury, MD (JDB and SMC), LabCorp Drug Development Greenfield, IN (JAH), The Department of Psychiatry, Johns Hopkins School of Medicine and Maryland Treatment Centers, Baltimore, Maryland, USA
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Allen C, Arredondo C, Dunham R, Fishman M, Lev L, Mace S, Parks J, Rosa D, Shoyinka S, White D, Williams A. Guidance for Handling the Increasing Prevalence of Drugs Adulterated or Laced With Fentanyl. Psychiatr Serv 2023; 74:1059-1062. [PMID: 37042103 DOI: 10.1176/appi.ps.202100660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
The use of fentanyl and its analogs is the primary driver of deaths related to the opioid overdose crisis. In fall 2021, the U.S. Drug Enforcement Administration issued its first public safety alert in 6 years to raise awareness of the escalating prevalence of fentanyl in counterfeit pills and in other opioids, such as heroin, and nonopioids, such as methamphetamine. In addition to increased public awareness, specific actions are needed to remediate the risk for fentanyl overdose. The authors endorse four principles to address the opioid overdose crisis and provide guidance for remediating its impacts: an incremental approach to behavior change or harm reduction; engagement strategies for individuals with substance use disorder; an integrated care approach to ensure better access to treatment programs and effective interventions; and vigilance among clinicians, program staff, and patients to the threat of fentanyl-adulterated drugs. The authors offer specific recommendations on how to apply these principles effectively within health care systems, communities, and law enforcement agencies across the United States.
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Affiliation(s)
- Craig Allen
- Addiction Services, Hartford HealthCare, Meriden, Connecticut (Allen); El Rio Community Health Center, Tucson (Arredondo); Metropolitan Human Services District, New Orleans (Dunham); Maryland Treatment Centers, Johns Hopkins University, Baltimore (Fishman); Beebe Healthcare, Lewes, Delaware (Lev); National Council for Mental Wellbeing, Washington, D.C. (Mace, Parks, Williams); Emergency Medicine, Acacia Network, New York City (Rosa); Department of Behavioral Health and Intellectual Disability Services, Philadelphia (Shoyinka); Psychiatric Emergency Services, Grady Health System, Emory University School of Medicine, Atlanta (White)
| | - Christina Arredondo
- Addiction Services, Hartford HealthCare, Meriden, Connecticut (Allen); El Rio Community Health Center, Tucson (Arredondo); Metropolitan Human Services District, New Orleans (Dunham); Maryland Treatment Centers, Johns Hopkins University, Baltimore (Fishman); Beebe Healthcare, Lewes, Delaware (Lev); National Council for Mental Wellbeing, Washington, D.C. (Mace, Parks, Williams); Emergency Medicine, Acacia Network, New York City (Rosa); Department of Behavioral Health and Intellectual Disability Services, Philadelphia (Shoyinka); Psychiatric Emergency Services, Grady Health System, Emory University School of Medicine, Atlanta (White)
| | - Rochelle Dunham
- Addiction Services, Hartford HealthCare, Meriden, Connecticut (Allen); El Rio Community Health Center, Tucson (Arredondo); Metropolitan Human Services District, New Orleans (Dunham); Maryland Treatment Centers, Johns Hopkins University, Baltimore (Fishman); Beebe Healthcare, Lewes, Delaware (Lev); National Council for Mental Wellbeing, Washington, D.C. (Mace, Parks, Williams); Emergency Medicine, Acacia Network, New York City (Rosa); Department of Behavioral Health and Intellectual Disability Services, Philadelphia (Shoyinka); Psychiatric Emergency Services, Grady Health System, Emory University School of Medicine, Atlanta (White)
| | - Marc Fishman
- Addiction Services, Hartford HealthCare, Meriden, Connecticut (Allen); El Rio Community Health Center, Tucson (Arredondo); Metropolitan Human Services District, New Orleans (Dunham); Maryland Treatment Centers, Johns Hopkins University, Baltimore (Fishman); Beebe Healthcare, Lewes, Delaware (Lev); National Council for Mental Wellbeing, Washington, D.C. (Mace, Parks, Williams); Emergency Medicine, Acacia Network, New York City (Rosa); Department of Behavioral Health and Intellectual Disability Services, Philadelphia (Shoyinka); Psychiatric Emergency Services, Grady Health System, Emory University School of Medicine, Atlanta (White)
| | - Leonard Lev
- Addiction Services, Hartford HealthCare, Meriden, Connecticut (Allen); El Rio Community Health Center, Tucson (Arredondo); Metropolitan Human Services District, New Orleans (Dunham); Maryland Treatment Centers, Johns Hopkins University, Baltimore (Fishman); Beebe Healthcare, Lewes, Delaware (Lev); National Council for Mental Wellbeing, Washington, D.C. (Mace, Parks, Williams); Emergency Medicine, Acacia Network, New York City (Rosa); Department of Behavioral Health and Intellectual Disability Services, Philadelphia (Shoyinka); Psychiatric Emergency Services, Grady Health System, Emory University School of Medicine, Atlanta (White)
| | - Shannon Mace
- Addiction Services, Hartford HealthCare, Meriden, Connecticut (Allen); El Rio Community Health Center, Tucson (Arredondo); Metropolitan Human Services District, New Orleans (Dunham); Maryland Treatment Centers, Johns Hopkins University, Baltimore (Fishman); Beebe Healthcare, Lewes, Delaware (Lev); National Council for Mental Wellbeing, Washington, D.C. (Mace, Parks, Williams); Emergency Medicine, Acacia Network, New York City (Rosa); Department of Behavioral Health and Intellectual Disability Services, Philadelphia (Shoyinka); Psychiatric Emergency Services, Grady Health System, Emory University School of Medicine, Atlanta (White)
| | - Joseph Parks
- Addiction Services, Hartford HealthCare, Meriden, Connecticut (Allen); El Rio Community Health Center, Tucson (Arredondo); Metropolitan Human Services District, New Orleans (Dunham); Maryland Treatment Centers, Johns Hopkins University, Baltimore (Fishman); Beebe Healthcare, Lewes, Delaware (Lev); National Council for Mental Wellbeing, Washington, D.C. (Mace, Parks, Williams); Emergency Medicine, Acacia Network, New York City (Rosa); Department of Behavioral Health and Intellectual Disability Services, Philadelphia (Shoyinka); Psychiatric Emergency Services, Grady Health System, Emory University School of Medicine, Atlanta (White)
| | - Daniel Rosa
- Addiction Services, Hartford HealthCare, Meriden, Connecticut (Allen); El Rio Community Health Center, Tucson (Arredondo); Metropolitan Human Services District, New Orleans (Dunham); Maryland Treatment Centers, Johns Hopkins University, Baltimore (Fishman); Beebe Healthcare, Lewes, Delaware (Lev); National Council for Mental Wellbeing, Washington, D.C. (Mace, Parks, Williams); Emergency Medicine, Acacia Network, New York City (Rosa); Department of Behavioral Health and Intellectual Disability Services, Philadelphia (Shoyinka); Psychiatric Emergency Services, Grady Health System, Emory University School of Medicine, Atlanta (White)
| | - Sosunmolu Shoyinka
- Addiction Services, Hartford HealthCare, Meriden, Connecticut (Allen); El Rio Community Health Center, Tucson (Arredondo); Metropolitan Human Services District, New Orleans (Dunham); Maryland Treatment Centers, Johns Hopkins University, Baltimore (Fishman); Beebe Healthcare, Lewes, Delaware (Lev); National Council for Mental Wellbeing, Washington, D.C. (Mace, Parks, Williams); Emergency Medicine, Acacia Network, New York City (Rosa); Department of Behavioral Health and Intellectual Disability Services, Philadelphia (Shoyinka); Psychiatric Emergency Services, Grady Health System, Emory University School of Medicine, Atlanta (White)
| | - DeJuan White
- Addiction Services, Hartford HealthCare, Meriden, Connecticut (Allen); El Rio Community Health Center, Tucson (Arredondo); Metropolitan Human Services District, New Orleans (Dunham); Maryland Treatment Centers, Johns Hopkins University, Baltimore (Fishman); Beebe Healthcare, Lewes, Delaware (Lev); National Council for Mental Wellbeing, Washington, D.C. (Mace, Parks, Williams); Emergency Medicine, Acacia Network, New York City (Rosa); Department of Behavioral Health and Intellectual Disability Services, Philadelphia (Shoyinka); Psychiatric Emergency Services, Grady Health System, Emory University School of Medicine, Atlanta (White)
| | - Aaron Williams
- Addiction Services, Hartford HealthCare, Meriden, Connecticut (Allen); El Rio Community Health Center, Tucson (Arredondo); Metropolitan Human Services District, New Orleans (Dunham); Maryland Treatment Centers, Johns Hopkins University, Baltimore (Fishman); Beebe Healthcare, Lewes, Delaware (Lev); National Council for Mental Wellbeing, Washington, D.C. (Mace, Parks, Williams); Emergency Medicine, Acacia Network, New York City (Rosa); Department of Behavioral Health and Intellectual Disability Services, Philadelphia (Shoyinka); Psychiatric Emergency Services, Grady Health System, Emory University School of Medicine, Atlanta (White)
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Schacht RL, Wenzel KR, Meyer LE, Mette M, Mallik-Kane K, Rabalais A, Berg SK, Fishman M. A pilot test of Written Exposure Therapy for PTSD in residential substance use treatment. Am J Addict 2023; 32:488-496. [PMID: 37329251 DOI: 10.1111/ajad.13442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/28/2023] [Accepted: 06/05/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES: Posttraumatic stress disorder (PTSD) is highly comorbid with substance use disorders (SUD) and can impede SUD recovery. Residential SUD treatment is a crucial opportunity to address PTSD. However, PTSD treatment is lacking in residential SUD care. METHODS We conducted a nonrandomized feasibility study of Written Exposure Therapy (WET), a brief, evidence-based treatment for PTSD, with patients in residential SUD treatment. We assessed attitudes towards treatment (Credibility and Expectancy Questionnaire, Barriers to Treatment Participation Scale) and mental health indicators (PTSD Checklist for DSM-5, Trauma Coping Self-Efficacy, Difficulties in Emotion Regulation-Short Form, and Brief Assessment of Recovery Capital). RESULTS Thirty of 49 eligible participants completed WET (61%) and 92% (n = 45) attended at least one WET session. Paired sample t-tests revealed significant posttreatment improvement across all mental health indicators, with medium to large effect sizes. DISCUSSION AND CONCLUSIONS Attendance and completion rates compared favorably to prior exposure-based treatment for PTSD in SUD settings. Although causality cannot be inferred without a randomized controlled trial, mental health indicators, including PTSD, improved significantly following WET. SCIENTIFIC SIGNIFICANCE These findings provide evidence that PTSD can be successfully treated in short-term residential care using brief exposure-based interventions, which is a crucial clinical need that has been minimally studied in the past.
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Affiliation(s)
- Rebecca L Schacht
- Department of Psychology, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | - Kevin R Wenzel
- Department of Psychology, University of Maryland, Baltimore County, Baltimore, Maryland, USA
- Maryland Treatment Centers, Baltimore, Maryland, USA
| | - Laurel E Meyer
- Department of Psychology, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | - Meghan Mette
- Department of Psychology, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | | | | | - Samantha K Berg
- Department of Psychology, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | - Marc Fishman
- Maryland Treatment Centers, Baltimore, Maryland, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Vest N, Wenzel K, Choo TH, Pavlicova M, Rotrosen J, Nunes E, Lee JD, Fishman M. Trajectories of depression among patients in treatment for opioid use disorder: A growth mixture model secondary analysis of the XBOT trial. Am J Addict 2023; 32:291-300. [PMID: 36645265 PMCID: PMC10332426 DOI: 10.1111/ajad.13371] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/21/2022] [Accepted: 12/10/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To inform clinical practice, we identified subgroups of adults based on levels of depression symptomatology over time during opioid use disorder (OUD) treatment. METHODS Participants were 474 adults in a 24-week treatment trial for OUD. Depression symptoms were measured using the 17-item Hamilton Depression Rating Scale (HAM-D) at nine-time points. This was a secondary analysis of the Clinical Trials Network Extended-Release Naltrexone versus Buprenorphine for Opioid Treatment (XBOT) trial using a growth mixture model. RESULTS Three distinct depression trajectories were identified: Class 1 High Recurring-10% with high HAM-D with initial partial reductions (of HAM-D across time), Class 2 Persistently High-5% with persistently high HAM-D, and Class 3 Low Declining-85% of the participants, with low HAM-D with early sustained reductions. The majority (low declining) had levels of depression that improved in the first 4 weeks and then stabilized across the treatment period. In contrast, 15% (high recurring and persistently high) had high initial levels that were more variable across time. The persistently high class had higher rates of opioid relapse. DISCUSSION AND CONCLUSIONS In this OUD sample, most depressive symptomatology was mild and improved after medication treatment for opioid use disorder (MOUD). Smaller subgroups had higher depressive symptoms that persisted or recurred after the initiation of MOUD. Depressive symptoms should be followed in patients initiating treatment for OUD, and when persistent, should prompt further evaluation and consideration of antidepressant treatment. SCIENTIFIC SIGNIFICANCE This study is the first to identify three distinct depression trajectories among a large clinical sample of individuals in MOUD treatment.
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Affiliation(s)
- Noel Vest
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin Wenzel
- Department of Research, Maryland Treatment Centers/Mountain Manor Treatment Center, Baltimore, Maryland, USA
| | - Tse-Hwei Choo
- Department of Psychiatry, Columbia University, New York, New York, USA
| | - Martina Pavlicova
- Department of Psychiatry, Columbia University, New York, New York, USA
| | - John Rotrosen
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Edward Nunes
- Department of Psychiatry, Columbia University, New York, New York, USA
| | - Joshua D Lee
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Marc Fishman
- Department of Research, Maryland Treatment Centers/Mountain Manor Treatment Center, Baltimore, Maryland, USA
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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9
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Greiner MG, Shulman M, Opara O, Potter K, Voronca DC, Tafessu HM, Hefner K, Hamilton A, Scheele C, Ho R, Dresser L, Jelstrom E, Fishman M, Ghitza UE, Rotrosen J, Nunes EV, Bisaga A. Surmounting Withdrawal to Initiate Fast Treatment with Naltrexone (SWIFT): A stepped wedge hybrid type 1 effectiveness-implementation study. Contemp Clin Trials 2023; 128:107148. [PMID: 36931426 PMCID: PMC10895892 DOI: 10.1016/j.cct.2023.107148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Extended-release injectable naltrexone (XR-NTX) is an effective treatment for opioid use disorder (OUD), but initiation remains a barrier to implementation. Standard practice requires a 10- to 15-day inpatient admission prior to XR-NTX initiation and involves a methadone or buprenorphine taper followed by a 7- to 10-day washout, as recommended in the Prescribing Information for XR-NTX. A 5- to 7-day rapid induction approach was developed that utilizes low-dose oral naltrexone and non-opioid medications. METHODS The CTN-0097 Surmounting Withdrawal to Initiate Fast Treatment with Naltrexone (SWIFT) study was a hybrid type I effectiveness-implementation trial that compared the effectiveness of the standard procedure (SP) to the rapid procedure (RP) for XR-NTX initiation across six community inpatient addiction treatment units, and evaluated the implementation process. Sites were randomized to RP every 14 weeks in an optimized stepped wedge design. Participants (target recruitment = 450) received the procedure (SP or RP) that the site was implementing at time of admission. The hypothesis was RP will be non-inferior to SP on proportion of inpatients who receive XR-NTX, with a shorter admission time for RP. Superiority testing of RP was planned if the null hypothesis of inferiority of RP to SP was rejected. DISCUSSION If RP for XR-NTX initiation is shown to be effective, the shorter inpatient stay could make XR-NTX more feasible and have an important public health impact expanding access to OUD pharmacotherapy. Further, a better understanding of facilitators and barriers to RP implementation can help with future translatability and uptake to other community programs. TRIAL REGISTRATION NCT04762537 Registered February 21, 2021.
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Affiliation(s)
- Miranda G Greiner
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, NY, United States of America
| | - Matisyahu Shulman
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, NY, United States of America
| | - Onumara Opara
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, NY, United States of America
| | - Kenzie Potter
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, NY, United States of America
| | | | - Hiwot M Tafessu
- The Emmes Company, LLC, Rockville, MD, United States of America
| | - Kathryn Hefner
- The Emmes Company, LLC, Rockville, MD, United States of America
| | - Amy Hamilton
- The Emmes Company, LLC, Rockville, MD, United States of America
| | | | - Rachel Ho
- The Emmes Company, LLC, Rockville, MD, United States of America
| | - Lauren Dresser
- The Emmes Company, LLC, Rockville, MD, United States of America
| | - Eve Jelstrom
- The Emmes Company, LLC, Rockville, MD, United States of America
| | - Marc Fishman
- Johns Hopkins University School of Medicine and Maryland Treatment Centers, Baltimore, MD, United States of America
| | - Udi E Ghitza
- National Institute on Drug Abuse (NIDA), Bethesda, MD, United States of America
| | - John Rotrosen
- New York University Grossman School of Medicine, New York, NY, United States of America
| | - Edward V Nunes
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, NY, United States of America
| | - Adam Bisaga
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, NY, United States of America.
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10
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Hogue A, Bobek M, Porter N, MacLean A, Wenzel K, Fishman M, Coatsworth JD, Langer DA. Launching Relationship-Oriented Behavioral Services for Youth Opioid Use Disorder: Innovations in Medication Decision-Making and Adherence Planning. Child Fam Behav Ther 2023; 45:199-225. [PMID: 37767113 PMCID: PMC10531035 DOI: 10.1080/07317107.2023.2172704] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/18/2023] [Accepted: 01/22/2023] [Indexed: 09/29/2023]
Abstract
This article presents behavioral interventions designed to enhance uptake and retention on medication for opioid use disorder (MOUD) among transition-age youth (16-25 years) enrolled in treatment services. The article describes three relationship-oriented interventions designed to address barriers to MOUD uptake, enhance MOUD adherence planning, and strengthen OUD recovery among youth: Relational Orientation; Medication Education and Decision-making Support, and Family Leadership and Ownership of Adherence to Treatment. These interventions are inter-connected can be delivered flexibly. The article concludes with three case examples that illustrate how these modular interventions can be tailored to meet the needs of diverse client profiles.
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Affiliation(s)
- Aaron Hogue
- Family & Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, USA
| | - Molly Bobek
- Family & Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, USA
| | - Nicole Porter
- Family & Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, USA
| | - Alexandra MacLean
- Family & Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, USA
| | - Kevin Wenzel
- Department of Psychiatry, Maryland Treatment Centers, Baltimore, Maryland, USA
| | - Marc Fishman
- Department of Psychiatry, Maryland Treatment Centers, Baltimore, Maryland, USA
| | - J. Douglas Coatsworth
- Knoxville Boyd Center for Business and Economic Research, Social Work, University of Tennessee, Knoxville, Tennessee, USA
| | - David. A. Langer
- Department of Psychology, Suffolk University, Boston, Massachusetts, USA
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11
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Hefner K, Choo TH, Shmueli-Blumberg D, Pavlicova M, King J, Fishman M, Shulman M, Campbell A, Greiner M, Scodes J, Meyers-Ohki S, Novo P, Nunes E, Rotrosen J. Time-lagged association between counseling and/or 12-Step attendance with subsequent opioid use in a secondary analysis from a randomized, clinical trial of medications for opioid use disorder. Drug Alcohol Depend Rep 2022; 5:100100. [PMID: 36644220 PMCID: PMC9838184 DOI: 10.1016/j.dadr.2022.100100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 09/16/2022] [Accepted: 09/26/2022] [Indexed: 01/19/2023]
Abstract
Introduction Psychosocial support is recommended in conjunction with medication for opioid use disorder (MOUD), although optimal "dose," modality, and timing of participation is not established. This study comprised a secondary analysis of counseling and 12-Step attendance and subsequent opioid use in a MOUD randomized clinical trial. Methods The parent study randomly assigned 570 participants to receive buprenorphine-naloxone (BUP-NX, n=287) or extended-release injectable naltrexone (XR-NTX, n=283). Mixed-effects logistic regression models were fit with opioid use as the response variable, and a counseling/12-Step attendance predictor. Differences by treatment assignment were examined. Results Any counseling or 12-Step attendance was associated with reduced odds of opioid use at the subsequent visit, whether considered individually or aggregated across type. A continuous relationship was observed for 12-Step attendance (F(1,5083)=5.01, p=.025); with each additional hour associated with 13% (95% CI: 0.83, 0.90) reduction in odds of opioid use. The strength of this association grew over time. In the BUP-NX arm, group counseling was associated with a greater reduction in odds of opioid use than for XR-NTX, (OR=0.32 (95% CI: .22, 0.48) vs. OR=0.69 (95% CI: 0.43, 1.08)). For XR-NTX, 12-Step was associated with a greater reduction in odds of opioid use (OR=0.35 (95% CI: 0.22, 0.54) vs. OR=0.65 (95% CI: 0.47, 0.89) for BUP-NX)). Conclusions Psychosocial engagement has a proximal association with opioid use, the strength of that association may grow with dose and time. Alternatively, more motivated individuals may both attend more counseling/12-Step and have better treatment outcomes, or the relationship may be reciprocal.
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Affiliation(s)
- Kathryn Hefner
- NIDA Data and Statistics Center for the NIDA CTN, The Emmes Company, LLC, 401 N Washington St, Rockville, MD 20850, United States
| | - Tse-Hwei Choo
- Department of Psychiatry, Columbia University, United States
| | - Dikla Shmueli-Blumberg
- NIDA Data and Statistics Center for the NIDA CTN, The Emmes Company, LLC, 401 N Washington St, Rockville, MD 20850, United States
| | - Martina Pavlicova
- Department of Biostatistics, Mailman School of Public Health, Columbia University, United States
| | - Jacquie King
- NIDA Data and Statistics Center for the NIDA CTN, The Emmes Company, LLC, 401 N Washington St, Rockville, MD 20850, United States
| | | | - Matisyahu Shulman
- Department of Psychiatry, Columbia University, United States
- New York State Psychiatric Institute, United States
| | - Aimee Campbell
- Department of Psychiatry, Columbia University, United States
- New York State Psychiatric Institute, United States
| | - Miranda Greiner
- Department of Psychiatry, Columbia University, United States
- New York State Psychiatric Institute, United States
| | - Jennifer Scodes
- Department of Psychiatry, Columbia University, United States
- New York State Psychiatric Institute, United States
| | | | - Patricia Novo
- New York University Grossman School of Medicine, United States
| | - Edward Nunes
- Department of Psychiatry, Columbia University, United States
- New York State Psychiatric Institute, United States
| | - John Rotrosen
- New York University Grossman School of Medicine, United States
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12
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Rudolph KE, Williams NT, Goodwin ATS, Shulman M, Fishman M, Díaz I, Luo S, Rotrosen J, Nunes EV. Buprenorphine & methadone dosing strategies to reduce risk of relapse in the treatment of opioid use disorder. Drug Alcohol Depend 2022; 239:109609. [PMID: 36075154 PMCID: PMC9741946 DOI: 10.1016/j.drugalcdep.2022.109609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although there is consensus that having a "high-enough" dose of buprenorphine (BUP-NX) or methadone is important for reducing relapse to opioid use, there is debate about what this dose is and how it should be attained. We estimated the extent to which different dosing strategies would affect risk of relapse over 12 weeks of treatment, separately for BUP-NX and methadone. METHODS This was a secondary analysis of three comparative effectiveness trials. We examined four dosing strategies: 1) increasing dose in response to participant-specific opioid use, 2) increasing dose weekly until some minimum dose (16 mg BUP, 100 mg methadone) was reached, 3) increasing dose weekly until some minimum and increasing dose in response to opioid use thereafter (referred to as the "hybrid strategy"), and 4) keeping dose constant after the first 2 weeks of treatment. We used a longitudinal sequentially doubly robust estimator to estimate contrasts between dosing strategies on risk of relapse. RESULTS For BUP-NX, increasing dose following the hybrid strategy resulted in the lowest risk of relapse. For methadone, holding dose constant resulted in greatest risk of relapse; the other three strategies performed similarly. For example, the hybrid strategy reduced week 12 relapse risk by 13 % (RR: 0.87, 95 %CI: 0.83-0.95) and by 20 % (RR: 0.80, 95 %CI: 0.71-0.90) for BUP-NX and methadone respectively, as compared to holding dose constant. CONCLUSIONS Doses should be targeted toward minimum thresholds and, in the case of BUP-NX, raised when patients continue to use opioids.
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Affiliation(s)
- Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Nicholas T Williams
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Alicia T Singham Goodwin
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Matisyahu Shulman
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
| | - Marc Fishman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, and Maryland Treatment Centers, Baltimore, MD, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Sean Luo
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
| | - John Rotrosen
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
| | - Edward V Nunes
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
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13
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Na PJ, Scodes J, Fishman M, Rotrosen J, Nunes EV. Co-occurring Depression and Suicidal Ideation in Opioid Use Disorder: Prevalence and Response During Treatment With Buprenorphine-Naloxone and Injection Naltrexone. J Clin Psychiatry 2022; 83. [PMID: 35452194 DOI: 10.4088/jcp.21m14140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objective: The concept of "deaths of despair" (suicide, overdose, and alcohol-related liver disease) highlights the importance of detecting and understanding the course of co-occurring depression in patients with opioid use disorder (OUD). Methods: In a 24-week trial of 570 patients with DSM-5-defined OUD randomized to buprenorphine-naloxone (BUP-NX) or extended-release naltrexone (XR-NTX) from January 2014 to January 2017, the prevalence of depression (assessed with Hamilton Depression Rating Scale [HDRS]) was examined at baseline and after 4 weeks of treatment, and the association between depression and relapse to opioid use was explored using logistic regression. Results: Among 473 patients who initiated medication, 14.2% (67/473) had moderate/severe depression (HDRS ≥ 17) and 34.9% (165/473) had mild depression (8 ≤ HDRS ≤ 16) at baseline. Patients with moderate/severe depression had more frequent histories of anxiety disorders and suicidal ideation. After 4 weeks of treatment, approximately two-thirds of participants with depression either responded (HDRS reduced ≥ 50% from baseline) or remitted (HDRS ≤ 7), with no significant differences between medication treatment groups. Those with moderate/severe depression were less likely to remit (52.8%; 28/53) compared to those with mild depression (76%; 98/129) at week 4 (OR = 0.43, 95% CI = 0.21-0.89, P = .02). Further, those who remitted at week 4 had lower, but not significantly different, risk of relapse to opioids compared to those who did not remit (OR = 0.55, 95% CI = 0.28-1.08, P = .08). Conclusions: Depression is common among patients with OUD and often remits after initiation of BUP-NX or XR-NTX, although when it does not remit it may be associated with worse opioid use outcome. Depression should be screened and followed during initiation of treatment and, when it does not remit, specific depression treatment should be considered. Trial Registration: ClinicalTrials.gov identifier: NCT02032433.
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Affiliation(s)
- Peter J Na
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut.,VA Connecticut Health Care System, West Haven, Connecticut.,Corresponding author: Peter J. Na, MD, MPH, Yale University School of Medicine, 300 George St Ste 901, New Haven, CT 06511
| | | | - Marc Fishman
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Maryland Treatment Centers, Baltimore, Maryland
| | - John Rotrosen
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York
| | - Edward V Nunes
- New York State Psychiatric Institute, New York, New York.,Columbia University Irving Medical Center, New York, New York
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14
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Krausz M, Westenberg JN, Tsang V, Suen J, Ignaszewski MJ, Mathew N, Azar P, Cabanis M, Elsner J, Vogel M, Spijkerman R, Orsolini L, Vo D, Moore E, Moe J, Strasser J, Köck P, Marian C, Dürsteler KM, Backmund M, Röhrig J, Post M, Haltmayer H, Wladika W, Trabi T, Muller C, Rechberger G, Teesson M, Farrell M, Christie G, Merry S, Mamdouh M, Alinsky R, Levy S, Fishman M, Rosenthal R, Jang K, Choi F. Towards an International Consensus on the Prevention, Treatment, and Management of High-Risk Substance Use and Overdose among Youth. Medicina (B Aires) 2022; 58:medicina58040539. [PMID: 35454376 PMCID: PMC9028633 DOI: 10.3390/medicina58040539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/29/2022] [Accepted: 04/11/2022] [Indexed: 11/26/2022] Open
Abstract
Background and Objectives: Now more than ever, there is an obvious need to reduce the overall burden of disease and risk of premature mortality that are associated with mental health and substance use disorders among young people. However, the current state of research and evidence-based clinical care for high-risk substance use among youth is fragmented and scarce. The objective of the study is to establish consensus for the prevention, treatment, and management of high-risk substance use and overdose among youth (10 to 24 years old). Materials and Methods: A modified Delphi technique was used based on the combination of scientific evidence and clinical experience of a group of 31 experts representing 10 countries. A semi-structured questionnaire with five domains (clinical risks, target populations, intervention goals, intervention strategies, and settings/expertise) was shared with the panelists. Based on their responses, statements were developed, which were subsequently revised and finalized through three iterations of feedback. Results: Among the five major domains, 60 statements reached consensus. Importantly, experts agreed that screening in primary care and other clinical settings is recommended for all youth, and that the objectives of treating youth with high-risk substance use are to reduce harm and mortality while promoting resilience and healthy development. For all substance use disorders, evidence-based interventions should be available and should be used according to the needs and preferences of the patient. Involuntary admission was the only topic that did not reach consensus, mainly due to its ethical implications and resulting lack of comparable evidence. Conclusions: High-risk substance use and overdoses among youth have become a major challenge. The system’s response has been insufficient and needs substantial change. Internationally devised consensus statements provide a first step in system improvement and reform.
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Affiliation(s)
- Michael Krausz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 2A1, Canada; (M.K.); (V.T.); (J.S.); (M.J.I.); (N.M.); (P.A.); (M.M.); (K.J.); (F.C.)
| | - Jean N. Westenberg
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 2A1, Canada; (M.K.); (V.T.); (J.S.); (M.J.I.); (N.M.); (P.A.); (M.M.); (K.J.); (F.C.)
- Center for Mental Health, Clinic for Addiction Medicine and Addictive Behavior, Klinikum Stuttgart, 70374 Stuttgart, Germany; (M.C.); (J.R.)
- Correspondence: ; Tel.: +1-604-827-4381
| | - Vivian Tsang
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 2A1, Canada; (M.K.); (V.T.); (J.S.); (M.J.I.); (N.M.); (P.A.); (M.M.); (K.J.); (F.C.)
| | - Janet Suen
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 2A1, Canada; (M.K.); (V.T.); (J.S.); (M.J.I.); (N.M.); (P.A.); (M.M.); (K.J.); (F.C.)
| | - Martha J. Ignaszewski
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 2A1, Canada; (M.K.); (V.T.); (J.S.); (M.J.I.); (N.M.); (P.A.); (M.M.); (K.J.); (F.C.)
- Complex Pain and Addiction Service, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
- BC Children’s Hospital, Vancouver, BC V6H 3N1, Canada;
| | - Nickie Mathew
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 2A1, Canada; (M.K.); (V.T.); (J.S.); (M.J.I.); (N.M.); (P.A.); (M.M.); (K.J.); (F.C.)
- Complex Pain and Addiction Service, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
- BC Mental Health & Substance Use Services, Provincial Health Services Authority, Vancouver, BC V5Z 3L7, Canada
| | - Pouya Azar
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 2A1, Canada; (M.K.); (V.T.); (J.S.); (M.J.I.); (N.M.); (P.A.); (M.M.); (K.J.); (F.C.)
- Complex Pain and Addiction Service, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Maurice Cabanis
- Center for Mental Health, Clinic for Addiction Medicine and Addictive Behavior, Klinikum Stuttgart, 70374 Stuttgart, Germany; (M.C.); (J.R.)
| | - Julie Elsner
- Department of Psychiatry, Psychiatric University Clinics Basel, University of Basel, 4002 Basel, Switzerland; (J.E.); (M.V.); (J.S.); (P.K.); (C.M.); (K.M.D.)
| | - Marc Vogel
- Department of Psychiatry, Psychiatric University Clinics Basel, University of Basel, 4002 Basel, Switzerland; (J.E.); (M.V.); (J.S.); (P.K.); (C.M.); (K.M.D.)
- Psychiatric Services of Thurgovia, Division of Substance Use Disorders, 8596 Münsterlingen, Switzerland
| | - Renske Spijkerman
- Parnassia Addiction Research Centre (PARC), Brijder Addiction Treatment, Parnassia Group, 2512 The Hague, The Netherlands; (R.S.); (M.P.)
| | - Laura Orsolini
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, School of Medicine and Surgery, Polytechnic University of Marche, 60121 Ancona, Italy;
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9EU, UK
| | - Dzung Vo
- BC Children’s Hospital, Vancouver, BC V6H 3N1, Canada;
- Division of Adolescent Health and Medicine, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada;
| | - Eva Moore
- Division of Adolescent Health and Medicine, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada;
| | - Jessica Moe
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada;
- BC Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada
| | - Johannes Strasser
- Department of Psychiatry, Psychiatric University Clinics Basel, University of Basel, 4002 Basel, Switzerland; (J.E.); (M.V.); (J.S.); (P.K.); (C.M.); (K.M.D.)
| | - Patrick Köck
- Department of Psychiatry, Psychiatric University Clinics Basel, University of Basel, 4002 Basel, Switzerland; (J.E.); (M.V.); (J.S.); (P.K.); (C.M.); (K.M.D.)
| | - Calin Marian
- Department of Psychiatry, Psychiatric University Clinics Basel, University of Basel, 4002 Basel, Switzerland; (J.E.); (M.V.); (J.S.); (P.K.); (C.M.); (K.M.D.)
| | - Kenneth M. Dürsteler
- Department of Psychiatry, Psychiatric University Clinics Basel, University of Basel, 4002 Basel, Switzerland; (J.E.); (M.V.); (J.S.); (P.K.); (C.M.); (K.M.D.)
| | - Markus Backmund
- Praxiszentrum im Tal, 80331 Munich, Germany;
- Ludwig-Maximilians-University, 80539 Munich, Germany
| | - Jeanette Röhrig
- Center for Mental Health, Clinic for Addiction Medicine and Addictive Behavior, Klinikum Stuttgart, 70374 Stuttgart, Germany; (M.C.); (J.R.)
| | - Marianne Post
- Parnassia Addiction Research Centre (PARC), Brijder Addiction Treatment, Parnassia Group, 2512 The Hague, The Netherlands; (R.S.); (M.P.)
| | | | - Wolfgang Wladika
- Department of Neurology and Psychiatry of Childhood and Adolescence, Klinikum Klagenfurt am Wörthersee, 9020 Klagenfurt, Austria;
| | - Thomas Trabi
- Department for Child and Adolescent Psychiatry and Pschotherapy, LKH Graz II, 8053 Graz, Austria;
| | - Christian Muller
- Department of Child & Youth Psychiatry and Psychotherapy, Psychosocial Service Burgenland GmbH, 7000 Eisenstadt, Austria;
| | - Gerhard Rechberger
- Verein Dialog, Integrative Suchtberatung Gudrunstraße, 1100 Wien, Austria;
| | - Maree Teesson
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, NSW 2006, Australia;
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2031, Australia;
| | - Grant Christie
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; (G.C.); (S.M.)
| | - Sally Merry
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; (G.C.); (S.M.)
| | - Mostafa Mamdouh
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 2A1, Canada; (M.K.); (V.T.); (J.S.); (M.J.I.); (N.M.); (P.A.); (M.M.); (K.J.); (F.C.)
- Department of Neuropsychiatry, Tanta University, Tanta 31527, Egypt
| | - Rachel Alinsky
- Division of Adolescent/Young Adult Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Sharon Levy
- Adolescent Substance Use and Addiction Program, Boston Children’s Hospital, Boston, MA 02115, USA;
| | - Marc Fishman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD 21205, USA;
- Mountain Manor Treatment Center, Baltimore, MD 21229, USA
| | - Richard Rosenthal
- Department of Psychiatry and Behavioral Health, Stony Brook University, New York, NY 11794, USA;
| | - Kerry Jang
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 2A1, Canada; (M.K.); (V.T.); (J.S.); (M.J.I.); (N.M.); (P.A.); (M.M.); (K.J.); (F.C.)
| | - Fiona Choi
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 2A1, Canada; (M.K.); (V.T.); (J.S.); (M.J.I.); (N.M.); (P.A.); (M.M.); (K.J.); (F.C.)
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15
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Rudolph KE, Shulman M, Fishman M, Díaz I, Rotrosen J, Nunes EV. Association between dynamic dose increases of buprenorphine for treatment of opioid use disorder and risk of relapse. Addiction 2022; 117:637-645. [PMID: 34338389 PMCID: PMC9717480 DOI: 10.1111/add.15654] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [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: 12/17/2020] [Accepted: 07/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Dynamic, adaptive pharmacologic treatment for opioid use disorder (OUD) has been previously recommended over static dosing to prevent relapse, and is aligned with personalized medicine. However, there has been no quantitative evidence demonstrating its advantage. Our objective was to estimate the extent to which a hypothetical intervention that increased buprenorphine dose in response to opioid use would affect risk of relapse over 24 weeks of follow-up. DESIGN A secondary analysis of the buprenorphine arm of an open-label randomized controlled 24-week comparative effectiveness trial, 2014-17. SETTING Eight community addiction treatment programs in the United States. PARTICIPANTS English-speaking adults with DSM-5 OUD, recruited during inpatient admission (n = 270). Participants were mainly white (65%) and male (72%). INTERVENTION(S) Participants were treated with daily sublingual buprenorphine-naloxone (BUP-NX), with dose based on clinical indication, determined by the provider. We examined a hypothetical intervention of increasing dose in response to opioid use. MEASUREMENTS Outcome was relapse to regular opioid use during the 24 weeks of outpatient treatment, assessed in a survival framework. We estimated the relapse-free survival curves of participants under a hypothetical (i.e. counterfactual) intervention in which their BUP-NX dosage would be increased following their own subject-specific opioid use during the first 12 weeks of treatment versus a hypothetical intervention in which dose would remain constant. FINDINGS We estimated that increasing BUP-NX dose in response to recent opioid use would lower risk of relapse by 19.17 percentage points [95% confidence interval (CI) = -32.17, -6.18) (additive risk)] and 32% (0.68, 95% CI = 0.49, 0.86) (relative risk). The number-needed-to-treat with this intervention to prevent a single relapse is 6. CONCLUSIONS In people with opioid use disorder, a hypothetical intervention that increases sublingual buprenorphine-naloxone dose in response to opioid use during the first 12 weeks of treatment appears to reduce risk of relapse over 24 weeks, compared with holding the dose constant after week 2.
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Affiliation(s)
- Kara E. Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Matisyahu Shulman
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - Marc Fishman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Maryland Treatment Centers, Baltimore, MD, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - John Rotrosen
- Department of Psychiatry, School of Medicine, New York University, New York, NY, USA
| | - Edward V. Nunes
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
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16
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Hammond CJ, Kady A, Park G, Vidal C, Wenzel K, Fishman M. Therapy Dose Mediates the Relationship Between Buprenorphine/Naloxone and Opioid Treatment Outcomes in Youth Receiving Medication for Opioid Use Disorder Treatment. J Addict Med 2022; 16:e97-e104. [PMID: 33973923 DOI: 10.1097/adm.0000000000000861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/25/2022]
Abstract
BACKGROUND Evidence-based interventions for treating opioid use disorder (OUD) in youth are limited and little is known about specific and general mechanisms of OUD treatments and how they promote abstinence. METHODS The present study used data from the NIDA-CTN-0010 trial to evaluate the mediating effects of psychosocial treatment-related variables (therapy dose and therapeutic alliance) on end-of-treatment opioid abstinence in a sample of youth with OUD (n = 152, 40% female, mean age = 19.7 years) randomized to receive either 12-weeks of treatment with Bup/Nal ("Bup-Nal") or up to 2 weeks of Bup/Nal detoxification ("Detox") with both treatment arms receiving weekly individual and group drug counseling ± family therapy. RESULTS Participants in the Bup-Nal group attended more therapy sessions (16 vs 6 sessions), had increased therapeutic alliance at week-4, and had less opioid use by week-12 compared to those in the Detox group. In both treatment arms, youth who attended more therapy sessions were less likely to have a week-12 opioid positive urine. In a multiple mediator model, therapy dose mediated the association between treatment arm and opioid abstinence. CONCLUSIONS These findings provide preliminary support for a "dose-response" effect of addiction-focused therapy on abstinence in youth OUD. Further, the results identified a mediating effect of therapy dose on the relationship between treatment assignment and opioid treatment outcomes, suggesting that extended Bup-Nal treatment may enhance abstinence, in part, through a mechanism of therapy facilitation, by increasing therapy dose during treatment.
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Affiliation(s)
- Christopher J Hammond
- Division of Child & Adolescent Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD (CJH, AK, GP, CV, MF), Behavioral Pharmacology Research Unit, Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD (CJH), Maryland Treatment Centers, Baltimore, MD (KW, MF)
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17
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Abstract
Background: Individuals with substance use disorder (SUD) may be particularly at risk during the COVID-19 pandemic. The purpose of this study was to examine attitudes to the pandemic among individuals with SUD. Methods: Survey responses from 266 patients entering a residential treatment program were analyzed. Results: Most participants were White or African American men. A third of participants reported that their substance use had increased during the pandemic (38%), and that they had stockpiled substances because of concerns about supply (30%). A majority of participants indicated more depression (60%), anxiety (61%), worry about finances (62%), and feeling worse about their substance use due to COVID-19 (67%). An exploratory factor analysis revealed five factors that measured interest in SUD treatment, psychological symptoms, adherence to health recommendations, perceptions of vulnerability to COVID-19, and substance use during COVID-19. African American participants indicated a greater interest in treatment than Whites, while White participants indicated increased symptoms and substance use during COVID-19 (p < .05). Further, African Americans were more likely to have known someone who had developed COVID-19 than whites (p < .05). Older participants indicated adhering to health recommendations more than younger participants, using substances less than younger participants, as well as feeling more vulnerable to COVID-19 (p < .05). Conclusions: This is the first study to examine patient attitudes and behaviors related to COVID-19 at a residential SUD treatment program. Treatment providers should be aware of patient attitudes and behaviors related to COVID-19 paying special attention to barriers to treatment engagement.
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Affiliation(s)
| | - Kevin Wenzel
- Mountain Manor Treatment Center, Baltimore, Maryland, USA
| | - Marc Fishman
- Mountain Manor Treatment Center, Baltimore, Maryland, USA.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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18
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Greiner MG, Shulman M, Scodes J, Choo TH, Pavlicova M, Opara O, Campbell ANC, Novo P, Fishman M, Lee JD, Rotrosen J, Nunes EV. Patient Characteristics Associated with Opioid Abstinence after Participation in a Trial of Buprenorphine versus Injectable Naltrexone. Subst Use Misuse 2022; 57:1732-1742. [PMID: 35975917 PMCID: PMC10044490 DOI: 10.1080/10826084.2022.2112230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Background and Objectives: Better understanding of predictors of opioid abstinence among patients with opioid use disorder (OUD) may help to inform interventions and personalize treatment plans. This analysis examined patient characteristics associated with opioid abstinence in the X:BOT (Extended-Release Naltrexone versus Buprenorphine for Opioid Treatment) trial. Methods: This post-hoc analysis examined factors associated with past-month opioid abstinence at the 36-week follow-up visit among participants in the X:BOT study. 428 participants (75% of original sample) attended the visit at 36 weeks. Logistic regression models were used to estimate the probability of opioid abstinence across various baseline sociodemographics, clinical characteristics, and treatment variables. Results: Of the 428 participants, 143 (33%) reported abstinence from non-prescribed opioids at the 36-week follow-up. Participants were more likely to be opioid abstinent if randomized to XR-NTX (compared to BUP-NX), were on XR-NTX at week 36 (compared to those off OUD pharmacotherapy), successfully inducted onto either study medication, had longer time on study medication, reported a greater number of abstinent weeks, or had longer time to relapse during the 24-week treatment trial. Participants were less likely to be abstinent if Hispanic, had a severe baseline Hamilton Depression Rating (HAM-D) score, or had baseline sedative use. Conclusions: A substantial proportion of participants was available at follow-up (75%), was on OUD pharmacotherapy (53%), and reported past-month opioid abstinence (33%) at 36 weeks. A minority of patients off medication for OUD reported abstinence and additional research is needed exploring patient characteristics that may be associated with successful treatment outcomes.
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Affiliation(s)
- Miranda G Greiner
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York, USA
| | - Matisyahu Shulman
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York, USA
| | - Jennifer Scodes
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York, USA
| | - Tse-Hwei Choo
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York, USA
| | - Martina Pavlicova
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Onumara Opara
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York, USA
| | - Aimee N C Campbell
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York, USA
| | - Patricia Novo
- Departments of Population Health and Psychiatry, New York University Grossman School of Medicine, New York, New York, USA
| | - Marc Fishman
- Department of Psychiatry, Johns Hopkins University School of Medicine and Maryland Treatment Centers, Baltimore, Maryland, USA
| | - Joshua D Lee
- Departments of Population Health and Psychiatry, New York University Grossman School of Medicine, New York, New York, USA
| | - John Rotrosen
- Departments of Population Health and Psychiatry, New York University Grossman School of Medicine, New York, New York, USA
| | - Edward V Nunes
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York, USA
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19
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Williams AR, Johnson KA, Thomas CP, Reif S, Socías ME, Henry BF, Neighbors C, Gordon AJ, Horgan C, Nosyk B, Drexler K, Krawczyk N, Gonsalves GS, Hadland SE, Stein BD, Fishman M, Kelley AT, Pincus HA, Olfson M. Opioid use disorder Cascade of care framework design: A roadmap. Subst Abuse 2022; 43:1207-1214. [PMID: 35657670 PMCID: PMC9577537 DOI: 10.1080/08897077.2022.2074604] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Unintentional overdose deaths, most involving opioids, have eclipsed all other causes of US deaths for individuals less than 50 years of age. An estimated 2.4 to 5 million individuals have opioid use disorder (OUD) yet a minority receive treatment in a given year. Medications for OUD (MOUD) are the gold standard treatment for OUD however early dropout remains a major challenge for improving clinical outcomes. A Cascade of Care (CoC) framework, first popularized as a public health accountability strategy to stem the spread of HIV, has been adapted specifically for OUD. The CoC framework has been promoted by the NIH and several states and jurisdictions for organizing quality improvement efforts through clinical, policy, and administrative levers to improve OUD treatment initiation and retention. This roadmap details CoC design domains based on available data and potential linkages as individual state agencies and health systems typically rely on limited datasets subject to diverse legal and regulatory requirements constraining options for evaluations. Both graphical decision trees and catalogued studies are provided to help guide efforts by state agencies and health systems to improve data collection and monitoring efforts under the OUD CoC framework.
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Affiliation(s)
- Arthur Robin Williams
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, New York, New York, USA
| | | | - Cindy Parks Thomas
- Brandeis University Schneider Institutes for Health Policy, Brandeis, Massachusetts, USA
| | - Sharon Reif
- Brandeis University Schneider Institutes for Health Policy, Brandeis, Massachusetts, USA
| | - M. Eugenia Socías
- Department of Medicine, University of British Columbia, British Columbia, Canada
| | - Brandy F. Henry
- Pennsylvania State University, State College, Pennsylvania, USA
| | | | - Adam J. Gordon
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Constance Horgan
- Brandeis University Schneider Institutes for Health Policy, Brandeis, Massachusetts, USA
| | - Bohdan Nosyk
- Centre for Health Evaluation & Outcome Sciences, Faculty of Health Sciences, Simon Fraser University, British Columbia, Canada
| | - Karen Drexler
- American Academy of Addiction Psychiatry, East Providence, Rhode Island, USA
| | - Noa Krawczyk
- New York University, New York City, New York, USA
| | | | - Scott E. Hadland
- Massachusetts General Hospital, Harvard University, Cambridge, Massachusetts, USA
| | - Bradley D. Stein
- American Academy of Addiction Psychiatry, East Providence, Rhode Island, USA
| | - Marc Fishman
- Mountain Manor Treatment Centers, Baltimore, Maryland, USA
| | - A. Taylor Kelley
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Harold A. Pincus
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, New York, New York, USA
| | - Mark Olfson
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, New York, New York, USA
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20
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Monico LB, Ludwig A, Lertch E, Schwartz RP, Fishman M, Mitchell SG. Post-residential treatment outpatient care preferences: Perspectives of youth with opioid use disorder. J Subst Abuse Treat 2021; 137:108692. [PMID: 34920900 DOI: 10.1016/j.jsat.2021.108692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 09/14/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION We know little about what youth with opioid use disorders (OUD) think about outpatient substance use treatment and 12-step meetings following discharge from residential substance use treatment. This study explores youths' preferences between intensive outpatient treatment (IOP) and community-based 12-step groups. METHOD The study recruited youth (n = 35) from a larger randomized trial (N = 288) that examined the effectiveness of extended-release naltrexone versus treatment-as-usual. This study asked the youth to participate in semi-structured qualitative interviews at baseline, 3 months, and 6 months post-residential treatment discharge. Qualitative interviews probed youths' key decision points during the six-months following residential treatment for OUD, including medication and counseling, and 12-step continuation in the community. RESULTS Qualitative analyses revealed three overarching themes related to youths' preferences for either IOP or 12-step meetings: structure of recovery support, mechanisms of accountability, and relationships. CONCLUSION Despite varying preferences, this analysis highlights the complexity of benefits that youth report receiving from each approach. Research has yet to determine the degree to which these approaches are complementary or supplementary for this population.
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Affiliation(s)
- Laura B Monico
- Friends Research Institute, Inc., 1040 Park Avenue, Suite 103, Baltimore, MD 21201, United States of America.
| | - Ariel Ludwig
- Friends Research Institute, Inc., 1040 Park Avenue, Suite 103, Baltimore, MD 21201, United States of America
| | - Elizabeth Lertch
- Friends Research Institute, Inc., 1040 Park Avenue, Suite 103, Baltimore, MD 21201, United States of America
| | - Robert P Schwartz
- Friends Research Institute, Inc., 1040 Park Avenue, Suite 103, Baltimore, MD 21201, United States of America
| | - Marc Fishman
- Mountain Manor Treatment Center, 3800 Frederick Ave, Baltimore, MD 21229, United States of America
| | - Shannon Gwin Mitchell
- Friends Research Institute, Inc., 1040 Park Avenue, Suite 103, Baltimore, MD 21201, United States of America
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21
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Greiner MG, Shulman M, Choo TH, Scodes J, Pavlicova M, Campbell ANC, Novo P, Fishman M, Lee JD, Rotrosen J, Nunes EV. Naturalistic follow-up after a trial of medications for opioid use disorder: Medication status, opioid use, and relapse. J Subst Abuse Treat 2021; 131:108447. [PMID: 34098301 PMCID: PMC8556394 DOI: 10.1016/j.jsat.2021.108447] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
AIM This report examined naturalistic opioid use outcomes and utilization of medications for opioid use disorder (MOUD) 36 weeks post-randomization in the National Drug Abuse Treatment Clinical Trials Network (CTN) Extended-Release Naltrexone (XR-NTX) versus Buprenorphine-Naloxone (BUP-NX) for Opioid Treatment trial (CTN-0051, X:BOT). DESIGN X:BOT was a multisite, randomized, 24-week comparative effectiveness trial of BUP-NX (N = 287) and XR-NTX (N = 283). Study medications were discontinued following treatment completion, relapse, or dropout. Participants were encouraged to continue MOUD. This report examined opioid use outcomes in 428 (75%) of the 570 participants who attended the 36-week follow-up visit. SETTING AND PARTICIPANTS Adults with opioid use disorder recruited from 8 community treatment programs across the United States. MEASUREMENTS Outcomes included medication status (on/off MOUD), type of MOUD (BUP-NX, XR-NTX, or methadone), abstinence from non-prescribed opioids, opioid use days, relapse, and other substance use 30 days prior to the 36-week visit. Relapse was defined as opioid use for 4 consecutive weeks or 7 consecutive days in the past month. Baseline and clinical variables included opioid use severity, intravenous drug use, study medication assignment, and induction status. FINDINGS Of the 428 participants who completed the 36-week visit, 225 (53%) of participants were receiving MOUD and 203 (47%) were not. Compared to those off medication, participants on medication had fewer opioid use days (4.4 days (SD 9.0) versus 9.8 days (SD 12.1)), fewer met relapse criteria (37 (16.4%) versus 79 (38.9%)), and reported less stimulant use (34 (15.2%) versus 56 (27.7%)) and sedative use (14 (6.3%) versus 31 (15.3%)). There was no difference in abstinence rates between those on or off MOUD. A greater proportion of participants on XR-NTX (47 (53.4%) of 88 participants) were abstinent from non-prescribed opioids compared to those on buprenorphine (28 (23.3%) of 120 participants). CONCLUSIONS Naturalistic outcomes data showed that despite potential barriers to continuing treatment in the community, about half of individuals were on opioid use disorder pharmacotherapy at follow-up and those on medication generally had better outcomes. Future research should explore barriers and facilitators to treatment retention in community settings; and developing interventions tailored to improve treatment engagement and adherence.
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Affiliation(s)
- Miranda G Greiner
- New York State Psychiatric Institute and Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY 10032, United States of America.
| | - Matisyahu Shulman
- New York State Psychiatric Institute and Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY 10032, United States of America.
| | - Tse-Hwei Choo
- New York State Psychiatric Institute and Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY 10032, United States of America.
| | - Jennifer Scodes
- New York State Psychiatric Institute and Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY 10032, United States of America.
| | - Martina Pavlicova
- Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY 10032, United States of America.
| | - Aimee N C Campbell
- New York State Psychiatric Institute and Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY 10032, United States of America.
| | - Patricia Novo
- New York University Grossman School of Medicine, 550 First Avenue, New York, NY 10016, United States of America.
| | - Marc Fishman
- Johns Hopkins University School of Medicine and Maryland Treatment Centers, 3800 Frederick Ave, Baltimore, MD 21229, United States of America
| | - Joshua D Lee
- New York University Grossman School of Medicine, 550 First Avenue, New York, NY 10016, United States of America.
| | - John Rotrosen
- New York University Grossman School of Medicine, 550 First Avenue, New York, NY 10016, United States of America.
| | - Edward V Nunes
- New York State Psychiatric Institute and Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY 10032, United States of America.
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22
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Hogue A, Becker SJ, Wenzel K, Henderson CE, Bobek M, Levy S, Fishman M. Family involvement in treatment and recovery for substance use disorders among transition-age youth: Research bedrocks and opportunities. J Subst Abuse Treat 2021; 129:108402. [PMID: 34080559 PMCID: PMC8380649 DOI: 10.1016/j.jsat.2021.108402] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 12/30/2022]
Abstract
This article presents a narrative review and conceptual framework for research on family involvement across the continuum of substance use disorder (SUD) services for transition-age youth (ages 15-26). Though families are powerful resources for enhancing treatment and recovery success among youth with SUDs, they are not routinely included in clinical practice. This article summarizes youth SUD prevalence and service utilization rates and presents developmental and empirical rationale for increasing family involvement in services. It then describes key research issues on family involvement across the SUD services continuum: Problem Identification, Treatment Engagement, Active Treatment, Recovery Support. Within each phase, it highlights bedrock research findings and suggests promising opportunities for advancing the scientific knowledge base on family involvement. The main goals are to endorse family-oriented practices for immediate adoption in routine care and identify areas of research innovation that could significantly enhance the quality of youth SUD services.
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Affiliation(s)
- Aaron Hogue
- Partnership to End Addiction, United States of America.
| | - Sara J Becker
- Center for Alcohol and Addictions Studies, Brown University School of Public Health, United States of America
| | - Kevin Wenzel
- Maryland Treatment Centers, United States of America
| | | | - Molly Bobek
- Partnership to End Addiction, United States of America
| | - Sharon Levy
- Boston Children's Hospital, Harvard Medical School, United States of America
| | - Marc Fishman
- Maryland Treatment Centers, United States of America
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23
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Fishman M, Wenzel K, Scodes J, Pavlicova M, Campbell ANC, Rotrosen J, Nunes E. Examination of Correlates of OUD Outcomes in Young Adults: Secondary Analysis From the XBOT Trial. Am J Addict 2021; 30:433-444. [PMID: 34075644 DOI: 10.1111/ajad.13176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Opioid use disorder (OUD) treatment outcomes are poorer for young adults than older adults. Developmental differences are broadly implicated, but particular vulnerability factor interactions are poorly understood. This study sought to identify moderators of OUD relapse between age groups. METHODS This secondary analysis compared young adults (18-25) to older adults (26+) from a comparative effectiveness trial ("XBOT") that randomized (N = 570) participants to extended-release naltrexone or sublingual buprenorphine-naloxone. We explored the relationship between 25 prespecified patient baseline characteristics and relapse to regular opioid use by age group and treatment condition, using logistic regression. RESULTS Young adults (n = 111) had higher rates of 24-week relapse than older adults (n = 459) (70.3% vs 58.8%) and differed on a number of specific characteristics, including more smokers, more intravenous opioid use, and more cannabis use. No significant moderators predicted relapse, in either three-way or two-way interactions. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE No baseline factors were identified as moderating the relationship between age group and opioid relapse, nor any interactions between baseline characteristics, age group, and treatment condition to predict opioid relapse. Poorer treatment outcomes for young adults are likely associated with multiple developmental vulnerabilities rather than any single predominant factor. Although not reaching significance, several characteristics (using heroin, smoking tobacco, high levels of depression/anxiety, or treatment because of family/friends) showed higher odds ratio point estimates for relapse in young adults than older adults. This is the first study to explore moderators of worse OUD treatment outcomes in young adults, highlighting the need to identify predictor variables that could inform treatment enhancements. (Am J Addict 2021;00:1-12).
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Affiliation(s)
- Marc Fishman
- Mountain Manor Treatment Center/Maryland Treatment Centers, Baltimore, Maryland.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kevin Wenzel
- Mountain Manor Treatment Center/Maryland Treatment Centers, Baltimore, Maryland
| | - Jennifer Scodes
- Division of Mental Health Data Science, New York State Psychiatric Institute, New York, New York
| | - Martina Pavlicova
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York
| | - Aimee N C Campbell
- Department of Psychiatry, Columbia University Irving Medical Center, Columbia University Medical Center, New York State Psychiatric Institute, New York, New York
| | - John Rotrosen
- Department of Psychiatry, Columbia University Irving Medical Center, New York State Psychiatric Institute, New York, New York
| | - Edward Nunes
- Department of Psychiatry, Columbia University Irving Medical Center, Columbia University Medical Center, New York State Psychiatric Institute, New York, New York
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Hammond CJ, Park G, Kady A, Rathod K, Rahman N, Vidal C, Wenzel K, Fishman M. Sex-based differences in psychiatric symptoms and opioid abstinence during buprenorphine/naloxone treatment in adolescents with opioid use disorders. J Subst Abuse Treat 2021; 133:108495. [PMID: 34218992 DOI: 10.1016/j.jsat.2021.108495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/29/2020] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recent studies indicate that sex-based differences exist in co-occurring psychiatric symptoms and disorders among individuals with opioid use disorders (OUD). Whether these associations are present in adolescent samples and change during OUD treatment is poorly understood. OBJECTIVES In the current study, we examined sex-based differences in psychiatric symptoms and relationships among sex, psychiatric symptoms, and opioid use outcomes in youth with OUD receiving buprenorphine/naloxone (Bup/Nal) and psychosocial treatment. METHODS The study randomly assigned one hundred and fifty-two youth (15-21 years old) diagnosed with OUD to either 12 weeks of treatment with Bup/Nal or up to 2 weeks of Bup/Nal detoxification with both treatment arms receiving weekly drug counseling as part of a multisite clinical trial (NIDA-CTN-0010). We compared psychiatric symptoms, assessed via the Youth Self Report (YSR) at baseline and week 12, across male and female OUD participants. The study used logistic regression models to identify sex and psychiatric symptom variables that were predictors of opioid positive urine (OPU) at week 12. RESULTS Compared to males, females with OUD had higher mean psychiatric symptom scores at baseline across broad-band and narrow-band symptom domains. The study observed significant reductions in psychiatric symptom scores in both males and females during treatment, and by week 12, females only differed from males on anxious-depressive symptom scores. Females, in general, and youth of both sexes presenting to treatment with higher anxious depression scores were less likely to have a week-12 OPU. CONCLUSIONS Clinically significant sex-based differences in psychiatric symptoms are present at baseline among youth with OUD receiving Bup/Nal-assisted treatment and mostly resolve during treatment.
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Affiliation(s)
- Christopher J Hammond
- Division of Child & Adolescent Psychiatry, Department of Psychiatry at Johns Hopkins University School of Medicine, United States of America; Behavioral Pharmacology Research Unit, Department of Psychiatry at Johns Hopkins University School of Medicine, United States of America.
| | - Grace Park
- Division of Child & Adolescent Psychiatry, Department of Psychiatry at Johns Hopkins University School of Medicine, United States of America
| | - Annabel Kady
- Division of Child & Adolescent Psychiatry, Department of Psychiatry at Johns Hopkins University School of Medicine, United States of America
| | - Krutika Rathod
- Division of Child & Adolescent Psychiatry, Department of Psychiatry at Johns Hopkins University School of Medicine, United States of America
| | - Naisa Rahman
- Division of Child & Adolescent Psychiatry, Department of Psychiatry at Johns Hopkins University School of Medicine, United States of America
| | - Carol Vidal
- Division of Child & Adolescent Psychiatry, Department of Psychiatry at Johns Hopkins University School of Medicine, United States of America
| | - Kevin Wenzel
- Mountain Manor Treatment Center, Maryland Treatment Centers, United States of America
| | - Marc Fishman
- Division of Child & Adolescent Psychiatry, Department of Psychiatry at Johns Hopkins University School of Medicine, United States of America; Mountain Manor Treatment Center, Maryland Treatment Centers, United States of America
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Wenzel K, Selby V, Wildberger J, Lavorato L, Thomas J, Fishman M. Choice of extended release medication for OUD in young adults (buprenorphine or naltrexone): A pilot enhancement of the Youth Opioid Recovery Support (YORS) intervention. J Subst Abuse Treat 2021; 125:108306. [PMID: 34016297 DOI: 10.1016/j.jsat.2021.108306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/18/2020] [Accepted: 01/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Youth Opioid Recovery Support (YORS) intervention is a promising approach for the treatment of opioid use disorder (OUD) in young adults that seeks to improve adherence to extended-release medications for OUD (XR-MOUD) and reduce opioid relapse through assertive outreach techniques. YORS was previously tested with individuals seeking extended-release naltrexone (XR-NTX), but has not been tested on individuals pursuing extended-release buprenorphine (XR-BUP). METHODS This pilot study tested the YORS intervention among a group choosing either XR-MOUD compared to historical treatment as usual (H-TAU) and intervention conditions from a previous study. This study also tested feasibility of a stepped care approach using a protocol for transition to standard care. Twenty-two young adults (ages 18-26) with OUD intending to pursue outpatient treatment with XR-NTX (n = 11) or XR-BUP (n = 11) were recruited from inpatient treatment and received 12-24 weeks of the YORS intervention. RESULTS Participants in YORS compared to H-TAU received more outpatient doses at 12 weeks (1.91 vs. 0.40, p < .001) and 24 weeks (3.76 vs. 0.70, p < .001), had lower relapse rates at 12 weeks (36.4% vs.75.0%; p = .012) and 24 weeks(52.9% vs. 95.0%; p = .003), and had greater cumulative relapse-free survival over 24 weeks (HR = 2.65, 95% CI: 1.17-6.02, p < .05). Rates of continuing MOUD in a standard care setting after the intervention ended were extremely poor. Outcomes did not differ by medication choice. CONCLUSIONS These results are consistent with previous findings and demonstrate feasibility and efficacy of YORS with patient choice of medication. The results highlight the need for innovative strategies to sustain positive outcomes and step-down care successfully in these vulnerable young adults.
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Affiliation(s)
- Kevin Wenzel
- Mountain Manor Treatment Center, 3800 Frederick Avenue, Baltimore 21229, MD, USA.
| | - Victoria Selby
- Mountain Manor Treatment Center, 3800 Frederick Avenue, Baltimore 21229, MD, USA; University of Maryland School of Nursing, Baltimore, MD, USA
| | - Jared Wildberger
- Mountain Manor Treatment Center, 3800 Frederick Avenue, Baltimore 21229, MD, USA
| | - Luciana Lavorato
- Mountain Manor Treatment Center, 3800 Frederick Avenue, Baltimore 21229, MD, USA
| | - Julia Thomas
- Mountain Manor Treatment Center, 3800 Frederick Avenue, Baltimore 21229, MD, USA
| | - Marc Fishman
- Mountain Manor Treatment Center, 3800 Frederick Avenue, Baltimore 21229, MD, USA; Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, MD, USA
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26
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Ludwig A, Monico LB, Gryczynski J, Lertch E, Schwartz RP, Fishman M, Dionne R, Mitchell SG. Drug and sexual HIV-risk behaviors among adolescents and young adults with opioid use disorder. J Subst Abuse Treat 2021; 130:108477. [PMID: 34118711 DOI: 10.1016/j.jsat.2021.108477] [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] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/08/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
Opioid use disorder (OUD) among adolescents and young adults (youth) is associated with drug use and sexual HIV-related risk behaviors and opioid overdose. This mixed methods analysis assesses risk behaviors among a sample of 15-21-year-olds (N = 288) who were being treated for OUD in a residential drug treatment program in Baltimore, Maryland. Participants were enrolled in a parent study in which they received either extended-release naltrexone (XR-NTX) or Treatment as Usual (TAU), consisting of outpatient counseling with or without buprenorphine, prior to discharge. At baseline, participants were administered the HIV-Risk Assessment Battery (RAB), and clinical intake records were reviewed to determine participants' history of sexual, physical, or other abuse, as well as parental and partner substance use. A sub-sample of study participants completed semi-structured qualitative interviews (N = 35) at baseline, three-, and six-month follow-up periods. This analysis identified gender (e.g., female IRR = 1.63, CI 1.10-2.42, p = .014), the experience of dependence (e.g., previous detoxification IRR = 1.08, CI 1.01-1.15, p = .033) and withdrawal (e.g., severe withdrawal symptoms IRR = 1.41, CI 1.08-1.84, p = .012), and the role of relationships (e.g., using with partner IRR = 2.45, CI 1.15-5.22, p = .021) as influencing high-risk substance use behaviors. Similarly, high-risk sex was influenced by gender (e.g., female IRR = 1.43, CI 1.28-1.59, p < .001), and the role of relationships (e.g., using with partner IRR = 0.78, CI 0.62-0.98, p = .036). These are key targets for future prevention, treatment, and intervention.
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Affiliation(s)
- Ariel Ludwig
- Friends Research Institute, Inc., 1040 Park Avenue, Suite 103, Baltimore, MD 21201, United States of America.
| | - Laura B Monico
- Friends Research Institute, Inc., 1040 Park Avenue, Suite 103, Baltimore, MD 21201, United States of America
| | - Jan Gryczynski
- Friends Research Institute, Inc., 1040 Park Avenue, Suite 103, Baltimore, MD 21201, United States of America
| | - Elizabeth Lertch
- Friends Research Institute, Inc., 1040 Park Avenue, Suite 103, Baltimore, MD 21201, United States of America.
| | - Robert P Schwartz
- Friends Research Institute, Inc., 1040 Park Avenue, Suite 103, Baltimore, MD 21201, United States of America
| | - Marc Fishman
- Mountain Manor Treatment Center, 3800 Frederick Ave, Baltimore, MD 21229, United States of America
| | - Ross Dionne
- Pacifica Graduate Institute, 249 Lambert Rd., Carpinteria, CA 93013, United States of America
| | - Shannon Gwin Mitchell
- Friends Research Institute, Inc., 1040 Park Avenue, Suite 103, Baltimore, MD 21201, United States of America
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Monico LB, Ludwig A, Lertch E, Dionne R, Fishman M, Schwartz RP, Mitchell SG. Opioid overdose experiences in a sample of US adolescents and young adults: a thematic analysis. Addiction 2021; 116:865-873. [PMID: 32770757 DOI: 10.1111/add.15216] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 04/23/2020] [Revised: 05/20/2020] [Accepted: 07/31/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Opioid overdose deaths among adolescents and young adults have risen sharply in the United States over recent decades. This study aimed to explore the nature of adolescent and young adult perspectives on overdose experiences. DESIGN This study involved thematic analysis of interviews undertaken as part of a mixed-methods, randomized trial of extended release naltrexone (XR-NTX) versus treatment-as-usual (TAU) for adolescents and young adults (aged 15-21 years) with opioid use disorder (OUD). SETTING Participants were recruited during a residential treatment episode at Mountain Manor Treatment Center, in Baltimore, MD, USA. PARTICIPANTS/CASES As part of the qualitative component of this study, 35 adolescents/young adults completed up to three interviews: at baseline, 3 and 6 months after release from residential opioid use disorder treatment. MEASUREMENTS Semi-structured interviews solicited participant experiences with opioid use disorder treatment; their satisfaction with the medications used to treat opioid use disorder; counseling received; current substance use; issues related to treatment retention; their treatment goals; and their future outlook. FINDINGS Four broad themes emerged: (1) adolescents/young adults had difficulty identifying overdoses due to interpreting subjective symptoms and a lack of memory of the event, (2) this sample had difficulty perceiving risk that is misaligned with traditional understandings of overdose intentionality, (3) adolescents/young adults did not interpret personal overdose events as a catalyst for behavior change and (4) this sample experienced a greater impact to behavior change through witnessing an overdose of someone in their social network. CONCLUSIONS The sample of US adolescents and young adults in treatment for opioid use disorder expressed difficulty identifying whether or not they had experienced an overdose, expressed fluctuating intentionality for those events and did not have clear intentions to change their behavior. Witnessing an overdose appeared to be as salient an experience as going through an overdose oneself.
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Affiliation(s)
| | | | | | - Ross Dionne
- Pacifica Graduate Institute, Carpinteria, CA, USA
| | - Marc Fishman
- Mountain Manor Treatment Center, Baltimore, MD, USA
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28
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Hogue A, Bobek M, Levy S, Henderson CE, Fishman M, Becker SJ, Dauber S, Porter N, Wenzel K. Conceptual framework for telehealth strategies to increase family involvement in treatment and recovery for youth opioid use disorder. J Marital Fam Ther 2021; 47:501-514. [PMID: 33760249 PMCID: PMC9830952 DOI: 10.1111/jmft.12499] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 06/12/2023]
Abstract
With opioid use at crisis levels, it is imperative to support youth ages with opioid use disorders (OUD) in taking medication and accessing behavioral services over long periods. This article presents a conceptual framework for telehealth strategies that can be adopted to increase family involvement across a four-stage continuum of youth OUD treatment and recovery: Treatment Preparation, Treatment Initiation, Treatment Stabilization, OUD Recovery. It first identifies provider-delivered tele-interventions that can enhance OUD services in each of the four stages, including family outreach, family engagement, family-focused intervention, and family-focused recovery maintenance. It then introduces several types of direct-to-family tele-supports that can be used to supplement provider-delivered interventions. These include both synchronous tele-supports (remote interactions that occur in real time) such as helplines, peer-to-peer coaching, and online support groups; and asynchronous tele-supports (communications that occur without participants being simultaneously present) such as automated text messaging, self-directed internet-based courses, and digital web support.
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Affiliation(s)
- Aaron Hogue
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, USA
| | - Molly Bobek
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, USA
| | - Sharon Levy
- Adolescent Substance Use and Addiction Program, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Craig E. Henderson
- Department of Psychology, Sam Houston, State University, Huntsville, TX, USA
| | | | - Sara J. Becker
- Center for Alcohol and Addictions, Studies, Brown University School of Public, Health, Providence, RI, USA
| | - Sarah Dauber
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, USA
| | - Nicole Porter
- Family and Adolescent Clinical Technology & Science, Partnership to End Addiction, New York, NY, USA
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29
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Fishman M, Wenzel K, Vo H, Wildberger J, Burgower R. A pilot randomized controlled trial of assertive treatment including family involvement and home delivery of medication for young adults with opioid use disorder. Addiction 2021; 116:548-557. [PMID: 32621368 DOI: 10.1111/add.15181] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 10/07/2019] [Revised: 01/22/2020] [Accepted: 06/29/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Although medications for opioid use disorder (OUD), including extended-release naltrexone (XR-NTX), have demonstrated effectiveness, adherence is often low. We tested the preliminary efficacy of youth opioid recovery support (YORS), a multi-component intervention designed to improve engagement and medication adherence for young adults with OUD. DESIGN Single-site randomized controlled trial with 24-week follow-up. SETTING Community substance use disorder treatment program in Baltimore, MD, USA. PARTICIPANTS Young adults aged 18-26 years enrolled in inpatient/residential OUD treatment intending to pursue outpatient OUD treatment with XR-NTX. Twenty-one participants were randomized to YORS and 20 to treatment as usual (TAU). The analyzed sample was 65.8% male. INTERVENTION AND COMPARATOR Components of YORS include: (1) home delivery of XR-NTX; (2) family engagement; (3) assertive outreach; and (4) contingency management for receipt of XR-NTX doses. The comparator was TAU, which consisted of a standard referral to outpatient care following an inpatient stay. MEASUREMENTS Primary outcomes were number of XR-NTX doses received over 24 weeks and relapse to opioid use (defined as ≥ 10 days of use within 28 days) at 24 weeks. FINDINGS Participants in the YORS condition received more XR-NTX doses [mean = 4.28; standard deviation (SD) = 2.3] compared with those in TAU (mean = 0.70; SD = 1.2), P < 0.01. Participants in the YORS group compared with TAU had lower rates of relapse (61 versus 95%; P < 0.01). Survival analyses revealed group differences on time to relapse with participants in TAU being more likely to relapse sooner compared with participants in the YORS condition [hazard ratio (HR) = 2.72, 95% confidence interval (CI) = 1.26-5.88, P < 0.01]. CONCLUSIONS The youth opioid recovery support intervention for extended-release naltrexone adherence and opioid relapse prevention among young adults with opioid use disorder appeared to improve treatment and relapse outcomes compared with standard treatment.
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Affiliation(s)
- Marc Fishman
- Mountain Manor Treatment Center, Baltimore, MD, USA.,Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin Wenzel
- Mountain Manor Treatment Center, Baltimore, MD, USA
| | - Hoa Vo
- Mountain Manor Treatment Center, Baltimore, MD, USA.,Department of Psychiatry, University of Texas Southwestern, Dallas, TX, USA
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30
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Bennett CL, Nagai S, Bennett AC, Hoque S, Nabhan C, Schoen MW, Hrushesky WJ, Luminari S, Ray P, Yarnold PR, Witherspoon B, Riente J, Bobolts L, Brusk J, Tombleson R, Knopf K, Fishman M, Yang YT, Carson KR, Djulbegovic B, Restaino J, Armitage JO, Sartor OA. The First 2 Years of Biosimilar Epoetin for Cancer and Chemotherapy-Induced Anemia in the U.S.: A Review from the Southern Network on Adverse Reactions. Oncologist 2021; 26:e1418-e1426. [PMID: 33586299 DOI: 10.1002/onco.13713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/05/2021] [Indexed: 11/09/2022] Open
Abstract
Biosimilars are biologic drug products that are highly similar to reference products in analytic features, pharmacokinetics and pharmacodynamics, immunogenicity, safety, and efficacy. Biosimilar epoetin received Food and Drug Administration (FDA) approval in 2018. The manufacturer received an FDA nonapproval letter in 2017, despite receiving a favorable review by FDA's Oncologic Drugs Advisory Committee (ODAC) and an FDA nonapproval letter in 2015 for an earlier formulation. We discuss the 2018 FDA approval, the 2017 FDA ODAC Committee review, and the FDA complete response letters in 2015 and 2017; review concepts of litigation, naming, labeling, substitution, interchangeability, and pharmacovigilance; review European and U.S. oncology experiences with biosimilar epoetin; and review the safety of erythropoiesis-stimulating agents. In 2020, policy statements from AETNA, United Health Care, and Humana indicated that new epoetin oncology starts must be for biosimilar epoetin unless medical need for other epoetins is documented. Empirical studies report that as of 2012, reference epoetin use decreased from 40%-60% of all patients with cancer with chemotherapy-induced anemia to <5% of such patients because of safety concerns. Between 2018 and 2020, biosimilar epoetin use varied, increasing to 81% among one private insurer's patients covered by Medicare whose cancer care is administered with Oncology Analytics and to 41% with the same private insurer's patients with cancer covered by commercial health insurance and administered by the private insurer, to 0% in several Veterans Administration Hospitals, increasing to 100% in one large county hospital in California, and with yet-to-be-reported data from most oncology settings. We conclude that biosimilar epoetin appears to have overcome some barriers since 2015, although current uptake in the U.S. is variable. Pricing and safety considerations for all erythropoiesis-stimulating agents are primary determinants of biosimilar epoetin oncology uptake. IMPLICATIONS FOR PRACTICE: Few oncologists understand substitution and interchangeability of biosimilars with reference drugs. Epoetin biosimilar is new to the market, and physician and patient understanding is limited. The development of epoetin biosimilar is not familiar to oncologists.
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Affiliation(s)
- Charles L Bennett
- Toni Stephenson Lymphoma Center, the Hematologic Malignancies Research Institute, the Beckman Research Institute, of the City of Hope Cancer Center, Duarte, California.,College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | | | - Andrew C Bennett
- College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - Shamia Hoque
- Department of Civil and Environmental Engineering, College of Engineering and Computing, University of South Carolina, Columbia, South Carolina
| | - Chadi Nabhan
- College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - Martin W Schoen
- Saint Louis University School of Medicine, Saint Louis, Missouri
| | | | - Stefano Luminari
- Hematology, AUSL IRCCS Reggio Emilia.,Department CHIMOMO, University of Modena and Reggio Emilia, Regio Emilia, Italy
| | - Paul Ray
- College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - Paul R Yarnold
- College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - Bart Witherspoon
- College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - Josh Riente
- William J Bryan Dorn Veterans Administration Medical Center, Columbia, South Carolina
| | - Laura Bobolts
- Oncology Analytics, Atlanta, Georgia.,College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - John Brusk
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Rebecca Tombleson
- College of Pharmacy, University of South Carolina, Columbia, South Carolina.,College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Kevin Knopf
- College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - Marc Fishman
- College of Pharmacy, University of South Carolina, Columbia, South Carolina.,Oncology Analytics, Atlanta, Georgia
| | - Y Tony Yang
- George Washington University School of Nursing and Milken Institute School of Public Health, Washington, DC
| | - Kenneth R Carson
- The Division of Hematology/Oncology, Department of Medicine, Rush University School of Medicine, Chicago, Illinois
| | - Benjamin Djulbegovic
- The City of Hope, Beckman Research Institute, Department of Computational and Quantitative Medicine, Division of Health Analytics, Evidence-based Medicine & Comparative Effectiveness Research, Duarte, CA
| | - John Restaino
- College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - James O Armitage
- The Department of Medicine, The University of Nebraska School of Medicine, Omaha, Nebraska
| | - Oliver A Sartor
- The Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
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Ludwig A, Monico LB, Lertch E, Schwartz RP, Fishman M, Mitchell SG. Until there's nothing left: Caregiver resource provision to youth with opioid use disorders. Subst Abuse 2021; 42:990-997. [PMID: 33759732 PMCID: PMC9813860 DOI: 10.1080/08897077.2021.1901178] [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] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background and Aims: Despite the considerable literature associating certain characteristics of caregivers and family structures with risks of adolescent/young adult (youth) substance use, there has been little study of the role of caregivers in opioid use disorder (OUD) treatment outcomes. This qualitative study sought to understand and contextualize the factors that influenced the resources caregivers provided their youth after residential treatment. Methods: In order to improve understandings of the role caregivers play both during and after residential OUD treatment, 31 caregivers of youth who were in a residential substance use disorder treatment center were interviewed at baseline, three-months, and six-months following their youth's discharge. Results: This analysis focused on the provision of caregiver resources and identified three key influences - OUD understandings and expectations, relationships with youth, and the emotional toll on caregivers. This has important implications as residential treatment success rates are relatively low among this population. Conclusions: These findings suggest that engagement of caregivers and families in outpatient care following residential treatment could offer an important opportunity for interventions that promote youth recovery.
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Affiliation(s)
- Ariel Ludwig
- Friends Research Institute, Inc, Baltimore, Maryland, USA
| | | | | | | | - Marc Fishman
- Mountain Manor Treatment Center, Baltimore, Maryland, USA
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32
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Bennett CL, Hoque S, Olivieri N, Taylor MA, Aboulafia D, Lubaczewski C, Bennett AC, Vemula J, Schooley B, Witherspoon BJ, Godwin AC, Ray PS, Yarnold PR, Ausdenmoore HC, Fishman M, Herring G, Ventrone A, Aldaco J, Hrushesky WJ, Restaino J, Thomsen HS, Yarnold PR, Marx R, Migliorati C, Ruggiero S, Nabhan C, Carson KR, McKoy JM, Yang YT, Schoen MW, Knopf K, Martin L, Sartor O, Rosen S, Smith WK. Consequences to patients, clinicians, and manufacturers when very serious adverse drug reactions are identified (1997-2019): A qualitative analysis from the Southern Network on Adverse Reactions (SONAR). EClinicalMedicine 2021; 31:100693. [PMID: 33554084 PMCID: PMC7846671 DOI: 10.1016/j.eclinm.2020.100693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/04/2020] [Accepted: 12/04/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Adverse drug/device reactions (ADRs) can result in severe patient harm. We define very serious ADRs as being associated with severe toxicity, as measured on the Common Toxicity Criteria Adverse Events (CTCAE)) scale, following use of drugs or devices with large sales, large financial settlements, and large numbers of injured persons. We report on impacts on patients, clinicians, and manufacturers following very serious ADR reporting. METHODS We reviewed clinician identified very serious ADRs published between 1997 and 2019. Drugs and devices associated with reports of very serious ADRs were identified. Included drugs or devices had market removal discussed at Food and Drug Advisory (FDA) Advisory Committee meetings, were published by clinicians, had sales > $1 billion, were associated with CTCAE Grade 4 or 5 toxicity effects, and had either >$1 billion in settlements or >1,000 injured patients. Data sources included journals, Congressional transcripts, and news reports. We reviewed data on: 1) timing of ADR reports, Boxed warnings, and product withdrawals, and 2) patient, clinician, and manufacturer impacts. Binomial analysis was used to compare sales pre- and post-FDA Advisory Committee meetings. FINDINGS Twenty very serious ADRs involved fifteen drugs and one device. Legal settlements totaled $38.4 billion for 753,900 injured persons. Eleven of 18 clinicians (61%) reported harms, including verbal threats from manufacturer (five) and loss of a faculty position (one). Annual sales decreased 94% from $29.1 billion pre-FDA meeting to $4.9 billion afterwards (p<0.0018). Manufacturers of four drugs paid $1.7 billion total in criminal fines for failing to inform the FDA and physicians about very serious ADRs. Following FDA approval, the median time to ADR reporting was 7.5 years (Interquartile range 3,13 years). Twelve drugs received Box warnings and one drug received a warning (median, 7.5 years following ADR reporting (IQR 5,11 years). Six drugs and 1 device were withdrawn from marketing (median, 5 years after ADR reporting (IQR 4,6 years)). INTERPRETATION Because very serious ADRs impacts are so large, policy makers should consider developing independently funded pharmacovigilance centers of excellence to assist with clinician investigations. FUNDING This work received support from the National Cancer Institute (1R01 CA102713 (CLB), https://www.nih.gov/about-nih/what-we-do/nih-almanac/national-cancer-institute-nci; and two Pilot Project grants from the American Cancer Society's Institutional Grant Award to the University of South Carolina (IRG-13-043-01) https://www.cancer.org/ (SH; BS).
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Affiliation(s)
- Charles L. Bennett
- City of Hope National Medical Center in Duarte, California, United States
- University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
| | - Shamia Hoque
- University of South Carolina College of Engineering and Computing in Columbia, South Carolina, United States
| | | | - Matthew A. Taylor
- University of South Carolina School of Medicine in Columbia, South Carolina, United States
| | - David Aboulafia
- Virginia Mason Medical Center in Seattle, Washington, United States
| | - Courtney Lubaczewski
- University of South Carolina College of Arts and Sciences in Columbia, South Carolina, United States
| | - Andrew C. Bennett
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
| | - Jay Vemula
- University of South Carolina College of Arts and Sciences in Columbia, South Carolina, United States
| | - Benjamin Schooley
- University of South Carolina College of Engineering and Computing in Columbia, South Carolina, United States
| | - Bartlett J. Witherspoon
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
| | - Ashley C Godwin
- University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
| | - Paul S. Ray
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
| | - Paul R. Yarnold
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
| | - Henry C. Ausdenmoore
- City of Hope National Medical Center in Duarte, California, United States
- University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
- University of South Carolina College of Engineering and Computing in Columbia, South Carolina, United States
- University of South Carolina College of Arts and Sciences in Columbia, South Carolina, United States
- University of South Carolina School of Medicine in Columbia, South Carolina, United States
- University of Miami Miller School of Medicine in Miami, Florida, United States
- Uniformed Services University F. Edward Hebert School of Medicine in Bethesda, Maryland, United States
- Tulane University School of Medicine in New Orleans, Louisiana, United States
- Northwestern University Feinberg School of Medicine in Chicago, Illinois, United States
- Rush University School of Medicine in Chicago, Illinois, United States
- Saint Louis University School of Medicine in Saint Louis, Missouri, United States
- University of Copenhagen in Copenhagen, Denmark
- Caris Life Sciences in Chicago, Illinois, United States
- Highland Hospital in Oakland, California, United States
- Virginia Mason Medical Center in Seattle, Washington, United States
- New York Center for Oral and Maxillofacial Surgery in New Hyde Park, New York, United States
- University of Florida in Gainesville, Florida, United States
| | - Marc Fishman
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
| | - Georgne Herring
- University of South Carolina College of Arts and Sciences in Columbia, South Carolina, United States
| | - Anne Ventrone
- University of South Carolina College of Arts and Sciences in Columbia, South Carolina, United States
| | - Juan Aldaco
- City of Hope National Medical Center in Duarte, California, United States
| | - William J. Hrushesky
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
| | - John Restaino
- University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
| | | | - Paul R. Yarnold
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
| | - Robert Marx
- University of Miami Miller School of Medicine in Miami, Florida, United States
| | | | - Salvatore Ruggiero
- New York Center for Oral and Maxillofacial Surgery in New Hyde Park, New York, United States
| | - Chadi Nabhan
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
- Caris Life Sciences in Chicago, Illinois, United States
| | - Kenneth R. Carson
- Rush University School of Medicine in Chicago, Illinois, United States
| | - June M. McKoy
- Northwestern University Feinberg School of Medicine in Chicago, Illinois, United States
| | - Y. Tony Yang
- George Washington University School of Nursing and Milken Institute School of Public Health in Washington, District of Columbia, United States
| | - Martin W. Schoen
- Saint Louis University School of Medicine in Saint Louis, Missouri, United States
| | - Kevin Knopf
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
- Highland Hospital in Oakland, California, United States
| | - Linda Martin
- The SONAR Project of University of South Carolina College of Pharmacy in Columbia, South Carolina, United States
| | - Oliver Sartor
- Tulane University School of Medicine in New Orleans, Louisiana, United States
| | - Steven Rosen
- City of Hope National Medical Center in Duarte, California, United States
| | - William K. Smith
- Uniformed Services University F. Edward Hebert School of Medicine in Bethesda, Maryland, United States
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Fishman M, Wenzel K, Scodes J, Pavlicova M, Lee JD, Rotrosen J, Nunes E. Young Adults Have Worse Outcomes Than Older Adults: Secondary Analysis of a Medication Trial for Opioid Use Disorder. J Adolesc Health 2020; 67:778-785. [PMID: 32873500 PMCID: PMC7683373 DOI: 10.1016/j.jadohealth.2020.07.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/17/2020] [Accepted: 07/23/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Young adults are disproportionately affected by the current opioid crisis. Although medications for opioid use disorder are broadly effective, with reductions in morbidity and mortality, the particular effectiveness of medications for opioid use disorder among young adults is less well understood. METHODS This secondary analysis compared young adults (aged 18-25 years) with older adults (aged ≥26 years) in a large comparative effectiveness trial ("XBOT") that randomized subjects to extended-release naltrexone or sublingual buprenorphine-naloxone for 6 months. Opioid relapse was defined by opioid use over four consecutive weeks or seven consecutive days, using urine testing and self-report. RESULTS Among subjects in the intention-to-treat sample (n = 570, all randomized participants), a main effect of age group was found, with higher relapse rates among young adults (70.3%) compared with older adults (58.2%), with an odds ratio of 1.72 (95% confidence interval = 1.08-2.70), p = .02. In the per-protocol sample (n = 474, only participants who started medication), relapse rates were higher among young adults (66.3%) compared with older adults (50.8%), with an odds ratio of 1.91 (95% confidence interval = 1.19-3.06). Among the intention-to-treat sample, survival analysis revealed a significant time-by-age group interaction (p = .01) with more relapse over time in young adults. No significant interactions between age and medication group were detected. CONCLUSIONS Young adults have increased rates of relapse compared with older adults, perhaps because of vulnerabilities that increase their risk for treatment dropout and medication nonadherence, regardless of medication assignment. These results suggest that specialized, developmentally informed interventions may be needed to improve retention and successful treatment of opioid use disorder among young adults.
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Affiliation(s)
- Marc Fishman
- Mountain Manor Treatment Center/Maryland Treatment Centers, Baltimore, Maryland; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Kevin Wenzel
- Mountain Manor Treatment Center/Maryland Treatment Centers 3800 Frederick Ave, Baltimore, MD 21229 USA,Corresponding Author. Marc Fishman. Phone: +1-410-233-1400. Fax: 410-233-0009
| | - Jennifer Scodes
- New York State Psychiatric Institute Division of Mental Health Data Science 1051 Riverside Dr., NY, NY 10032 USA
| | - Martina Pavlicova
- NYU Grossman School of Medicine Department of Psychiatry 1 Park Ave, NY, NY 10016 USA
| | - Joshua D Lee
- NYU Grossman School of Medicine Department of Psychiatry 1 Park Ave, NY, NY 10016 USA
| | - John Rotrosen
- NYU Grossman School of Medicine Department of Psychiatry 1 Park Ave, NY, NY 10016 USA
| | - Edward Nunes
- Columbia University Mailman School of Public Health, Department of Biostatistics 722 West 168th St. NY, NY 10032 USA
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Hogue A, Becker SJ, Fishman M, Henderson CE, Levy S. Youth OUD treatment during and after COVID: Increasing family involvement across the services continuum. J Subst Abuse Treat 2020; 120:108159. [PMID: 33298299 PMCID: PMC7538390 DOI: 10.1016/j.jsat.2020.108159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 10/04/2020] [Indexed: 12/17/2022]
Abstract
Telehealth innovations in substance use treatment necessitated by the COVID-19 pandemic present a generational opportunity to increase family involvement in medication for opioid use disorders (MOUD) among youth. This commentary describes a conceptual framework for engaging and retaining youth and families across four stages of MOUD services: Preparation, Initiation, Stabilization, Remission & Recovery. Case vignettes illustrate provider-delivered and direct-to-family tele-interventions for augmenting family involvement in each MOUD stage: Family Outreach, Family Engagement, Family Training, Family Recovery Maintenance. COVID-19 has necessitated that substance use treatment services rely on tele-interventions. Youth and their families are difficult to engage and retain in medication for opioid use disorder (MOUD). Tele-interventions can increase family involvement across the youth MOUD services continuum. Case vignettes illustrate provider-delivered and direct-to-family tele-intervention strategies.
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Affiliation(s)
- Aaron Hogue
- Partnership to End Addiction, United States of America.
| | - Sara J Becker
- Center for Alcohol and Addictions Studies at Brown University School of Public Health, United States of America
| | - Marc Fishman
- Maryland Treatment Centers, United States of America
| | | | - Sharon Levy
- Boston Children's Hospital, Harvard Medical School, United States of America
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Wenzel K, Fishman M. Mobile van delivery of extended-release buprenorphine and extended-release naltrexone for youth with OUD: An adaptation to the COVID-19 emergency. J Subst Abuse Treat 2020; 120:108149. [PMID: 33303086 DOI: 10.1016/j.jsat.2020.108149] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/31/2020] [Accepted: 09/21/2020] [Indexed: 02/05/2023]
Abstract
The Youth Opioid Recovery Support (YORS) intervention is a novel treatment for young adults with opioid use disorder (OUD) that uses developmentally informed strategies to reduce barriers to treatment engagement. YORS strategies, such as home delivery of extended-release buprenorphine and extended-release naltrexone for OUD, are designed to increase engagement in treatment, but with the COVID-19 pandemic these strategies increase risk of virus exposure and spread to patients and staff entering homes. We present mobile van service delivery as a potential solution to continuing to provide low-barrier care for young adults with OUD while reducing risk associated with COVID-19. Initial feedback from patients and staff is positive and lays the groundwork to test feasibility and acceptability of this intervention rigorously in future work. Mobile van delivery of extended-release medications for OUD may be a promising treatment modification for mitigating risk of COVID-19, as well as a useful option for ongoing enhancement of care.
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Affiliation(s)
- Kevin Wenzel
- Mountain Manor Treatment Center/Maryland Treatment Centers, 3800 Frederick Ave, Baltimore, MD 21229, USA.
| | - Marc Fishman
- Mountain Manor Treatment Center/Maryland Treatment Centers, 3800 Frederick Ave, Baltimore, MD 21229, USA; Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, 600 N Wolfe St, Baltimore, MD 21205, USA
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Affiliation(s)
- George E Woody
- Substance Use Disorder and Treatment Center, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marc Fishman
- Maryland Treament Centers, Baltimore, Maryland; Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
: In the past decade, a new cohort of adolescents and young adults with opioid use disorders (OUD) has emerged. While medications and psychosocial treatments are available, few adolescents and young adults with OUD can access and remain in treatment. Effective, practical, and scalable treatment paradigms for this young population are needed. Buprenorphine is a medication with unique pharmacological and regulatory characteristics that make it a promising component of adolescent and young adult OUD treatment models. Three randomized controlled trials and multiple observational studies have evaluated the use of buprenorphine to treat this population. However, data from these studies have not been consolidated into an up-to-date summary that may be useful to clinicians. The objective of this narrative review is to inform clinical practice by summarizing results of primary and secondary analyses from randomized controlled clinical trials and observational studies that have evaluated the use of buprenorphine to treat adolescents and young adults with OUD. Based on results from these studies, we encourage the conceptualization of OUD among youth as a chronic medical condition requiring a long-term management strategy. This includes treatment with buprenorphine in conjunction with medication-prescribing protocols that do not necessarily require daily clinic attendance for observed medication adherence. However, more study of treatment delivery models, addressing such issues as medication adherence and intensity requirements, is needed to determine practices that optimize outcomes for youth.
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Affiliation(s)
- Jacob T. Borodovsky
- Center for Technology and Behavioral Health, Dartmouth Geisel School
of Medicine, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice,
Dartmouth Geisel School of Medicine, Lebanon, NH
| | - Sharon Levy
- Adolescent Substance Abuse Program, Boston Children's
Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Marc Fishman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins
University School of Medicine, Baltimore, MD
- Maryland Treatment Centers, Baltimore, MD
| | - Lisa A. Marsch
- Center for Technology and Behavioral Health, Dartmouth Geisel School
of Medicine, Lebanon, NH
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Abroms LC, Fishman M, Vo H, Chiang SC, Somerville V, Rakhmanov L, Ruggiero M, Greenberg D. A Motion-Activated Video Game for Prevention of Substance Use Disorder Relapse in Youth: Pilot Randomized Controlled Trial. JMIR Serious Games 2019; 7:e11716. [PMID: 31124471 PMCID: PMC6552452 DOI: 10.2196/11716] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 11/17/2022] Open
Abstract
Background Body motion-activated video games are a promising strategy for promoting engagement in and adherence to addiction treatment among youth. Objective This pilot randomized trial (N=80) investigated the feasibility of a body motion–activated video game prototype, Recovery Warrior 2.0, targeting relapse prevention in the context of a community inpatient care program for youth. Methods Participants aged 15-25 years were recruited from an inpatient drug treatment program and randomized to receive treatment as usual (control) or game play with treatment as usual (intervention). Assessments were conducted at baseline, prior to discharge, and at 4 and 8 weeks postdischarge. Results The provision of the game play intervention was found to be feasible in the inpatient setting. On an average, participants in the intervention group played for 36.6 minutes and on 3.6 different days. Participants in the intervention group mostly agreed that they would use the refusal skills taught by the game. Participants in the intervention group reported attending more outpatient counseling sessions than those in the control group (10.8 versus 4.8), but the difference was not significant (P=.32). The game had no effect on drug use at 4 or 8 weeks postdischarge, with the exception of a benefit reported at the 4-week follow-up among participants receiving treatment for marijuana addiction (P=.04). Conclusions Preliminary evidence indicates that a motion-activated video game for addiction recovery appears to be feasible and acceptable for youth within the context of inpatient treatment, but not outpatient treatment. With further development, such games hold promise as a tool for the treatment of youth substance use disorder. Trial Registration ClinicalTrials.gov NCT03957798; https://clinicaltrials.gov/show/NCT03957798 (Archived by WebCite at http://www.webcitation.org/78XU6ENB4)
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Affiliation(s)
- Lorien C Abroms
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, DC, United States
| | - Marc Fishman
- Mountain Manor Treatment Center, Baltimore, MD, United States
| | - Hoa Vo
- Mountain Manor Treatment Center, Baltimore, MD, United States
| | - Shawn C Chiang
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, DC, United States
| | - Victoria Somerville
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, DC, United States
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Gordon MS, Vocci FJ, Taxman F, Fishman M, Sharma B, Blue TR, O'Grady KE. A randomized controlled trial of buprenorphine for probationers and parolees: Bridging the gap into treatment. Contemp Clin Trials 2019; 79:21-27. [PMID: 30797042 PMCID: PMC6436986 DOI: 10.1016/j.cct.2019.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/07/2019] [Accepted: 02/19/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Buprenorphine can be effective in a variety of community substance use treatment settings outside of methadone programs, including outpatient programs and medical practices. In these settings, it has been found to be effective in reducing opioid use and retaining patients in treatment. Despite its effectiveness and safety, it is rarely provided to individuals with opioid use disorders in probation and parole settings. METHODS Male and female individuals under probation or parole supervision (N = 320) with histories of opioid use disorder will be enrolled in this randomized controlled trial. Participants will be randomized to one of two study arms: Buprenorphine Bridge Treatment (BBT): Participants will begin buprenorphine using the MedicaSafe dispensing device immediately after an on-site intake at a community supervision office and continue such treatment until they are transitioned to a community program; or Treatment as Usual (TAU): Participants will receive a referral to buprenorphine pharmacotherapy treatment in the community. Treatment outcomes will be: (a) illicit opioid oral saliva drug test results; and (b) treatment adherence (i. entered community based treatment; ii. number of days receiving opioid treatment). RESULTS We describe the background and rationale for the study, its aims, hypotheses, and study design. CONCLUSIONS If shown to increase compliance rates with conditions of probation and parole, buprenorphine treatment co-located at community supervision field offices could have a major impact on delivery of buprenorphine treatment to the criminal justice population. The public health impact of the proposed study would be widespread because this intervention could be implemented throughout areas of the US.
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Affiliation(s)
| | | | - Faye Taxman
- Department of Criminology, Law & Society, George Mason University, Fairfax, VA, USA
| | - Marc Fishman
- Mountain Manor Treatment Center, Baltimore, MD, USA
| | | | - Thomas R Blue
- Department of Criminology, Law & Society, George Mason University, Fairfax, VA, USA
| | - Kevin E O'Grady
- Department of Psychology, University of Maryland, College Park, MD, USA
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Fishman M, Dutcher JP, Clark JI, Alva A, Miletello GP, Curti B, Agarwal N, Hauke R, Mahoney KM, Moon H, Treisman J, Tykodi SS, Daniels G, Morse MA, Wong MKK, Kaufman H, Gregory N, McDermott DF. Overall survival by clinical risk category for high dose interleukin-2 (HD IL-2) treated patients with metastatic renal cell cancer (mRCC): data from the PROCLAIM SM registry. J Immunother Cancer 2019; 7:84. [PMID: 30917871 PMCID: PMC6437874 DOI: 10.1186/s40425-019-0567-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/14/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Prognostic scoring systems are used to estimate the risk of mortality from metastatic renal cell carcinoma (mRCC). Outcomes from different therapies may vary within each risk group. These survival algorithms have been applied to assess outcomes in patients receiving T-cell checkpoint inhibitory immunotherapy and tyrosine kinase inhibitor therapy, but have not been applied extensively to patients receiving high dose interleukin-2 (HD IL-2) immunotherapy. METHODS Survival of 810 mRCC patients treated from 2006 to 2017 with high dose IL-2 (aldesleukin) and enrolled in the PROCLAIMSM registry data base was assessed utilizing the International Metastatic RCC Database Consortium (IMDC) risk criteria. Median follow-up is 23.4 months (mo.) (range 0.2-124 mo.). Subgroup evaluations were performed by separating patients by prior or no prior therapy, IL-2 alone, or therapy subsequent to IL-2. Some patients were in two groups. We will focus on the 356 patients who received IL-2 alone, and evaluate outcome by risk factor categories. RESULTS Among the 810 patients, 721 were treatment-naïve (89%) and 59% were intermediate risk. Overall, of the 249 patients with favorable risk, the median overall survival (OS) is 63.3 mo. and the 2-year OS is 77.6%. Of 480 patients with intermediate risk, median OS is 42.4 mo., 2-year OS 68.2%, and of 81 patients with poor risk, median OS 14 mo., 2-year OS 40.4%. Among those who received IL-2 alone (356 patients), median OS is 64.5, 57.6, and 14 months for favorable, intermediate and poor risk categories respectively. Two year survival among those treated only with HD IL-2 is 73.4, 63.7 and 39.8%, for favorable, intermediate and poor risk categories respectively. CONCLUSIONS Among mRCC patients treated with HD IL-2, all risk groups have median and 2-year survival consistent with recent reports of checkpoint or targeted therapies for mRCC. Favorable and intermediate risk (by IMDC) patients treated with HD IL-2 have longer OS compared with poor risk patients, with most durable OS observed in favorable risk patients. Favorable risk patients treated with HD IL-2 alone have a 2-year OS of 74%. These data continue to support a recommendation for HD IL-2 for patients with mRCC who meet eligibility criteria. TRIAL REGISTRATION PROCLAIM, NCT01415167 was registered with ClinicalTrials.gov on August 11, 2011, and initiated for retrospective data collection until 2006, and prospective data collection ongoing since 2011.
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Affiliation(s)
| | | | - J. I. Clark
- Loyola University Medical Center, Maywood, IL USA
| | - A. Alva
- University of Michigan, Ann Arbor, MI USA
| | | | - B. Curti
- Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, OR USA
| | - Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT USA
| | - R. Hauke
- Nebraska Cancer Specialist, Omaha, NE USA
| | - K. M. Mahoney
- Beth Israel Deaconess Medical Center, Boston, MA USA
| | - H. Moon
- Southern California Permanente Medical Group, Pasadena, CA USA
| | - J. Treisman
- Medical College of Wisconsin, Milwaukee, WI USA
| | - S. S. Tykodi
- University of Washington and Fred Hutchinson Cancer Center, Seattle, WA USA
| | - G. Daniels
- University of California San Diego, San Diego, CA USA
| | | | | | - H. Kaufman
- Massachusetts General Hospital, Boston, MA USA
| | - N. Gregory
- Prometheus Laboratories, San Diego, CA USA
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Ryan S, Pirner M, Clinch T, Fishman M. 8 A Double-Blind, Placebo-Controlled Trial of Lofexidine for Opioid Withdrawal Syndrome. Ann Emerg Med 2018. [DOI: 10.1016/j.annemergmed.2018.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lee JD, Nunes EV, Novo P, Bachrach K, Bailey GL, Bhatt S, Farkas S, Fishman M, Gauthier P, Hodgkins CC, King J, Lindblad R, Liu D, Matthews AG, May J, Peavy KM, Ross S, Salazar D, Schkolnik P, Shmueli-Blumberg D, Stablein D, Subramaniam G, Rotrosen J. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial. Lancet 2018; 391:309-318. [PMID: 29150198 PMCID: PMC5806119 DOI: 10.1016/s0140-6736(17)32812-x] [Citation(s) in RCA: 440] [Impact Index Per Article: 73.3] [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] [Received: 09/22/2017] [Revised: 10/20/2017] [Accepted: 10/24/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Extended-release naltrexone (XR-NTX), an opioid antagonist, and sublingual buprenorphine-naloxone (BUP-NX), a partial opioid agonist, are pharmacologically and conceptually distinct interventions to prevent opioid relapse. We aimed to estimate the difference in opioid relapse-free survival between XR-NTX and BUP-NX. METHODS We initiated this 24 week, open-label, randomised controlled, comparative effectiveness trial at eight US community-based inpatient services and followed up participants as outpatients. Participants were 18 years or older, had Diagnostic and Statistical Manual of Mental Disorders-5 opioid use disorder, and had used non-prescribed opioids in the past 30 days. We stratified participants by treatment site and opioid use severity and used a web-based permuted block design with random equally weighted block sizes of four and six for randomisation (1:1) to receive XR-NTX or BUP-NX. XR-NTX was monthly intramuscular injections (Vivitrol; Alkermes) and BUP-NX was daily self-administered buprenorphine-naloxone sublingual film (Suboxone; Indivior). The primary outcome was opioid relapse-free survival during 24 weeks of outpatient treatment. Relapse was 4 consecutive weeks of any non-study opioid use by urine toxicology or self-report, or 7 consecutive days of self-reported use. This trial is registered with ClinicalTrials.gov, NCT02032433. FINDINGS Between Jan 30, 2014, and May 25, 2016, we randomly assigned 570 participants to receive XR-NTX (n=283) or BUP-NX (n=287). The last follow-up visit was Jan 31, 2017. As expected, XR-NTX had a substantial induction hurdle: fewer participants successfully initiated XR-NTX (204 [72%] of 283) than BUP-NX (270 [94%] of 287; p<0·0001). Among all participants who were randomly assigned (intention-to-treat population, n=570) 24 week relapse events were greater for XR-NTX (185 [65%] of 283) than for BUP-NX (163 [57%] of 287; hazard ratio [HR] 1·36, 95% CI 1·10-1·68), most or all of this difference accounted for by early relapse in nearly all (70 [89%] of 79) XR-NTX induction failures. Among participants successfully inducted (per-protocol population, n=474), 24 week relapse events were similar across study groups (p=0·44). Opioid-negative urine samples (p<0·0001) and opioid-abstinent days (p<0·0001) favoured BUP-NX compared with XR-NTX among the intention-to-treat population, but were similar across study groups among the per-protocol population. Self-reported opioid craving was initially less with XR-NTX than with BUP-NX (p=0·0012), then converged by week 24 (p=0·20). With the exception of mild-to-moderate XR-NTX injection site reactions, treatment-emergent adverse events including overdose did not differ between treatment groups. Five fatal overdoses occurred (two in the XR-NTX group and three in the BUP-NX group). INTERPRETATION In this population it is more difficult to initiate patients to XR-NTX than BUP-NX, and this negatively affected overall relapse. However, once initiated, both medications were equally safe and effective. Future work should focus on facilitating induction to XR-NTX and on improving treatment retention for both medications. FUNDING NIDA Clinical Trials Network.
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Affiliation(s)
- Joshua D Lee
- Department of Population Health, New York University School of Medicine, New York, NY, USA.
| | - Edward V Nunes
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, New York, NY, USA
| | - Patricia Novo
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | | | - Genie L Bailey
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence RI, USA; Stanley Street Treatment and Resources, Fall River, MA, USA
| | - Snehal Bhatt
- Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Sarah Farkas
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Marc Fishman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Maryland Treatment Centers, Baltimore, MD, USA
| | - Phoebe Gauthier
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | | | | | | | - David Liu
- National Institute on Drug Abuse, Rockville, MD, USA
| | | | | | | | - Stephen Ross
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | | | | | | | | | | | - John Rotrosen
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
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Abstract
Deaths due to prescription and illicit opioid overdose have been rising at an alarming rate, particularly in the USA. Although naloxone injection is a safe and effective treatment for opioid overdose, it is frequently unavailable in a timely manner due to legal and practical restrictions on its use by laypeople. As a result, an effort spanning decades has resulted in the development of strategies to make naloxone available for layperson or "take-home" use. This has included the development of naloxone formulations that are easier to administer for nonmedical users, such as intranasal and autoinjector intramuscular delivery systems, efforts to distribute naloxone to potentially high-impact categories of nonmedical users, as well as efforts to reduce regulatory barriers to more widespread distribution and use. Here we review the historical and current literature on the efficacy and safety of naloxone for use by nonmedical persons, provide an evidence-based discussion of the controversies regarding the safety and efficacy of different formulations of take-home naloxone, and assess the status of current efforts to increase its public distribution. Take-home naloxone is safe and effective for the treatment of opioid overdose when administered by laypeople in a community setting, shortening the time to reversal of opioid toxicity and reducing opioid-related deaths. Complementary strategies have together shown promise for increased dissemination of take-home naloxone, including 1) provision of education and training; 2) distribution to critical populations such as persons with opioid addiction, family members, and first responders; 3) reduction of prescribing barriers to access; and 4) reduction of legal recrimination fears as barriers to use. Although there has been considerable progress in decreasing the regulatory and legal barriers to effective implementation of community naloxone programs, significant barriers still exist, and much work remains to be done to integrate these programs into efforts to provide effective treatment of opioid use disorders.
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Affiliation(s)
- Christa R Lewis
- Maryland Treatment Centers, Baltimore, MD, USA.,Department of Psychology, Towson University, Towson, MD, USA
| | - Hoa T Vo
- Maryland Treatment Centers, Baltimore, MD, USA
| | - Marc Fishman
- Maryland Treatment Centers, Baltimore, MD, USA.,Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Abstract
BACKGROUND Many youth initiate opioid misuse with prescription opioids and transition over time to more severe substance-using behaviors, including injection. Trait mindfulness is a potentially protective factor. OBJECTIVES This is a cross-sectional study characterizing a sample of opioid-using youth by level of mindfulness and examines the potential effect modification of emotion regulation on the relationship between mindfulness and progression to injection opioid use. METHODS A convenience sample of 112 youth (ages 14-24) was recruited during an episode of inpatient detoxification and residential treatment for opioid use disorders. We examined emotion regulation (Difficulties in Emotion Regulation Scale), mindfulness (Child Acceptance and Mindfulness Measure), and opioid use. We completed multivariable regressions stratified by degree of emotion regulation looking at relationship of mindfulness on time to injection use from age of first prescription opioid. RESULTS Youth had difficulties in emotion regulation (m = 104.2; SD = 2.41) and low mindfulness (m = 19.1;SD = 0.59). While we found overall that mindfulness was associated with time to progression to injection opioid use, there was significant effect modification. Among youth with high levels of difficulty in emotion regulation, those with high mindfulness trait had quicker progressions to injection (-1.31 years; p =.003). In contrast, youth with normal emotion regulation and high mindfulness trait had a slower progression to injection (1.67 years; p =.041). Conclusion/Importance: Our study showed a majority of youth presenting with opioid use disorders have impairments in emotion regulation and deficits in trait mindfulness. The relationship between mindfulness and opioid use is impacted by emotion regulation capacity. More research is needed to understand the various facets of mindfulness and how they interact with emotion regulation in youth.
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Affiliation(s)
- J Deanna Wilson
- a Department of General Pediatrics and Adolescent Medicine , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
| | - Hoa Vo
- b Mountain Manor Treatment Center , Baltimore , Maryland , USA
| | - Pamela Matson
- a Department of General Pediatrics and Adolescent Medicine , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
| | - Hoover Adger
- a Department of General Pediatrics and Adolescent Medicine , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
| | | | - Marc Fishman
- b Mountain Manor Treatment Center , Baltimore , Maryland , USA.,c Department of Psychiatry , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
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Nunes EV, Lee JD, Sisti D, Segal A, Caplan A, Fishman M, Bailey G, Brigham G, Novo P, Farkas S, Rotrosen J. Ethical and clinical safety considerations in the design of an effectiveness trial: A comparison of buprenorphine versus naltrexone treatment for opioid dependence. Contemp Clin Trials 2016; 51:34-43. [PMID: 27687743 PMCID: PMC5466164 DOI: 10.1016/j.cct.2016.09.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/12/2016] [Accepted: 09/25/2016] [Indexed: 10/20/2022]
Abstract
We examine ethical challenges encountered in the design of an effectiveness trial (CTN-0051; X:BOT), comparing sublingual buprenorphine-naloxone (BUP-NX), an established treatment for opioid dependence, to the newer extended-release injectable naltrexone (XR-NTX). Ethical issues surrounded: 1) known poor effectiveness of one possible, commonly used treatment as usual control condition-detoxification followed by counseling without medication; 2) the role of patients' preferences for treatments, given that treatments were clinically approved and available to the population; 3) differences between the optimal "usual treatment" clinical settings for different treatments making it challenging to design a fair comparison; 4) vested interest groups favoring different treatments exerting potential influence on the design process; 5) potentially vulnerable populations of substance users and prisoners; 6) potential therapeutic misconception in the implementation of safety procedures; and 7) high cost of a large trial limiting questions that could be addressed. We examine how the design features underlying these ethical issues are characteristic of effectiveness trials, which are often large trials that compare treatments with varying degrees of existing effectiveness data and familiarity to patients and clinicians, in community-based treatment settings, with minimal exclusion criteria that could involve vulnerable populations. Hence, investigators designing effectiveness trials may wish to remain alert to the possibility of similar ethical issues.
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Affiliation(s)
- Edward V Nunes
- Columbia University Medical Center, New York State Psychiatric Institute, United States.
| | - Joshua D Lee
- NYU School of Medicine, Department of Population Health, United States
| | - Dominic Sisti
- Perelman School of Medicine, University of Pennsylvania, United States
| | - Andrea Segal
- Perelman School of Medicine, University of Pennsylvania, United States
| | - Arthur Caplan
- NYU School of Medicine, Division of Medical Ethics, United States
| | - Marc Fishman
- Johns Hopkins University School of Medicine, Mountain Manor Treatment Program, United States
| | - Genie Bailey
- Warren Alpert Medical School of Brown University, Stanley Street Treatment and Resources, United States
| | | | - Patricia Novo
- NYU School of Medicine, Department of Psychiatry, United States
| | - Sarah Farkas
- NYU School of Medicine, Department of Psychiatry, United States
| | - John Rotrosen
- NYU School of Medicine, Department of Psychiatry, United States
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Lee JD, Nunes EV, Mpa PN, Bailey GL, Brigham GS, Cohen AJ, Fishman M, Ling W, Lindblad R, Shmueli-Blumberg D, Stablein D, May J, Salazar D, Liu D, Rotrosen J. NIDA Clinical Trials Network CTN-0051, Extended-Release Naltrexone vs. Buprenorphine for Opioid Treatment (X:BOT): Study design and rationale. Contemp Clin Trials 2016; 50:253-64. [PMID: 27521809 DOI: 10.1016/j.cct.2016.08.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/26/2016] [Accepted: 08/09/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION For opioid-dependent patients in the US and elsewhere, detoxification and counseling-only aftercare are treatment mainstays. Long-term abstinence is rarely achieved; many patients relapse and overdose after detoxification. Methadone, buprenorphine-naloxone (BUP-NX) and extended-release naltrexone (XR-NTX) can prevent opioid relapse but are underutilized. This study is intended to develop an evidence-base to help patients and providers make informed choices and to foster wider adoption of relapse-prevention pharmacotherapies. METHODS The National Institute on Drug Abuse's Clinical Trials Network (CTN) study CTN-0051, X:BOT, is a comparative effectiveness study of treatment for 24weeks with XR-NTX, an opioid antagonist, versus BUP-NX, a high affinity partial opioid agonist, for opioid dependent patients initiating treatment at 8 short-term residential (detoxification) units and continuing care as outpatients. Up to 600 participants are randomized (1:1) to XR-NTX or BUP-NX. RESULTS The primary outcome is time to opioid relapse (i.e., loss of persistent abstinence) across the 24-week treatment phase. Differences between arms in the distribution of time-to-relapse will be compared (construction of the asymptotic 95% CI for the hazard ratio of the difference between arms). Secondary outcomes include proportions retained in treatment, rates of opioid abstinence, adverse events, cigarette, alcohol, and other drug use, and HIV risk behaviors; opioid cravings, quality of life, cognitive function, genetic moderators, and cost effectiveness. CONCLUSIONS XR-NTX and BUP-NX differ considerably in their characteristics and clinical management; no studies to date have compared XR-NTX with buprenorphine maintenance. Study design choices and compromises inherent to a comparative effectiveness trial of distinct treatment regimens are reviewed. CLINICAL TRIAL REGISTRATION NCT02032433.
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Affiliation(s)
- Joshua D Lee
- New York University School of Medicine, New York, NY, United States.
| | - Edward V Nunes
- New York State Psychiatric Institute, Columbia University Medical Center, New York, NY, United States
| | | | - Genie L Bailey
- Warren Alpert Medical School, Brown University, Providence, RI, United States; Stanley Street Treatment & Resources, Fall River, MA, United States
| | | | - Allan J Cohen
- Bay Area Addiction Research & Treatment, San Francisco, CA, United States
| | - Marc Fishman
- Mountain Manor Treatment Center, Baltimore, MD, United States
| | - Walter Ling
- UCLA Integrated Substance Abuse Program, Los Angeles, CA, United States
| | | | | | - Don Stablein
- The Emmes Corporation, Rockville, MD, United States
| | - Jeanine May
- The Emmes Corporation, Rockville, MD, United States
| | | | - David Liu
- National Institute on Drug Abuse, Rockville, MD, United States
| | - John Rotrosen
- New York University School of Medicine, New York, NY, United States
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Abstract
Opioid use and addiction in adolescents and young adults is a health problem of epidemic proportions, with devastating consequences for youth and their families. Opioid overdose is a life-threatening emergency that should be treated with naloxone, and respiratory support if necessary. Overdose should always be an opportunity to initiate addiction treatment. Detoxification is often a necessary, but never sufficient, component of treatment for OUDs. Treatment for OUDs is effective but treatment capacity is alarmingly limited and under-developed. Emerging consensus supports the incorporation of relapse prevention medications such as buprenorphine and extended release naltrexone into comprehensive psychosocial treatment including counseling and family involvement.
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Affiliation(s)
| | - Ann Bruner
- Mountain Manor Treatment Center, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | | | - Marc Fishman
- Mountain Manor Treatment Center, Baltimore, MD, USA; Department of Psychiatry, Johns Hopkins University, Baltimore, MD, USA.
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Lee JD, Friedmann PD, Kinlock TW, Nunes EV, Boney TY, Hoskinson RA, Wilson D, McDonald R, Rotrosen J, Gourevitch MN, Gordon M, Fishman M, Chen DT, Bonnie RJ, Cornish JW, Murphy SM, O'Brien CP. Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders. N Engl J Med 2016; 374:1232-42. [PMID: 27028913 PMCID: PMC5454800 DOI: 10.1056/nejmoa1505409] [Citation(s) in RCA: 212] [Impact Index Per Article: 26.5] [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: 11/19/2022]
Abstract
BACKGROUND Extended-release naltrexone, a sustained-release monthly injectable formulation of the full mu-opioid receptor antagonist, is effective for the prevention of relapse to opioid dependence. Data supporting its effectiveness in U.S. criminal justice populations are limited. METHODS In this five-site, open-label, randomized trial, we compared a 24-week course of extended-release naltrexone (Vivitrol) with usual treatment, consisting of brief counseling and referrals for community treatment programs, for the prevention of opioid relapse among adult criminal justice offenders (i.e., persons involved in the U.S. criminal justice system) who had a history of opioid dependence and a preference for opioid-free rather than opioid maintenance treatments and who were abstinent from opioids at the time of randomization. The primary outcome was the time to an opioid-relapse event, which was defined as 10 or more days of opioid use in a 28-day period as assessed by self-report or by testing of urine samples obtained every 2 weeks; a positive or missing sample was computed as 5 days of opioid use. Post-treatment follow-up occurred at weeks 27, 52, and 78. RESULTS A total of 153 participants were assigned to extended-release naltrexone and 155 to usual treatment. During the 24-week treatment phase, participants assigned to extended-release naltrexone had a longer median time to relapse than did those assigned to usual treatment (10.5 vs. 5.0 weeks, P<0.001; hazard ratio, 0.49; 95% confidence interval [CI], 0.36 to 0.68), a lower rate of relapse (43% vs. 64% of participants, P<0.001; odds ratio, 0.43; 95% CI, 0.28 to 0.65), and a higher rate of opioid-negative urine samples (74% vs. 56%, P<0.001; odds ratio, 2.30; 95% CI, 1.48 to 3.54). At week 78 (approximately 1 year after the end of the treatment phase), rates of opioid-negative urine samples were equal (46% in each group, P=0.91). The rates of other prespecified secondary outcome measures--self-reported cocaine, alcohol, and intravenous drug use, unsafe sex, and reincarceration--were not significantly lower with extended-release naltrexone than with usual treatment. Over the total 78 weeks observed, there were no overdose events in the extended-release naltrexone group and seven in the usual-treatment group (P=0.02). CONCLUSIONS In this trial involving criminal justice offenders, extended-release naltrexone was associated with a rate of opioid relapse that was lower than that with usual treatment. Opioid-use prevention effects waned after treatment discontinuation. (Funded by the National Institute on Drug Abuse; ClinicalTrials.gov number, NCT00781898.).
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Affiliation(s)
- Joshua D Lee
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Peter D Friedmann
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Timothy W Kinlock
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Edward V Nunes
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Tamara Y Boney
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Randall A Hoskinson
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Donna Wilson
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Ryan McDonald
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - John Rotrosen
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Marc N Gourevitch
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Michael Gordon
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Marc Fishman
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Donna T Chen
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Richard J Bonnie
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - James W Cornish
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Sean M Murphy
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Charles P O'Brien
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
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49
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Abstract
BACKGROUND Despite the well-known effectiveness and widespread use of relapse prevention medications such as extended release naltrexone (XR-NTX) and buprenorphine for opioid addiction in adults, less is known about their use in younger populations. METHODS This was a naturalistic study using retrospective chart review of N = 56 serial admissions into a specialty community treatment program that featured the use of relapse prevention medications for young adults (19-26 years old) with opioid use disorders. Treatment outcomes over 24 weeks included retention and weekly opioid-negative urine tests. RESULTS Patients were of mean age 23.1, 70% male, 86% Caucasian, 82% with history of injection heroin use, and treated with either buprenorphine (77%) or XR-NTX (23%). The mean number of XR-NTX doses received was 4.1. Retention was approximately 65% at 12 weeks and 40% at 24 weeks, and rates of opioid-negative urine were 50% at 12 weeks and 39% at 24 weeks, with missing samples imputed as positive. There were no statistically significant differences in retention (t = 1.87, P = .06) or in rates of weekly opioid-negative urine tests (t = 1.96, P = .06) between medication groups, over the course of 24 weeks. The XR-NTX group had higher rates of weekly negative urine drug tests for other nonopioid substances (t = 2.83, P < .05) compared with the buprenorphine group. Males were retained in treatment longer and had higher rates of opioid-negative weeks compared with females. CONCLUSIONS These results suggest that relapse prevention medications including both buprenorphine and XR-NTX can be effectively incorporated into standard community treatment for opioid addiction in young adults with good results. Specialty programming focused on opioid addiction in young adults may provide a promising model for further treatment development.
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Affiliation(s)
- Hoa T Vo
- a Maryland Treatment Centers , Baltimore , Maryland , USA
| | - Erika Robbins
- a Maryland Treatment Centers , Baltimore , Maryland , USA
| | | | - Debra Lezama
- a Maryland Treatment Centers , Baltimore , Maryland , USA
| | - Marc Fishman
- a Maryland Treatment Centers , Baltimore , Maryland , USA.,b Johns Hopkins School of Medicine , Baltimore , Maryland , USA
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50
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Abstract
BACKGROUND Cannabis and opioid use are associated with cognitive impairment, whether preexisting or substance-induced, but there have been few substance-specific assessments of cognitive functioning in adolescent substance users. Working memory impairment may be particularly important, as it has been linked to poorer performance in substance abuse treatment. METHODS Working memory (Wechsler Intelligence Scale for Children-IV or Adult Intelligence Scale-IV) and baseline substance use were assessed in 42 youth (mean age = 17.9 years, SD = 1.3, range: 16-20; 65% Caucasian, 30% female) 1-2 weeks after admission to residential treatment with supervised abstinence, 19 for primary cannabis dependence and 23 for primary opioid dependence. RESULTS There were substantial deficits in working memory in both groups, with significant differences (P < .001) between the opioid (M = 39.1th%ile, SD = 25.6) and cannabis (M = 16.3th%ile, SD = 13.6) groups. The primary opioid group had high rates of cannabis use, with no significant difference in past-month days of cannabis use from the primary cannabis group. The opioid group was older and had completed more years of formal education. Seventy-nine percent of the cannabis group had public health care coverage (mostly Medicaid), compared with 24% of the opioid sample. CONCLUSIONS Working memory impairment was substantial in treatment-seeking youth with primary cannabis and opioid dependence (the latter actually having comparable rates of cannabis use), and significantly more pronounced in the primary cannabis-dependent group. Without an assessment of working memory prior to substance exposure, the differential contributions of substance-induced vs. preexisting impairment are unclear. Lower scores in the cannabis group may reflect lower socioeconomic status (SES), which is typically correlated with cognitive performance. These findings highlight underrecognized cognitive impairment in youth with SUDs, especially inner-city cannabis-dependent youth. Modification of treatments to account for cognitive capacity and/or cognitive remediation interventions may be indicated to improve treatment outcomes.
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Affiliation(s)
- Hoa T Vo
- a Mountain Manor Treatment Center , Baltimore , Maryland , USA
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