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Babbel DM, Liu P, Chen DR, Vaughn VM, Zickmund S, Bloomquist K, Zickmund T, Howell EF, Johnson SA. Inpatient opioid withdrawal: a qualitative study of the patient perspective. Intern Emerg Med 2024:10.1007/s11739-024-03604-9. [PMID: 38642310 DOI: 10.1007/s11739-024-03604-9] [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] [Received: 09/27/2023] [Accepted: 04/02/2024] [Indexed: 04/22/2024]
Abstract
Opioid withdrawal is common among hospitalized patients. Those with substance use disorders exhibit higher rates of patient-directed discharge. The literature lacks information regarding the patient perspective on opioid withdrawal in the hospital setting. In this study, we aimed to capture the patient-reported experience of opioid withdrawal during hospitalization and its impact on the desire to continue treatment for opioid use disorder after discharge. We performed a single-center qualitative study involving semi-structured interviews of hospitalized patients with opioid use disorder (OUD) experiencing opioid withdrawal. Investigators conducted in-person interviews utilizing a combination of open-ended and dichotomous questions. Interview transcripts were then analyzed with open coding for emergent themes. Nineteen interviews were performed. All participants were linked to either buprenorphine (79%) or methadone (21%) at discharge. Eight of nineteen patients (42%) reported a patient-directed discharge during prior hospitalizations. Themes identified from the interviews included: (1) opioid withdrawal was well-managed in the hospital; (2) patients appreciated receiving medication for opioid use disorder (MOUD) for withdrawal symptoms; (3) patients valued and felt cared for by healthcare providers; and (4) most patients had plans to follow-up for opioid use disorder treatment after hospitalization. In this population with historically high rates of patient-directed discharge, patients reported having a positive experience with opioid withdrawal management during hospitalization. Amongst our hospitalized patients, we observed several different individualized MOUD induction strategies. All participants were offered MOUD at discharge and most planned to follow-up for further treatment.
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Affiliation(s)
- Danielle M Babbel
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA.
| | - Patricia Liu
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health and Science University, Portland, OR, USA
| | - David R Chen
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Susan Zickmund
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Healthcare System, University of Utah, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kennedi Bloomquist
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Tobias Zickmund
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elizabeth F Howell
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Stacy A Johnson
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA
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Chow JJ, Pitts KM, Chabot JM, Ito R, Shaham Y. A rat model of operant negative reinforcement in opioid-dependent males and females. Psychopharmacology (Berl) 2024:10.1007/s00213-024-06594-w. [PMID: 38642101 DOI: 10.1007/s00213-024-06594-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/14/2024] [Indexed: 04/22/2024]
Abstract
RATIONALE AND OBJECTIVE Avoidance of opioid withdrawal plays a key role in human opioid addiction. Here, we present a procedure for studying operant negative reinforcement in rats that was inspired by primate procedures where opioid-dependent subjects lever-press to prevent naloxone infusions. METHODS In Experiment 1, we trained rats (n = 30, 15 females) to lever-press to escape and then avoid mild footshocks (0.13-0.27 mA) for 35 days (30 trials/d). Next, we catheterized them and implanted minipumps containing methadone (10 mg/kg/day) or saline. We then paired (4 times, single session) a light cue (20-s) with a naloxone infusion (20 µg/kg, i.v) that precipitated opioid withdrawal. Next, we trained the rats to escape naloxone injections for 10 days (30 trials/d). Each trial started with the onset of the opioid-withdrawal cue. After 20-s, the lever extended, and an infusion of naloxone (1 to 2.2 µg/kg/infusion) began; a lever-press during an 11-s window terminated the withdrawal-paired cue and the infusion. In Experiment 2, we trained rats (n = 34, 17 females) on the same procedure but decreased the footshock escape/avoidance training to 20 days. RESULTS All rats learned to lever-press to escape or avoid mild footshocks. In both experiments, a subset, 56% (10/18) and 33% (8/24) of methadone-dependent rats learned to lever-press to escape naloxone infusions. CONCLUSIONS We introduce an operant negative reinforcement procedure where a subset of opioid-dependent rats learned to lever-press to escape withdrawal-inducing naloxone infusions. The procedure can be used to study mechanisms of individual differences in opioid negative reinforcement-related behaviors in opioid-dependent rats.
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Affiliation(s)
| | - Kayla M Pitts
- Intramural Research Program, NIDA, NIH, Baltimore, USA
| | | | - Rutsuko Ito
- Department of Psychology, University of Toronto Scarborough, Toronto, ON, Canada
| | - Yavin Shaham
- Intramural Research Program, NIDA, NIH, Baltimore, USA.
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Jones BLH, Geier M, Neuhaus J, Coffin PO, Snyder HR, Soran CS, Knight KR, Suen LW. Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study. Harm Reduct J 2024; 21:80. [PMID: 38594721 PMCID: PMC11005253 DOI: 10.1186/s12954-024-00998-9] [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: 01/03/2024] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients. METHODS We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics. RESULTS There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation. CONCLUSIONS Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients' withdrawal experiences.
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Affiliation(s)
- Benjamin L H Jones
- Medical Student Center, UCSF School of Medicine, 533 Parnassus Avenue, S-245, San Francisco, CA, 94143, USA.
| | - Michelle Geier
- San Francisco Department of Public Health, 101 Grove Street, San Francisco, CA, 94102, USA
| | - John Neuhaus
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, 2nd Floor, San Francisco, CA, 94158, USA
| | - Phillip O Coffin
- San Francisco Department of Public Health, 101 Grove Street, San Francisco, CA, 94102, USA
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Hannah R Snyder
- Department of Family and Community Medicine, University of California San Francisco, 995 Potrero Avenue, San Francisco, CA, 94110, USA
| | - Christine S Soran
- Division of General Internal Medicine, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- Division of Substance Abuse and Addiction Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
| | - Kelly R Knight
- Department of Humanities and Social Sciences, University of California San Francisco, 490 Illinois Street, 7th Floor, San Francisco, CA, 94143, USA
| | - Leslie W Suen
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
- Division of General Internal Medicine, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- Division of Substance Abuse and Addiction Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
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Cañas CA, Posso-Osorio I, Rivera-Londoño R, Bolaños JD, Granados AM. Severe cerebral edema related to oral methadone: A case report and literature review. Heliyon 2024; 10:e26111. [PMID: 38390136 PMCID: PMC10881884 DOI: 10.1016/j.heliyon.2024.e26111] [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: 08/14/2023] [Revised: 01/13/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction Opioids are widely used for pain management, and increased intracranial pressure (ICP) has been evidenced in some cases. We reported a patient with severe cerebral edema after initiating methadone and its complete resolution upon discontinuing the medication. Additionally, a review of the literature is made. Case report A 53-year-old woman patient with a history of systemic lupus erythematosus developed mechanic chronic lower back pain, refractory to conventional treatments. She presented improvement with oxycodone. She withdrew this medication due to a lack of supplies in her country (Colombia) and showed withdrawal symptoms. She consulted the emergency department, where oral methadone was started and symptom control was achieved. Three days after admission, she presented intense headaches and emesis. A brain CT scan was performed in which severe cerebral edema was appreciated. Methadone was discontinued, and neurological symptoms quickly disappeared. A follow-up brain CT scan was performed later, finding full resolution of the edema. Conclusion A case of severe cerebral edema associated with the initiation of oral methadone and its rapid resolution without neurological sequelae after its withdrawal is presented, clinicians must be attentive to this adverse event.
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Affiliation(s)
- Carlos A Cañas
- Universidad Icesi, CIRAT: Research Center in Rheumatology, Autoimmunity and Translational Medicine, Valle del Cauca, Cali, Colombia
- Fundación Valle del Lili, Rheumatology Unit, Valle del Cauca, Cra. 98 No. 18-49, Cali, 760032, Colombia
| | - Ivan Posso-Osorio
- Fundación Valle del Lili, Rheumatology Unit, Valle del Cauca, Cra. 98 No. 18-49, Cali, 760032, Colombia
- Universidad Icesi, Faculty of Health Sciences, Valle del Cauca, Cali, Colombia
| | | | - Juan D Bolaños
- Fundación Valle del Lili, Clinical Research Center, Cali, 760032, Colombia
| | - Ana M Granados
- Fundación Valle del Lili, Radiology Unit, Valle del Cauca, Cra. 98 No. 18-49, Cali, 760032, Colombia
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Kaufman MJ, Meloni EG, Qrareya AN, Paronis CA, Bogin V. Effects of inhaled low-concentration xenon gas on naltrexone-precipitated withdrawal symptoms in morphine-dependent mice. Drug Alcohol Depend 2024; 255:110967. [PMID: 38150894 PMCID: PMC10841182 DOI: 10.1016/j.drugalcdep.2023.110967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Opioid withdrawal symptoms (OWS) are highly aversive and prompt unprescribed opioid use, which increases morbidity, mortality, and, among individuals being treated for opioid use disorder (OUD), recurrence. OWS are driven by sympathetic nervous system (SNS) hyperactivity that occurs when blood opioid levels wane. We tested whether brief inhalation of xenon gas, which inhibits SNS activity and is used clinically for anesthesia and diagnostic imaging, attenuates naltrexone-precipitated withdrawal-like signs in morphine-dependent mice. METHODS Adult CD-1 mice were implanted with morphine sulfate-loaded (60 mg/ml) minipumps and maintained for 6 days to establish morphine dependence. On day 7, mice were given subcutaneous naltrexone (0.3 mg/kg) and placed in a sealed exposure chamber containing either 21% oxygen/balance nitrogen (controls) or 21% oxygen/added xenon peaking at 30%/balance nitrogen. After 10 minutes, mice were transferred to observation chambers and videorecorded for 45 minutes. Videos were scored in a blind manner for morphine withdrawal behaviors. Data were analyzed using 2-way ANOVAs testing for treatment and sex effects. RESULTS AND CONCLUSIONS Xenon-exposed mice exhibited fewer jumps (P = 0.010) and jumping suppression was detectible within the first 10-minute video segment, but no sex differences were detected. Brief inhalation of low concentration xenon rapidly and substantially attenuated naltrexone-precipitated jumping in morphine-dependent mice, suggesting that it can inhibit OWS. If xenon effects translate to humans with OUD, xenon inhalation may be effective for reducing OWS, unprescribed opioid use, and for easing OUD treatment initiation, which could help lower excess morbidity and mortality associated with OUD.
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Affiliation(s)
- Marc J Kaufman
- Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA 02478, USA.
| | - Edward G Meloni
- Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA 02478, USA
| | - Alaa N Qrareya
- University of Mississippi School of Pharmacy, Faser Hall Room 331, University, MS 38677, USA
| | - Carol A Paronis
- Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA 02478, USA
| | - Vlad Bogin
- Nobilis Therapeutics, Inc., US Bancorp Tower, 111 S.W. Fifth Avenue, Suite 3150, Portland, OR 97204, USA
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Ellis MM, Eberhart ND, Warner NS, Hooten WM. Low dose lofexidine for medically directed outpatient opioid tapering in adults with chronic pain: a prospective case series. J Med Case Rep 2024; 18:20. [PMID: 38229200 DOI: 10.1186/s13256-023-04309-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 12/06/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND In adults with chronic pain, mild-to-moderate withdrawal symptoms during medically directed opioid tapering in the outpatient setting may not be accompanied by hypertension or tachycardia. This clinical scenario could limit the use of lofexidine at dosages reported in clinical trials of opioid withdrawal precipitated by abrupt opioid discontinuation. Thus, the primary aim of this prospective case series is to describe the use of low dose lofexidine for opioid withdrawal in patients with chronic pain undergoing medically directed opioid tapering in an outpatient setting. METHODS Six patients (white 5, Latino 1) admitted to an outpatient interdisciplinary pain rehabilitation program met inclusion and exclusion criteria. Patients self-selected to undergo medically directed opioid tapering, and the medication the patients were prescribed upon admission was used in the taper schedule. Upon initiation of the opioid taper, patients received 0.18 mg of lofexidine every 6 hours. RESULTS Five of the six patients were women, and the median morphine milligram equivalents at baseline were 36.9. The median taper duration was 15 days, and the median duration of lofexidine administration was 14 days. Withdrawal scores were mild throughout the taper in four patients, and two patients with fibromyalgia experienced single episodes of moderately severe withdrawal symptoms at the median morphine milligram equivalent midpoint of the taper. No hypotension or sustained bradycardia were observed, and no adverse effects related to lofexidine were reported. CONCLUSION The observations from this prospective case series suggest that low-dose lofexidine may be a feasible adjunct medication to attenuate withdrawal symptoms in adults with chronic pain undergoing outpatient opioid tapering.
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Affiliation(s)
- Megan M Ellis
- Department of Anesthesiology and Perioperative Medicine, Mayo School of Graduate Education, Mayo Clinic, 200 First St SW, Charlton 1-145, Rochester, MN, 55905, USA
| | - Nathan D Eberhart
- Department of Anesthesiology and Perioperative Medicine, Mayo School of Graduate Education, Mayo Clinic, 200 First St SW, Charlton 1-145, Rochester, MN, 55905, USA
| | - Nafisseh S Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo School of Graduate Education, Mayo Clinic, 200 First St SW, Charlton 1-145, Rochester, MN, 55905, USA
| | - W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo School of Graduate Education, Mayo Clinic, 200 First St SW, Charlton 1-145, Rochester, MN, 55905, USA.
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Padhan M, Maiti R, Mohapatra D, Mishra BR. Efficacy and safety of tramadol in the treatment of opioid withdrawal: A meta-analysis of randomized controlled trials. Addict Behav 2023; 147:107815. [PMID: 37517376 DOI: 10.1016/j.addbeh.2023.107815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/13/2023] [Accepted: 07/24/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Pharmacotherapeutic options for the treatment of opioid withdrawal are limited by abuse potential, adverse effects, and lack of availability of existing drugs. The results from previous clinical trials on tramadol are contradictory and non-conclusive; hence the present meta-analysis was conducted to evaluate the efficacy and safety of tramadol in the treatment of opioid withdrawal. METHODS Reviewers extracted data from eight relevant clinical trials after a literature search on MEDLINE/PubMed, Cochrane databases, and clinical trial registries. Quality assessment was done using the risk-of-bias assessment tool, and the random-effects model was used to estimate effect size in frequentist and Bayesian approaches. Subgroup analysis, meta-regression, and sensitivity analysis were done as applicable. PRISMA guidelines were followed in reporting findings. RESULTS Tramadol significantly reduced opioid withdrawal scale score (SMD: -0.44; 95%CI: -0.76 to -0.13; PI: -1.54 to 0.71; p = 0.006) when all comparators were considered together in the frequentist approach but the reduction was non-significant in Bayesian approach. However, the subgroup analysis revealed no significant difference between tramadol and comparators like placebo (SMD: -1.12; 95%CI: -2.69 to 0.45) buprenorphine (SMD: -0.21; 95%CI: -0.43 to 0.01), clonidine (SMD: -0.26; 95%CI: -0.55 to 0.02) and methadone (SMD: -0.84; 95%CI: -1.78 to 0.10). Meta-regression showed non-significant associations between the SMD in opioid withdrawal score with the duration and dose of tramadol therapy. There were no significant differences in treatment retention at the end of studies between tramadol and comparators. Safety data in the individual studies were inadequate to analyze. CONCLUSION Authors conclude that the efficacy of tramadol in reducing opioid withdrawal symptoms is not significantly different from comparators with low certainty of evidence against placebo, moderate against methadone, whereas with high certainty of evidence against buprenorphine and clonidine.
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Affiliation(s)
- Milan Padhan
- All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India.
| | - Rituparna Maiti
- All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India.
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Mannes ZL, Livne O, Knox J, Hasin DS, Kranzler HR. Prevalence and correlates of DSM-5 opioid withdrawal syndrome in U.S. adults with non-medical use of prescription opioids: results from a national sample. Am J Drug Alcohol Abuse 2023; 49:799-808. [PMID: 37948571 PMCID: PMC10867630 DOI: 10.1080/00952990.2023.2248646] [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: 11/30/2022] [Accepted: 08/13/2023] [Indexed: 11/12/2023]
Abstract
Background: In the U.S. non-medical use of prescription opioids (NMOU) is prevalent and often accompanied by opioid withdrawal syndrome (OWS). OWS has not been studied using nationally representative data.Objectives: We examined the prevalence and clinical correlates of OWS among U.S. adults with NMOU.Methods: We used data from 36,309 U.S. adult participants in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, 1,527 of whom reported past 12-month NMOU. Adjusted linear and logistic regression models examined associations between OWS and its clinical correlates, including psychiatric disorders, opioid use disorder (OUD; excluding the withdrawal criterion), medical conditions, and healthcare utilization among people with regular (i.e. ≥3 days/week) NMOU (n = 534).Results: Over half (50.4%) of the sample was male. Approximately 9% of people with NMOU met criteria for DSM-5 OWS, with greater prevalence of OWS (∼20%) among people with regular NMOU. Individuals with bipolar disorder, dysthymia, panic disorder, and borderline personality disorder had greater odds of OWS (aOR range = 2.71-4.63). People with OWS had lower mental health-related quality of life (β=-8.32, p < .001). Individuals with OUD also had greater odds of OWS (aOR range = 26.02-27.77), an association that increased with more severe OUD. People using substance use-related healthcare services also had greater odds of OWS (aOR range = 6.93-7.69).Conclusion: OWS was prevalent among people with OUD and some psychiatric disorders. These findings support screening for OWS in people with NMOU and suggest that providing medication- assisted treatments and behavioral interventions could help to reduce the burden of withdrawal in this patient population.
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Affiliation(s)
- Zachary L. Mannes
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St., New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Ofir Livne
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Justin Knox
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY, 10032, USA
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, 722 West 168th St. New York, NY, 10032, USA
| | - Deborah S. Hasin
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St., New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Henry R. Kranzler
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, Philadelphia, PA, 19104, USA
- Mental Illness Research, Education, and Clinical Center, Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, 19104, USA
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Arenson A, Campbell CI, Remler I. Psychoactive plant derivatives (ayahuasca, ibogaine, kratom) and their application in opioid withdrawal and use disorder - a narrative review. J Addict Dis 2023:1-11. [PMID: 37199191 DOI: 10.1080/10550887.2023.2195777] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
The opioid epidemic and limited access to treatment for opioid withdrawal (OW) and opioid use disorder (OUD) has led individuals to seek alternative treatments. This narrative review aims to educate clinicians on the mechanisms of action, toxicity, and applications of psychoactive plant-based substances patients may be using to self-treat OUD and OW. We specifically discuss ayahuasca, ibogaine, and kratom as they have the most evidence for applications in OUD and OW from the last decade (2012-2022). Evidence suggests these substances may have efficacy in treating OW and OUD through several therapeutic mechanisms including their unique pharmacodynamic effects, rituals performed around ingestion, and increased neuroplasticity. The current evidence for their therapeutic application in OUD and OW is primarily based on small observational studies or animal studies. High-quality, longitudinal studies are needed to clarify safety and efficacy of these substances in treatment of OW and OUD.
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Affiliation(s)
- Alexandra Arenson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Psychiatry and Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Ilan Remler
- Addiction Medicine and Recovery Services, Kaiser Permanente San Leandro Medical Center, San Leandro, CA, USA
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Thakrar AP, Uritsky TJ, Christopher C, Winston A, Ronning K, Sigueza AL, Caputo A, McFadden R, Olenik JM, Perrone J, Delgado MK, Lowenstein M, Compton P. Safety and preliminary outcomes of short-acting opioid agonist treatment (sOAT) for hospitalized patients with opioid use disorder. Addict Sci Clin Pract 2023; 18:13. [PMID: 36829242 PMCID: PMC9951406 DOI: 10.1186/s13722-023-00368-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 09/14/2022] [Accepted: 02/07/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Patients with opioid use disorder (OUD) frequently leave the hospital as patient directed discharges (PDDs) because of untreated withdrawal and pain. Short-acting opioids can complement methadone, buprenorphine, and non-opioid adjuvants for withdrawal and pain, however little evidence exists for this approach. We described the safety and preliminary outcomes of short-acting opioid agonist treatment (sOAT) for hospitalized patients with OUD at an academic hospital in Philadelphia, PA. METHODS From August 2021 to March 2022, a pharmacist guided implementation of a pilot sOAT protocol consisting of escalating doses of oxycodone or oral hydromorphone scheduled every four hours, intravenous hydromorphone as needed, and non-opioid adjuvants for withdrawal and pain. All patients were encouraged to start methadone or buprenorphine treatment for OUD. We abstracted data from the electronic health record into a secure platform. The primary outcome was safety: administration of naloxone, over-sedation, or a fall. Secondary outcomes were PDDs and respective length of stay (LOS), discharges on methadone or buprenorphine, and discharges with naloxone. We compared secondary outcomes to hospitalizations in the 12 months prior to the index hospitalization among the same cohort. RESULTS Of the 23 cases, 13 (56.5%) were female, 19 (82.6%) were 40 years or younger, and 22 (95.7%) identified as White. Twenty-one (91.3%) regularly injected opioids and four (17.3%) were enrolled in methadone or buprenorphine prior to hospitalization. sOAT was administered at median doses of 200-320 morphine milligram equivalents per 24-h period. Naloxone administration was documented once in the operating room, over-sedation was documented once after unsanctioned opioid use, and there were no falls. The PDD rate was 44% with median LOS 5 days (compared to PDD rate 69% with median LOS 3 days for prior admissions), 65% of sOAT cases were discharged on buprenorphine or methadone (compared to 33% for prior admissions), and 65% of sOAT cases were discharged with naloxone (compared to 19% for prior admissions). CONCLUSIONS Pilot implementation of sOAT was safe. Compared to prior admissions in the same cohort, the PDD rate was lower, LOS for PDDs was longer, and more patients were discharged on buprenorphine or methadone and with naloxone, however efficacy for these secondary outcomes remains to be established.
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Affiliation(s)
- Ashish P Thakrar
- National Clinician Scholars Program at the Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania, Philadelphia, USA.
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA.
| | - Tanya J Uritsky
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Cara Christopher
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Anna Winston
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Kaitlin Ronning
- School of Nursing, University of Pennsylvania, Philadelphia, USA
| | - Anna Lee Sigueza
- School of Nursing, University of Pennsylvania, Philadelphia, USA
| | - Anne Caputo
- School of Nursing, University of Pennsylvania, Philadelphia, USA
| | - Rachel McFadden
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Jennifer M Olenik
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Jeanmarie Perrone
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - M Kit Delgado
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Margaret Lowenstein
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Peggy Compton
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
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11
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Jones JD, Rajachandran L, Yocca F, Risinger R, De Vivo M, Sabados J, Levin FR, Comer SD. Sublingual dexmedetomidine (BXCL501) reduces opioid withdrawal symptoms: findings from a multi-site, phase 1b/2, randomized, double-blind, placebo-controlled trial. Am J Drug Alcohol Abuse 2023; 49:109-122. [PMID: 36630319 PMCID: PMC11036405 DOI: 10.1080/00952990.2022.2144743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 10/30/2022] [Accepted: 11/03/2022] [Indexed: 01/12/2023]
Abstract
Background: Like other alpha-2-adrenergic receptor agonists, dexmedetomidine may reduce the severity of opioid withdrawal but with fewer adverse cardiovascular effects.Objective: This study assessed the safety of sublingual dexmedetomidine (BXCL501) and its preliminary efficacy in treating opioid withdrawal (ClinicalTrials.gov: NCT04470050).Methods: Withdrawal was induced among individuals with physiological dependence on opioids via discontinuation of oral morphine (Days 1-5). Participants were randomized to receive placebo or active BXCL501: 30, 60, 90, 120, 180, and 240 μg twice daily (Days 6-12). Treatment-emergent adverse events (TEAEs) were the primary outcome measure. Secondary outcomes included the Clinical and Subjective Opiate Withdrawal Scales (COWS and SOWS-Gossop, respectively), and the Agitation and Calmness Evaluation Scale (ACES).Results: Of 225 participants enrolled, 90 discontinued during morphine stabilization. Post-BXCL501 randomization (Day 6) data were available from 135 participants (73% male), with 33% completing thru Day 12. In total, 36 subjects reported 1 or more TEAE. Higher doses of BXCL501 (i.e. 180 and 240 µg, twice daily) increased the frequency of: hypotension, orthostatic hypotension, and somnolence. TEAEs related to BXCL501 were mild or moderate in severity, except for one participant in the 120 µg condition whose orthostatic hypotension and bradycardia were classified as severe. Higher BXCL501 dose conditions (120, 180, and 240 µg) resulted in statistically significant reductions in COWS & SOWS scores. Mean ratings on the ACES were between 3 (mild), 4 (normal), and 5 (mild calmness), with few significant differences as a function of dose.Conclusions: These findings support the continued development of BXCL501 for the management of opioid withdrawal.
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Affiliation(s)
- Jermaine D. Jones
- Division on Substance Use Disorders, Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, NY, USA
| | | | - Frank Yocca
- BioXcel Therapeutics, Inc, New Haven, CT, USA
| | | | | | | | - Frances R. Levin
- Division on Substance Use Disorders, Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, NY, USA
| | - Sandra D. Comer
- Division on Substance Use Disorders, Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, NY, USA
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12
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St Onge CM, Taylor KM, Marcus MM, Townsend EA. Sensitivity of a fentanyl-vs.-social interaction choice procedure to environmental and pharmacological manipulations. Pharmacol Biochem Behav 2022; 221:173473. [PMID: 36228740 PMCID: PMC9729431 DOI: 10.1016/j.pbb.2022.173473] [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: 07/22/2022] [Revised: 09/27/2022] [Accepted: 10/05/2022] [Indexed: 12/14/2022]
Abstract
Recent studies have shown that social interaction can serve as an alternative reinforcer to opioid self-administration under a choice context in rats. However, additional parametric studies are needed to evaluate the sensitivity of opioid-vs.-social interaction procedures relative to more established opioid-vs.-food procedures. The current study evaluated the sensitivity of a novel fentanyl-vs.-social interaction choice procedure to environmental and pharmacological manipulations previously shown to affect fentanyl-vs.-food choice. Male and female rats (responder rats; n = 6/sex) were trained to respond in a discrete-trial choice procedure for either 30-s access to a same-sex "partner" rat or an intravenous fentanyl infusion. Once trained, the effects of fentanyl unit dose (0, 0.32-10 μg/kg/inf), partner rat presence, opioid-dependence status, chronic naltrexone administration (0.032, 0.1 mg/kg/h), and response requirement for fentanyl self-administration (fixed ratio 1-320) were determined across weeks. The fentanyl-vs.-social interaction choice procedure was sensitive to the unit dose of fentanyl, chronic naltrexone treatment, and fentanyl response requirement. However, the magnitude of these effects on fentanyl choice was smaller than those reported in published fentanyl-vs.-food choice studies. Furthermore, fentanyl-vs.-social interaction choice was not sensitive to removal of the partner rat or opioid-dependence status. Minimal sex differences were detected. These results suggest that this fentanyl-vs.-social interaction choice procedure is less sensitive to environmental and pharmacological interventions than previously established opioid-vs.-food choice procedures. The observed discrepancy in sensitivity between the procedures suggests that social interaction may have qualitatively different reinforcing properties compared to more commonly assessed alternative reinforcers such as food (preclinical) or money (human laboratory).
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Affiliation(s)
- Celsey M St Onge
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA, USA
| | - Kaia M Taylor
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Madison M Marcus
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - E Andrew Townsend
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA; Division of Therapeutics and Medical Consequences, National Institute on Drug Abuse, North Bethesda, MD, USA.
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13
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Armstrong C, Ferrante J, Lamichhane N, Reavis Z, Walker D, Patkar A, Kuhn C. Rapastinel accelerates loss of withdrawal signs after repeated morphine and blunts relapse to conditioned place preference. Pharmacol Biochem Behav 2022; 221:173485. [PMID: 36302442 DOI: 10.1016/j.pbb.2022.173485] [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] [Received: 08/04/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022]
Abstract
The purpose of the present study was to evaluate the efficacy of rapastinel, an allosteric modulator of NMDA receptor function, to accelerate the loss of opioid withdrawal symptoms and blunt or prevent relapse to morphine conditioned place preference (CPP) in rats. Two studies were conducted. In study 1, adult and adolescent male and female rats were treated with increasing doses of morphine (5 mg/kg, bid to 25 mg/kg bid) for 5 days. On day 6 animals were treated with naloxone (1 mg/kg) and withdrawal was assessed. They were then treated with saline or rapastinel (5 mg/kg) on days 6 and 8, and withdrawal was assessed on day 9. Rapastinel treated animals exhibited significantly lower levels of withdrawal signs on day 9. No sex or age differences were observed. In Study 2, CPP for morphine was established in adult rats (males and females) by 4 daily pairings with saline and morphine (am/pm alternation). They were tested for CPP on day 5, and then treated with rapastinel (5 mg/kg) or saline daily on days 6-10 of extinction. On day 11 they received a final dose of rapastinel or saline followed by extinction trial. On day 12, animals received 1 mg/kg of morphine and were tested for relapse. Rapastinel did not affect extinction of CPP, but rapastinel-treated animals spent significantly less time in the previously morphine-paired side than saline-treated animals during the relapse trial. These findings of accelerated loss of withdrawal signs and blunted relapse to CPP suggest that rapastinel could provide an adjunctive therapy for opioid dependence during initiation of pharmacotherapy for opioid dependence.
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Affiliation(s)
- Christopher Armstrong
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC 27710, United States of America
| | - Julia Ferrante
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC 27710, United States of America; Department of Psychiatry, Duke University Medical Center, Durham, NC 27710, United States of America
| | - Nidesh Lamichhane
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC 27710, United States of America; Department of Psychiatry, Duke University Medical Center, Durham, NC 27710, United States of America
| | - Zachery Reavis
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC 27710, United States of America; Department of Psychiatry, Duke University Medical Center, Durham, NC 27710, United States of America
| | - David Walker
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC 27710, United States of America; Department of Psychiatry, Duke University Medical Center, Durham, NC 27710, United States of America
| | - Ashwin Patkar
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC 27710, United States of America; Department of Psychiatry, Duke University Medical Center, Durham, NC 27710, United States of America; Avance Psychiatry, 7850 Brier Creek Pkwy, Ste. 102, Raleigh, NC 27617, United States of America
| | - Cynthia Kuhn
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC 27710, United States of America; Department of Psychiatry, Duke University Medical Center, Durham, NC 27710, United States of America.
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14
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Taylor JL, Laks J, Christine PJ, Kehoe J, Evans J, Kim TW, Farrell NM, White CS, Weinstein ZM, Walley AY. Bridge clinic implementation of "72-hour rule" methadone for opioid withdrawal management: Impact on opioid treatment program linkage and retention in care. Drug Alcohol Depend 2022; 236:109497. [PMID: 35607834 DOI: 10.1016/j.drugalcdep.2022.109497] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 03/18/2022] [Revised: 05/05/2022] [Accepted: 05/10/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Methadone for opioid use disorder (OUD) treatment is restricted to licensed opioid treatment programs (OTPs) with substantial barriers to entry. Underutilized regulations allow non-OTP providers to administer methadone for opioid withdrawal for up to 72 h while arranging ongoing care. Our low-barrier bridge clinic implemented a new pathway to treat opioid withdrawal and facilitate OTP linkage utilizing the "72-hour rule." METHODS Patients presenting to a hospital-based bridge clinic were evaluated for OUD, opioid withdrawal, and treatment goals. Eligible patients were offered methadone opioid withdrawal management with rapid OTP referral. OTPs accepted patients as direct admissions. We described bridge clinic patients who received at least one dose of methadone between March-August 2021 and key clinical outcomes including OTP referral completion within 72 h. For the subset of patients referred to our two primary OTP partners, we described OTP linkage (i.e., attended at least one OTP visit within one month) and OTP retention at one month. RESULTS Methadone was administered during 150 episodes of care for 142 unique patients, the majority of whom were male (73%), white (67%), and used fentanyl (85%). In 92% of episodes (138/150), a plan for ongoing care was in place within 72 h. Among 121 referrals to two primary OTP partners, 87% (105/121) linked and 58% (70/121) were retained at one month. CONCLUSIONS Methadone administration for opioid withdrawal with direct OTP admission under the "72-hour rule" is feasible in an outpatient bridge clinic and resulted in high OTP linkage and 1-month retention rates. This model has the potential to improve methadone access.
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Affiliation(s)
- Jessica L Taylor
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA; Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.
| | - Jordana Laks
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA; Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Paul J Christine
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA; Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Jessica Kehoe
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
| | - James Evans
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
| | - Theresa W Kim
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA; Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Natalija M Farrell
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA; Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Cedric S White
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA
| | - Zoe M Weinstein
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA; Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Alexander Y Walley
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA; Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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15
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Harris M, Holland A, Lewer D, Brown M, Eastwood N, Sutton G, Sansom B, Cruickshank G, Bradbury M, Guest I, Scott J. Barriers to management of opioid withdrawal in hospitals in England: a document analysis of hospital policies on the management of substance dependence. BMC Med 2022; 20:151. [PMID: 35418095 PMCID: PMC9007696 DOI: 10.1186/s12916-022-02351-y] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/24/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND People who use illicit opioids are more likely to be admitted to hospital than people of the same age in the general population. Many admissions end in discharge against medical advice, which is associated with readmission and all-cause mortality. Opioid withdrawal contributes to premature discharge. We sought to understand the barriers to timely provision of opioid substitution therapy (OST), which helps to prevent opioid withdrawal, in acute hospitals in England. METHODS We requested policies on substance dependence management from 135 National Health Service trusts, which manage acute hospitals in England, and conducted a document content analysis. Additionally, we reviewed an Omitted and Delayed Medicines Tool (ODMT), one resource used to inform critical medicine categorisation in England. We worked closely with people with lived experience of OST and/or illicit opioid use, informed by principles of community-based participatory research. RESULTS Eighty-six (64%) trusts provided 101 relevant policies. An additional 44 (33%) responded but could not provide relevant policies, and five (4%) did not send a definitive response. Policies illustrate procedural barriers to OST provision, including inconsistent application of national guidelines across trusts. Continuing community OST prescriptions for people admitted in the evening, night-time, or weekend was often precluded by requirements to confirm doses with organisations that were closed during these hours. 42/101 trusts (42%) required or recommended a urine drug test positive for OST medications or opioids prior to OST prescription. The language used in many policies was stigmatising and characterised people who use drugs as untrustworthy. OST was not specifically mentioned in the reviewed ODMT, with 'drugs used in substance dependence' collectively categorised as posing low risk if delayed and moderate risk if omitted. CONCLUSIONS Many hospitals in England have policies that likely prevent timely and effective OST. This was underpinned by the 'low-risk' categorisation of OST delay in the ODMT. Delays to continuity of OST between community and hospital settings may contribute to inpatient opioid withdrawal and increase the risk of discharge against medical advice. Acute hospitals in England require standardised best practice policies that account for the needs of this patient group.
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Affiliation(s)
- Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Adam Holland
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield Grove, Clifton, Bristol, BS8 2BN, UK
| | - Dan Lewer
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Michael Brown
- Division of Infection, University College London Hospital, London, UK.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | - Gary Sutton
- Release, 61 Mansell Street, London, E1 8AN, UK
| | - Ben Sansom
- Bristol Medical School, University of Bristol, Oakfield Grove, Clifton, Bristol, BS8 2BN, UK
| | - Gabby Cruickshank
- Bristol Medical School, University of Bristol, Oakfield Grove, Clifton, Bristol, BS8 2BN, UK
| | - Molly Bradbury
- Severn Foundation School, Park House, 1200 Parkway, Bristol, BS34 8YU, UK
| | - Isabelle Guest
- Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, BS10 5NB, UK
| | - Jenny Scott
- Department of Pharmacy & Pharmacology, University of Bath, Claverton Down, Bath, BA2 7AY, UK
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16
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Baidoo N, Leri F. Extended amygdala, conditioned withdrawal and memory consolidation. Prog Neuropsychopharmacol Biol Psychiatry 2022; 113:110435. [PMID: 34509531 DOI: 10.1016/j.pnpbp.2021.110435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/23/2021] [Accepted: 09/06/2021] [Indexed: 11/30/2022]
Abstract
Opioid withdrawal can be associated to environmental cues through classical conditioning. Exposure to these cues can precipitate a state of conditioned withdrawal in abstinent subjects, and there are suggestions that conditioned withdrawal can perpetuate the addiction cycle in part by promoting the storage of memories. This review discusses evidence supporting the hypothesis that conditioned withdrawal facilitates memory consolidation by activating a neurocircuitry that involves the extended amygdala. Specifically, the central amygdala, the bed nucleus of the stria terminalis, and the nucleus accumbens shell interact functionally during withdrawal, mediate expression of conditioned responses, and are implicated in memory consolidation. From this perspective, the extended amygdala could be a neural pathway by which drug-seeking behaviour performed during a state of conditioned withdrawal is more likely to become habitual and persistent.
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Affiliation(s)
- Nana Baidoo
- Department of Psychology & Neuroscience, Guelph, Ontario, Canada
| | - Francesco Leri
- Department of Psychology & Neuroscience, Guelph, Ontario, Canada.
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17
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Slater T, Rodney T, Kozachik SL, Finnell DS. Recommendations for Emergency Departments Caring for Persons with Opioid Use and Opioid Use Disorders: An Integrative Review. J Emerg Nurs 2022:S0099-1767(21)00306-8. [PMID: 35031133 DOI: 10.1016/j.jen.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 09/18/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The emergency department is a primary portal to care for persons after an opioid overdose and those with an opioid use disorder. The aim of this integrative review was to provide best practice recommendations for nurses caring for this highly stigmatized and often undertreated population. METHODS An integrative review was conducted using studies focusing on adults treated with opioid agonist-antagonist medications in the emergency department. The integrative review method by Whittemore and Knafl was used to guide this review and enhance its rigor. RESULTS Twelve studies were included in the review. Opioid care begins with identifying opioid use risk, followed by implementing tailored strategies including opioid agonist-antagonist treatment if indicated, referral to treatment when warranted, and follow-up opioid use monitoring when feasible. Eleven recommendations provide guidance on integrating best practices into routine emergency care. DISCUSSION The emergency department is an ideal setting for addressing the opioid crisis. Nurses can use the recommendations from this review to lead system change and more effectively manage the care of persons with opioid use and opioid withdrawal, and those at risk for opioid overdose.
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18
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Laks J, Kehoe J, Farrell NM, Komaromy M, Kolodziej J, Walley AY, Taylor JL. Methadone initiation in a bridge clinic for opioid withdrawal and opioid treatment program linkage: a case report applying the 72-hour rule. Addict Sci Clin Pract 2021; 16:73. [PMID: 34961554 PMCID: PMC8712102 DOI: 10.1186/s13722-021-00279-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/10/2021] [Indexed: 11/30/2022] Open
Abstract
Background In the United States, methadone for opioid use disorder (OUD) is limited to highly regulated opioid treatment programs (OTPs), rendering it inaccessible to many patients. The “72-hour rule” allows non-OTP providers to administer methadone for emergency opioid withdrawal management while arranging ongoing care. Low-barrier substance use disorder (SUD) bridge clinics provide rapid access to buprenorphine but offer an opportunity to treat acute opioid withdrawal while facilitating OTP linkage. We describe the case of a patient with OUD who received methadone for opioid withdrawal in a bridge clinic and linked to an OTP within 72 h. Case presentation A 54-year-old woman with severe OUD was seen in a SUD bridge clinic requesting OTP linkage and assessed with a clinical opiate withdrawal scale (COWS) score of 12. She reported daily nasal use of 1 g heroin/fentanyl. Prior OUD treatment included buprenorphine-naloxone, which was only partially effective. Her acute opioid withdrawal was treated with a single observed oral dose of methadone 20 mg. She returned the following day with persistent opioid withdrawal (COWS score 11) and was treated with methadone 40 mg. On day 3, the patient was successfully admitted to a local OTP, where she remained engaged 3 months later. Conclusions While patients continue to face substantial access barriers, bridge clinics can play an important role in treating opioid withdrawal, building partnerships with OTPs to initiate methadone on demand, and preventing life-threatening delays to methadone treatment. Federal policy reform is urgently needed to make methadone more accessible to people with OUD.
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Affiliation(s)
- Jordana Laks
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA. .,Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA.
| | - Jessica Kehoe
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
| | - Natalija M Farrell
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Miriam Komaromy
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
| | | | - Alexander Y Walley
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
| | - Jessica L Taylor
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
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19
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Hoffman KA, Baker R, Fanucchi LC, Lum PJ, Kunkel LE, Ponce Terashima J, McCarty D, Jacobs P, Korthuis PT. Perspectives on extended-release naltrexone induction among patients living with HIV and opioid use disorder: a qualitative analysis. Addict Sci Clin Pract 2021; 16:67. [PMID: 34758887 PMCID: PMC8579672 DOI: 10.1186/s13722-021-00277-z] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 11/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The CHOICES study randomized participants with HIV and opioid use disorder (OUD) to HIV clinic-based extended-release naltrexone (XR-NTX), which requires complete cessation of opioid use, versus treatment-as-usual (i.e., buprenorphine, methadone). Study participants randomized to XR-NTX were interviewed to assess their experiences with successful and unsuccessful XR-NTX induction. METHODS Semi-structured qualitative interviews were completed with a convenience sample of study participants with HIV and OUD (n = 37) randomized to XR-NTX in five HIV clinics between 2018 and 2019. All participants approached agreed to be interviewed. Interviews were digitally recorded, professionally transcribed, and analyzed using thematic analysis. RESULTS Participants included women (43%), African Americans (62%) and Hispanics (16%), between 27 to 69 years of age. Individuals who completed XR-NTX induction (n = 20) reported experiencing (1) readiness for change, (2) a supportive environment during withdrawal including comfort medications, and (3) caring interactions with staff. Four contrasting themes emerged among participants (n = 17) who did not complete induction: (1) concern and anxiety about withdrawal including past negative experiences, (2) ambivalence about or reluctance to stop opioids, (3) concerns about XR-NTX effects, and (4) preferences for other medications. CONCLUSIONS The results highlight opportunities to improve initiation of XR-NTX in high-need groups. Addressing expectations regarding induction may enhance XR-NTX initiation rates. Trial Registration ClinicalTrials.gov: NCT03275350. Registered September 7, 2017. https://clinicaltrials.gov/ct2/show/NCT03275350?term=extended+release+naltrexone&cond=Opioid+Use .
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Affiliation(s)
- Kim A Hoffman
- Oregon Health and Science University-Portland State University School of Public Health, Portland, OR, USA.
| | - Robin Baker
- Oregon Health and Science University-Portland State University School of Public Health, Portland, OR, USA
| | | | - Paula J Lum
- Department of Medicine, Division of HIV, ID & Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Lynn E Kunkel
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA
| | | | - Dennis McCarty
- Department of Medicine, Division of HIV, ID & Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Petra Jacobs
- National Institute on Drug Abuse, Center for the Clinical Trials Network, North Bethesda, MD, USA
| | - P Todd Korthuis
- Oregon Health and Science University-Portland State University School of Public Health, Portland, OR, USA.,Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA
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Townsend EA, Kim RK, Robinson HL, Marsh SA, Banks ML, Hamilton PJ. Opioid withdrawal produces sex-specific effects on fentanyl-vs.-food choice and mesolimbic transcription. Biol Psychiatry Glob Open Sci 2021; 1:112-122. [PMID: 34458885 DOI: 10.1016/j.bpsgos.2021.04.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Opioid withdrawal is a key driver of opioid addiction and an obstacle to recovery. However, withdrawal effects on opioid reinforcement and mesolimbic neuroadaptation are understudied and the role of sex is largely unknown. Methods Male (n=13) and female (n=12) rats responded under a fentanyl-vs.-food "choice" procedure during daily 2h sessions. In addition to the daily choice sessions, rats were provided extended access to fentanyl during 12h self-administration sessions. After two weeks of this self-administration regimen, the nucleus accumbens (NAc) and ventral tegmental area (VTA) of a subset of rats were subjected to RNA sequencing. In the remaining rats, a third week of this self-administration regimen was conducted, during which methadone effects on fentanyl-vs.-food choice were determined. Results Prior to opioid dependence, male and female rats similarly allocated responding between fentanyl and food. Abstinence from extended fentanyl access elicited similar increases in somatic withdrawal signs in both sexes. Despite similar withdrawal signs and extended access fentanyl intake, opioid withdrawal was accompanied by a maladaptive increase in fentanyl choice in males, but not females. Behavioral sex differences corresponded with a greater number of differentially expressed genes in the NAc and VTA of opioid-withdrawn females relative to males. Methadone blocked withdrawal-associated increases in fentanyl choice in males, but failed to further decrease fentanyl choice in females. Conclusions These results provide foundational evidence of sex-specific neuroadaptations to opioid withdrawal, which may be relevant to the female-specific resilience to withdrawal-associated increases in opioid choice and aid in the identification of novel therapeutic targets.
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Affiliation(s)
- E Andrew Townsend
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298 USA
| | - R Kijoon Kim
- Department of Anatomy and Neurobiology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298 USA
| | - Hannah L Robinson
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298 USA
| | - Samuel A Marsh
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298 USA
| | - Matthew L Banks
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298 USA
| | - Peter J Hamilton
- Department of Anatomy and Neurobiology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298 USA
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21
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Thomaz AC, Iyer V, Woodward TJ, Hohmann AG. Fecal microbiota transplantation and antibiotic treatment attenuate naloxone-precipitated opioid withdrawal in morphine-dependent mice. Exp Neurol 2021; 343:113787. [PMID: 34153321 DOI: 10.1016/j.expneurol.2021.113787] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/13/2021] [Accepted: 06/16/2021] [Indexed: 12/20/2022]
Abstract
Opioid addiction can produce severe side effects including physical dependence and withdrawal. Perturbations of the gut microbiome have recently been shown to alter opioid-induced side-effects such as addiction, tolerance and dependence. In the present study, we investigated the influence of the gut microbiome on opioid withdrawal by evaluating the effects of fecal microbiota transplantation (FMT), antibiotic and probiotic treatments, and pharmacological inhibition of gut permeability in a mouse model of opioid dependence. Repeated intraperitoneal (i.p.) morphine treatment produced physical dependence that was quantified by measuring somatic signs of withdrawal (i.e. number of jumps) precipitated using the opioid antagonist naloxone. Morphine-dependent mice that received FMT from morphine-treated donor mice exhibited fewer naloxone-precipitated jumps compared to morphine-dependent counterparts receiving FMT from saline-treated donor mice. Microbial contents in the mouse cecum were altered by morphine treatment but were not differentially impacted by FMT. A broad-spectrum antibiotic cocktail (ABX) regimen reduced the bacterial load and attenuated naloxone-precipitated morphine withdrawal in morphine-dependent mice, whereas commercially available probiotic strains did not reliably alter somatic signs of opioid withdrawal. ML-7, a pharmacological inhibitor of gut permeability, reduced the morphine-induced increase in gut permeability in vivo but did not reliably alter somatic signs of naloxone-precipitated opioid withdrawal. Our results suggest that the gut microbiome impacts the development of physical dependence induced by chronic morphine administration, and that therapeutic manipulations of the gut microbiome may reduce opioid withdrawal.
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22
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Wolińska R, Kleczkowska P, de Cordé-Skurska A, Poznański P, Sacharczuk M, Mika J, Bujalska-Zadrożny M. Nitric oxide modulates tapentadol antinociceptive tolerance and physical dependence. Eur J Pharmacol 2021; 907:174245. [PMID: 34126091 DOI: 10.1016/j.ejphar.2021.174245] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/31/2021] [Accepted: 06/07/2021] [Indexed: 11/22/2022]
Abstract
Tapentadol, an analgesic with a dual mechanism of action, involving both μ-opioid receptor agonism and noradrenaline reuptake inhibition (MOP-NRI), was designed for the treatment of moderate to severe pain. However, the widely acknowledged risk of analgesic tolerance and development of physical dependence following sustained opioid use may hinder their effectiveness. One of the possible mechanisms behind these phenomena are alterations in nitric oxide synthase (NOS) system activity. The aim of the study was to investigate the tolerance and dependence potential of tapentadol in rodent models and to evaluate the possible role of nitric oxide (NO) in these processes. Our study showed that chronic tapentadol treatment resulted in tolerance to its antinociceptive effects to an extent similar to tramadol, but much less than morphine. A single injection of a non-selective NOS inhibitor, NG-nitro-L-arginine (L-NOArg), reversed the tapentadol tolerance. In dependence studies, repeated administration of L-NOArg attenuated naloxone-precipitated withdrawal in tapentadol-treated mice, whereas a single injection of L-NOArg was ineffective. Biochemical analysis revealed that tapentadol decreased nNOS protein levels in the dorsal root ganglia of rats following 31 days of treatment, while no significant changes were found in iNOS and eNOS protein expression. Moreover, pre-treatment with L-NOArg augmented tapentadol antinociception in an opioid- and α2-adrenoceptor-dependent manner. In conclusion, our data suggest that the NOS system plays an important role in the attenuation of tapentadol-induced tolerance and withdrawal. Thus, inhibition of NOS activity can serve as a promising treatment option for long-term tapentadol use by extending its effectiveness and improving the side-effects profile.
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23
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Sullivan RW, Szczesniak LM, Wojcik SM. Bridge clinic buprenorphine program decreases emergency department visits. J Subst Abuse Treat 2021; 130:108410. [PMID: 34118702 DOI: 10.1016/j.jsat.2021.108410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Opioid withdrawal due to opioid use disorder (OUD) is an increasing health emergency and complaint in emergency departments (EDs) across the United States. As a response to the increased need for OUD treatment, a low threshold buprenorphine program, or Bridge Clinic, was established within our hospital system. Patients are primarily connected to the Bridge Clinic through the ED, and are able to complete their consultation appointment reliably within 1-3 days of referral. This program also serves to connect patients to community resources for continued treatment of OUD. METHODS A retrospective chart review was performed to identify ED-based referrals to the Bridge Clinic in the period from January 1, 2017 - December 31, 2018. Outcomes of interest included: (1) ED utilization in the six months before and after consultation at the Bridge Clinic and (2) adherence to buprenorphine therapy at 2-year follow-up. RESULTS A total of 269 patients were included in the study, with 167 males (62%) and a mean age of 37.8 years. There were 654 total visits to the ED six months before referral to the Bridge Clinic and 381 visits in the six-month period after the initial appointment. There was a high adherence to buprenorphine treatment at 2 year follow up (56%). CONCLUSIONS These early results suggest that prompt referral to a buprenorphine treatment program significantly reduces ED utilization and connects patients to community resources for continued buprenorphine treatment for OUD.
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Affiliation(s)
- Ross W Sullivan
- Department of Emergency Medicine, Upstate Medical University, Syracuse, NY, USA.
| | | | - Susan M Wojcik
- Department of Emergency Medicine, Upstate Medical University, Syracuse, NY, USA
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24
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Wiercigroch D, Hoyeck P, Sheikh H, Hulme J. A qualitative examination of the current management of opioid use disorder and barriers to prescribing buprenorphine in a Canadian emergency department. BMC Emerg Med 2021; 21:48. [PMID: 33858328 PMCID: PMC8051038 DOI: 10.1186/s12873-021-00443-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/25/2021] [Indexed: 11/18/2022] Open
Abstract
Background Emergency departments (EDs) across Canada are increasingly prescribing buprenorphine for opioid use disorder (OUD). The objective of this study was to identify the current knowledge, attitudes, and behaviours of ED physicians on the management of OUD in the ED, including barriers and facilitators to prescribing buprenorphine. Methods We purposefully selected emergency physicians from one ED in Toronto which had recently received education on OUD management and had a new addiction medicine follow-up clinic, to participate in semi-structured interviews. We used semi-structured interviews to explore experiences with patients with OUD, conceptions of role of the ED in addressing OUD, and specifically ask about perceptions and experience on using buprenorphine for opioid withdrawal. Our analysis was informed by constructivist grounded theory to help uncover contextualized social processes and focus on what people do and why they do it. Two researchers independently coded transcripts using an iterative constant comparative and interpretative approach. Results Results fell broadly into facilitators and barriers. Generally, management of OUD in the ED varied significantly. Physician-level facilitators to treating opioid withdrawal with buprenorphine included: knowledge about OUD an7d buprenorphine, positive experiences with substitution therapy in the past, and the presence of physician champions. Systems-level facilitators included timely access to follow-up care and pre-printed order sets. Barriers included provider inexperience, lack of feedback on treatment effectiveness, limited time to counsel patients, and pressure to discharge patients quickly. Additional barriers included concerns about precipitating withdrawal, prescribing a chronic medication in acute care, and patient attitudes. Conclusion This study describes barriers and facilitators to addressing OUD and prescribing buprenorphine in a Canadian ED. These findings suggest a role for additional provider education, involvement of allied health professionals in counseling, and mentorship by physician champions in the department. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00443-1.
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Affiliation(s)
- David Wiercigroch
- Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Canada.
| | - Patricia Hoyeck
- Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Canada
| | - Hasan Sheikh
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada.,University Health Network Emergency Department, Toronto, Canada
| | - Jennifer Hulme
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada.,University Health Network Emergency Department, Toronto, Canada
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25
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Jamshidi N, Clark D, Murnion B. Recurrent Takotsubo Cardiomyopathy Associated with Opioid Withdrawal During Buprenorphine Induction. Cardiovasc Toxicol 2021; 21:349-353. [PMID: 33481183 DOI: 10.1007/s12012-020-09624-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
This case report describes a 65-year-old female with iatrogenic opioid use disorder for chronic lower back pain, who developed Takotsubo cardiomyopathy on multiple occasions following buprenorphine induction. This patient had three opioid transfers to buprenorphine, over 4 years, two of which were complicated by Takotsubo cardiomyopathy. In the transfer where she did not develop Takotsubo cardiomyopathy, she was treated with high doses of the centrally acting agonist, clonidine (three times a day, total of 600 mcg/day), up to and including the day of her transfer. This case highlights the potential consequences of a precipitated withdrawal with buprenorphine in an opioid transfer and its possible prevention with clonidine. To our knowledge, this is the first description of the recurrent Takotsubo cardiomyopathy in an opioid transfer setting. Given that buprenorphine is a partial agonist, in the presence of a full opioid agonist, it can precipitate withdrawal within minutes to hours of its administration. Opioid withdrawal can result in a sympathetic overdrive. Although complications of opioid withdrawal are extensively documented, cardiotoxicity is uncommon. As the use of buprenorphine and its new injectable formulations rise, it is important for prescribers to be aware of this life threatening complication. The prophylactic administration of clonidine can be considered to reduce the risk of cardiotoxicity, as well as manage opioid withdrawal symptoms.
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Affiliation(s)
- Nazila Jamshidi
- Department of Clinical Pharmacology and Toxicology and Drug health services, Royal Prince Alfred Hospital, Level 6, King George Building, Missenden Rd, Camperdown, NSW, Australia.
| | - Danielle Clark
- Emergency Department, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Bridin Murnion
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.,Drug and Alcohol Services, Central Coast Local Health District, Sydney, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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26
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Mahmoud S, Anderson E, Vosooghi A, Herring AA. Treatment of opioid and alcohol withdrawal in a cohort of emergency department patients. Am J Emerg Med 2021; 43:17-20. [PMID: 33476917 DOI: 10.1016/j.ajem.2020.12.074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 09/19/2020] [Revised: 12/02/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND The safety of combining buprenorphine with a benzodiazepine or barbiturate in the treatment of concurrent alcohol and opioid withdrawal has not been well established. In this study we examine a cohort of patients treated with buprenorphine and phenobarbital or benzodiazepines for co-occurring opioid and alcohol withdrawal. METHODS This is a retrospective cohort study of ED patients treated for opioid and alcohol withdrawal from January through December 2018. The primary outcome was unexpected airway intervention, or the administration of naloxone for respiratory depression. RESULTS There were 16 patients treated for opioid and alcohol withdrawal. The mean age was 44.3 (standard deviation [SD] 13.1), 12 (75.0%) were male, and 8 (50.0%) of the patients were admitted to the hospital. For opioid withdrawal, six patients received intravenous buprenorphine, with doses between 0.3 mg to 1.8 mg; 12 patients received sublingual buprenorphine, with doses between 4 mg to 32 mg. For alcohol withdrawal, 10 patients received lorazepam with doses between 1 mg and 8 mg; 10 patients received phenobarbital with doses between 260 mg to 1040 mg. There were no unexpected airway interventions related to medications used for opioid or alcohol withdrawal. One patient with severe pneumonia was an expected intubation for respiratory failure. CONCLUSIONS We describe a cohort of patients treated for opioid and alcohol withdrawal in the ED. There were no serious adverse events related to the medications used to treat opioid or alcohol withdrawal. Further work should assess optimal use of medical therapy for opioid and alcohol withdrawal and the transition to maintenance treatment for substance use disorders.
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Affiliation(s)
- Sally Mahmoud
- Department of Emergency Medicine, Highland Hospital, Oakland, CA, USA.
| | - Erik Anderson
- Department of Emergency Medicine, Substance Use Disorder Treatment Program, Alameda Health System, Oakland, CA, USA
| | - Aidan Vosooghi
- University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Andrew A Herring
- Department of Emergency Medicine, Substance Use Disorder Treatment Program, Alameda Health System, Oakland, CA, USA
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27
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Verster JC, Scholey A, Dahl TA, Iversen JM. Functional observation after morphine withdrawal: effects of SJP-005. Psychopharmacology (Berl) 2021; 238:1449-1460. [PMID: 33555386 PMCID: PMC8139893 DOI: 10.1007/s00213-021-05771-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 01/21/2021] [Indexed: 10/27/2022]
Abstract
RATIONALE AND OBJECTIVE SJP-005 (ketotifen and ibuprofen) is being developed as a potential new treatment for opioid withdrawal. Three studies were conducted to evaluate the early phase (acute, day 1) and late phase (days 2-12) effects of SJP-005 on discontinuation-induced morphine withdrawal. METHODS Sprague-Dawley rats received subcutaneous morphine twice daily for 18 days and ceased on day 19. Twice daily, oral dosages of placebo or SJP-005 (1 mg/kg ketotifen and 15 mg/kg ibuprofen) were administered starting 4 days before (study 1), 2 days before (study 2), or immediately after (study 3) morphine cessation. Functional observations were made up to 12 h after treatment cessation on day 19 (early phase), and immediately after treatment on days 20-30 (late phase). Treatment effects (mean overall score, and individual symptoms) were compared with placebo using ANOVA, and Tukey's tests in case of multiple comparisons. RESULTS Across the studies, the number of withdrawal signs on day 19 (early phase) and days 20-30 (late phase) was lower with SJP-005 compared with placebo. The effects of SJP-005 when treatment was initiated 2 days before morphine cessation by discontinuation were most pronounced and statistically significant in the late phase (F(1,18) = 14.10, p = 0.001). In particular, a significant reduction was observed in hypersensitivity to touch (F(1,18) = 13.65, p = 0.002). A 50% reduction in withdrawal symptoms was observed 9.0 days after placebo versus 4.5 days after SJP-005. After 9.0 days, all withdrawal symptoms were absent in the SJP-005 group, while symptoms in the placebo group were still evident on day 18. CONCLUSION Compared to placebo, SJP-005 significantly reduced the incidence and duration of discontinuation-induced morphine withdrawal symptoms when treatment was initiated 2 days before morphine cessation.
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Affiliation(s)
- Joris C. Verster
- grid.5477.10000000120346234Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, 3584CG, Utrecht, The Netherlands ,grid.1027.40000 0004 0409 2862Centre for Human Psychopharmacology, Swinburne University, Melbourne, VIC 3122 Australia ,grid.5477.10000000120346234Psychopharmacology, Utrecht University, Po Box 80082, 3508TB Utrecht, Netherlands
| | - Andrew Scholey
- grid.1027.40000 0004 0409 2862Centre for Human Psychopharmacology, Swinburne University, Melbourne, VIC 3122 Australia
| | - Thomas A. Dahl
- Sen-Jam Pharmaceutical, 223 Wall St., #130, Huntington, NY 11743 USA
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Bertin C, Delage N, Rolland B, Pennel L, Fatseas M, Trouvin AP, Delorme J, Chenaf C, Authier N. Analgesic opioid use disorders in patients with chronic non-cancer pain: A holistic approach for tailored management. Neurosci Biobehav Rev 2020; 121:160-174. [PMID: 33358994 DOI: 10.1016/j.neubiorev.2020.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/21/2022]
Abstract
Chronic pain is a major public health issue that frequently leads to analgesic opioid prescriptions. These prescriptions could cause addiction issues in high-risk patients with associated comorbidities, especially those of a psychiatric, addictive, and social nature. Pain management in dependent patients is complex and is yet to be established. By combining the views of professionals from various specialties, we conducted an integrative review on this scope. This methodology synthesizes knowledge and results of significant practical studies to provide a narrative overview of the literature. The main results consisted in first proposing definitions that could allow shared vocabulary among health professionals regardless of their specialties. Next, a discussion was conducted around the main strategies for managing prescription opioid dependence, as well as pain in the context of opioid dependence and associated comorbidities. As a conclusion, we proposed to define the contours of holistic management by outlining the main guidelines for creating a multidisciplinary care framework for multi-comorbid patients with chronic pathologies.
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Affiliation(s)
- Célian Bertin
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France; Fondation Institut Analgesia, Faculté de Médecine, F-63001, Clermont-Ferrand, France.
| | - Noémie Delage
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France
| | - Benjamin Rolland
- Service Universitaire d'Addictologie de Lyon (SUAL), CH Le Vinatier, Université de Lyon, UCBL1, INSERM U1028, CNRS UMR 5292, Bron, France
| | - Lucie Pennel
- Service Universitaire de Pharmaco-Addictologie - CSAPA, CHU Grenoble Alpes, UFR de médecine, Université Grenoble-Alpes, 38043 Grenoble, France
| | - Mélina Fatseas
- University of Bordeaux, 33076 Bordeaux Cedex, France; CNRS-UMR 5287- Institut de Neurosciences Cognitives et Intégratives d'Aquitaine (INCIA), Bordeaux, France; CHU de Bordeaux, France
| | - Anne-Priscille Trouvin
- Centre d'Evaluation et Traitement de la Douleur, Université Paris Descartes, Hôpital Cochin, Paris, France; U987, INSERM, Boulogne Billancourt, France
| | - Jessica Delorme
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France
| | - Chouki Chenaf
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France
| | - Nicolas Authier
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France; Fondation Institut Analgesia, Faculté de Médecine, F-63001, Clermont-Ferrand, France
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Morgan MM, Peecher DL, Streicher JM. Use of home cage wheel running to assess the behavioural effects of administering a mu/delta opioid receptor heterodimer antagonist for spontaneous morphine withdrawal in the rat. Behav Brain Res 2020; 397:112953. [PMID: 33031872 DOI: 10.1016/j.bbr.2020.112953] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023]
Abstract
Opioid abuse is a major health problem. The objective of the present study was to evaluate the potentially disruptive side effects and therapeutic potential of a novel antagonist (D24M) of the mu-/delta-opioid receptor (MOR/DOR) heterodimer in male rats. Administration of high doses of D24M (1 & 10 nmol) into the lateral ventricle did not disrupt home cage wheel running. Repeated twice daily administration of increasing doses of morphine (5-20 mg/kg) over 5 days depressed wheel running and induced antinociceptive tolerance measured with the hot plate test. Administration of D24M had no effect on morphine tolerance, but tended to prolong morphine antinociception in non-tolerant rats. Spontaneous morphine withdrawal was evident as a decrease in body weight, a reduction in wheel running and an increase in sleep during the normally active dark phase of the circadian cycle, and an increase in wheel running and wakefulness in the normally inactive light phase. Administration of D24M during the dark phase on the third day of withdrawal had no effect on wheel running. These data provide additional evidence for the clinical relevance of home cage wheel running as a method to assess spontaneous opioid withdrawal in rats. These data also demonstrate that blocking the MOR/DOR heterodimer does not produce disruptive side effects or block the antinociceptive effects of morphine. Although administration of D24M had no effect on morphine withdrawal, additional studies are needed to evaluate withdrawal to continuous morphine administration and other opioids in rats with persistent pain.
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Affiliation(s)
- Michael M Morgan
- Department of Psychology, Washington State University Vancouver, 14204 NE Salmon Creek Ave., Vancouver, WA, 98686, United States.
| | - Danielle L Peecher
- Department of Psychology, Washington State University Vancouver, 14204 NE Salmon Creek Ave., Vancouver, WA, 98686, United States.
| | - John M Streicher
- Department of Pharmacology, College of Medicine, University of Arizona, LSN563, Box 245050, 1501 N. Campbell Ave., Tucson, AZ, 85724, United States.
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Dunn K, Bergeria C, Huhn AS, Strain EC. Differences in patient-reported and observer-rated opioid withdrawal symptom etiology, time course, and relationship to clinical outcome. Drug Alcohol Depend 2020; 215:108212. [PMID: 32781310 DOI: 10.1016/j.drugalcdep.2020.108212] [Citation(s) in RCA: 4] [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: 03/07/2020] [Revised: 07/18/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022]
Abstract
Although opioid withdrawal ratings are frequently used as primary outcomes for therapeutic trials, there has been limited empirical examination of opioid withdrawal symptom onset or etiology as an outcome, and also little examination of differences in outcomes between patient-reported and observer-ratings of withdrawal. Patient-reported (Subjective Opiate Withdrawal Scale, SOWS) and observer ratings (Clinical Opiate Withdrawal Scale, COWS) of opioid withdrawal collected as part of a randomized controlled residential clonidine, tramadol-extended release, and buprenorphine/naloxone 7-day taper for opioid withdrawal management were analyzed. Withdrawal ratings were collected seven times daily and primary outcomes were percent of participants (N = 103) endorsing symptoms, time of symptom onset, and relationship of scales to taper completion. Participants had variable endorsement of specific symptoms, ranging from 37 % ("feel like vomiting") to 97 % ("change in resting pulse"). Symptoms were more likely to be reported on the SOWS than COWS. Most symptoms began around 8 h after last dose, though comparison of like symptoms across the scales revealed patients reported symptoms on the SOWS > 10 h before they were observed on the COWS. SOWS peak severity score was more closely associated with taper completion than the COWS. Data suggest the patient-reported SOWS demonstrated a higher level of symptom endorsement, earlier detection of symptom onset, and better association with taper completion relative to the observer rated COWS. These data provide insight into the etiology of opioid withdrawal symptom expression and time course that can be used to inform treatment intervention timing and provide a baseline for other withdrawal evaluations.
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Affiliation(s)
- Kelly Dunn
- 5510 Nathan Shock Dr, Baltimore, MD, 21224, United States.
| | | | - Andrew S Huhn
- 5510 Nathan Shock Dr, Baltimore, MD, 21224, United States
| | - Eric C Strain
- 5510 Nathan Shock Dr, Baltimore, MD, 21224, United States
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Bergeria CL, Huhn AS, Dunn KE. The impact of naturalistic cannabis use on self-reported opioid withdrawal. J Subst Abuse Treat 2020; 113:108005. [PMID: 32359667 PMCID: PMC7212528 DOI: 10.1016/j.jsat.2020.108005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 10/17/2019] [Revised: 02/25/2020] [Accepted: 03/28/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Four states have legalized medical cannabis for the purpose of treating opioid use disorder. It is unclear whether cannabinoids improve or exacerbate opioid withdrawal. A more thorough examination of cannabis and its impact on specific symptoms of opioid withdrawal is warranted. METHOD Two hundred individuals recruited through Amazon Mechanical Turk with past month opioid and cannabis use and experience of opioid withdrawal completed the survey. Participants indicated which opioid withdrawal symptoms improved or worsened with cannabis use and indicated the severity of their opioid withdrawal on days with and without cannabis. RESULTS 62.5% (n = 125) of 200 participants had used cannabis to treat withdrawal. Participants most frequently indicated that cannabis improved: anxiety, tremors, and trouble sleeping. A minority of participants (6.0%, n = 12) indicated cannabis worsened opioid withdrawal, specifically symptoms of yawning, teary eyes, and runny nose. Across all symptoms, more participants indicated that symptoms improved with cannabis compared to those that indicated symptoms worsened with cannabis. Women reported greater relief from withdrawal with cannabis use than men. DISCUSSION These results show that cannabis may improve opioid withdrawal symptoms and that the size of the effect is clinically meaningful. It is important to note that symptoms are exacerbated with cannabis in only a minority of individuals. Prospectively designed studies examining the impact of cannabis and cannabinoids on opioid withdrawal are warranted.
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Affiliation(s)
- Cecilia L Bergeria
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, United States of America.
| | - Andrew S Huhn
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, United States of America
| | - Kelly E Dunn
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, United States of America
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Baidoo N, Wolter M, Leri F. Opioid withdrawal and memory consolidation. Neurosci Biobehav Rev 2020; 114:16-24. [PMID: 32294487 DOI: 10.1016/j.neubiorev.2020.03.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 03/20/2020] [Accepted: 03/29/2020] [Indexed: 12/14/2022]
Abstract
It is well established that learning and memory are central to substance dependence. This paper specifically reviews the effect of opioid withdrawal on memory consolidation. Although there is evidence that opioid withdrawal can interfere with initial acquisition and retrieval of older memories, there are several reasons to postulate a facilitatory action on the consolidation of newly acquired memories. In fact, there is substantial evidence that memory consolidation is facilitated by the release of stress hormones, that it requires the activation of the amygdala, of central noradrenergic and cholinergic pathways, and that it involves long-term potentiation. This review highlights evidence that very similar neurobiological processes are involved in opioid withdrawal, and summarizes recent results indicating that naltrexone-precipitated withdrawal enhanced consolidation in rats. From this neurocognitive perspective, therefore, opioid use may escalate during the addiction cycle in part because memories of stimuli and actions experienced during withdrawal are strengthened.
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Affiliation(s)
- Nana Baidoo
- Department of Psychology & Neuroscience, Guelph, Ontario, Canada
| | - Michael Wolter
- Department of Psychology & Neuroscience, Guelph, Ontario, Canada
| | - Francesco Leri
- Department of Psychology & Neuroscience, Guelph, Ontario, Canada.
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Alam D, Tirado C, Pirner M, Clinch T. Efficacy of lofexidine for mitigating opioid withdrawal symptoms: results from two randomized, placebo-controlled trials. J Drug Assess 2020; 9:13-19. [PMID: 32002194 PMCID: PMC6968526 DOI: 10.1080/21556660.2019.1704416] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/11/2019] [Indexed: 11/27/2022] Open
Abstract
Objectives Fear of opioid withdrawal syndrome (OWS) often dissuades opioid discontinuation. Lofexidine is an FDA-approved, alpha2-adrenergic receptor agonist for treatment of OWS. Pivotal trial results from the per-protocol statistical analyses have been published. However, the FDA prescribing information presents these efficacy results using a different, standardized statistical approach that does not transform data or impute missing values. This analysis is easier to interpret and allows comparison across studies. This reanalysis is presented here. Methods Studies were double-blind, placebo-controlled for 7 days in Study 1 and 5 days in Study 2. Opioid-dependent adults received placebo or lofexidine; efficacy was assessed using the Short Opioid Withdrawal Scale of Gossop (SOWS-G) daily. Results Study 1 (N = 602) mean SOWS-G scores were 6.1 (SE: 0.35), 6.5 (SE: 0.34), and 8.8 (SE: 0.47) over Days 1–7 for lofexidine 2.88 mg/day, 2.16 mg/day, and placebo, respectively (for 2.88, p < .0001; for 2.16 mg, p < .0001). Study 2 (N = 264) mean SOWS-G scores were 7.0 (SE: 0.44) and 8.9 (SE: 0.48) over Days 1–5 for lofexidine 2.16 mg/day and placebo, respectively (p = .0037). Median time to treatment discontinuation was approximately 2 days later with lofexidine treatment than with placebo and significantly more lofexidine-treated subjects completed the studies. Hypotension and bradycardia were more common with lofexidine. More placebo subjects withdrew prematurely for lack of efficacy. Conclusion This simplified analysis confirmed previous per-protocol results, that lofexidine better reduces OWS severity and increases retention compared with placebo in opioid-dependent adults. These results are robust and comparable across studies using various methods of analysis. ClinicalTrials.gov identifier Study 1, NCT01863186; Study 2 NCT00235729. URL: https://clinicaltrials.gov/
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Affiliation(s)
- Danesh Alam
- Northwestern Medicine Central DuPage Hospital, Winfield, IL, USA
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Welsch L, Bailly J, Darcq E, Kieffer BL. The Negative Affect of Protracted Opioid Abstinence: Progress and Perspectives From Rodent Models. Biol Psychiatry 2020; 87:54-63. [PMID: 31521334 PMCID: PMC6898775 DOI: 10.1016/j.biopsych.2019.07.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/04/2019] [Accepted: 07/30/2019] [Indexed: 12/20/2022]
Abstract
Opioid use disorder (OUD) is characterized by the development of a negative emotional state that develops after a history of long-term exposure to opioids. OUD represents a true challenge for treatment and relapse prevention. Human research has amply documented emotional disruption in individuals with an opioid substance use disorder, at both behavioral and brain activity levels; however, brain mechanisms underlying this particular facet of OUD are only partially understood. Animal research has been instrumental in elucidating genes and circuits that adapt to long-term opioid use or are modified by acute withdrawal, but research on long-term consequences of opioid exposure and their relevance to the negative affect of OUD remains scarce. In this article, we review the literature with a focus on two questions: 1) Do we have behavioral models in rodents, and what do they tell us? and 2) What do we know about the neuronal populations involved? Behavioral rodent models have successfully recapitulated behavioral signs of the OUD-related negative affect, and several neurotransmitter systems were identified (i.e., serotonin, dynorphin, corticotropin-releasing factor, oxytocin). Circuit mechanisms driving the negative mood of prolonged abstinence likely involve the 5 main reward-aversion brain centers (i.e., nucleus accumbens, bed nucleus of the stria terminalis, amygdala, habenula, and raphe nucleus), all of which express mu opioid receptors and directly respond to opioids. Future work will identify the nature of these mu opioid receptor-expressing neurons throughout reward-aversion networks, characterize their adapted phenotype in opioid abstinent animals, and hopefully position these primary events in the broader picture of mu opioid receptor-associated brain aversion networks.
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Affiliation(s)
- Lola Welsch
- Douglas Mental Health Institute, Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Julie Bailly
- Douglas Mental Health Institute, Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Emmanuel Darcq
- Douglas Mental Health Institute, Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Brigitte Lina Kieffer
- Douglas Mental Health Institute, Department of Psychiatry, McGill University, Montreal, Quebec, Canada.
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Darpö B, Pirner M, Longstreth J, Ferber G. Effect of lofexidine on cardiac repolarization during treatment of opioid withdrawal. Drug Alcohol Depend 2019; 205:107596. [PMID: 31606589 PMCID: PMC7153804 DOI: 10.1016/j.drugalcdep.2019.107596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 04/08/2019] [Revised: 07/19/2019] [Accepted: 07/23/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Lofexidine is a non-opioid treatment for opioid withdrawal syndrome. Its sympatholytic actions counteract the nor-adrenergic hyperactivity that occurs during abrupt opioid withdrawal. METHODS The effect of lofexidine 2.16 and 2.88 mg/day on QTcF (QT interval, heart-rate corrected, Fridericia formula) was studied as part of a large, double-blind, placebo-controlled trial (ClinicalTrials.gov identifier: NCT01863186). ECGs were time-matched to blood sampling for lofexidine concentration and were collected at prespecified timepoints over a 7-day inpatient period. Analyses included mean change-from-baseline QTcF and exposure-response modeling to predict QTcF at relevant lofexidine concentrations. RESULTS A total of 681 adult men and women received at least 1 dose of study drug; 566 qualified for inclusion in the concentration-QTcF analysis. Most subjects were withdrawing from heroin. During the first 24 h (Days 1-2) post-baseline, small increases in QTcF were observed in all groups: 4.7 ms for lofexidine 2.16 mg, 7.4 ms for lofexidine 2.88 mg and 1.4 ms for placebo. These increases were transient; by Day 4, when lofexidine levels had reached steady-state, QTcF increases were not present. By Day 7, QTcF was decreased from baseline in all groups. Exposure-response modeling predicted <10 ms increases in QTcF at lofexidine concentrations 3 times those obtained at maximal recommended dose. CONCLUSIONS Lofexidine was associated with small, transient QTcF increases. Decreases in QTcF that occurred with higher lofexidine concentrations argue for an indirect QTcF effect, potentially from changes in autonomic tone. Both opioid withdrawal and lofexidine's sympatholytic actions would be expected to alter sympathetic outflow over the 7-day withdrawal.
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Affiliation(s)
- Börje Darpö
- Department of Clinical Sciences, Karolinska Institute, Danderyd's Hospital, 182 88 Stockholm, Sweden.
| | - Mark Pirner
- Department of Clinical Research and Medical Affairs, US WorldMeds, LLC, 4441 Springdale Rd, Louisville, KY 40241, USA
| | - James Longstreth
- Longstreth and Associates, Inc., 450 N Lakeshore Dr, Mundelein, IL 60060, USA
| | - Georg Ferber
- Statistik Georg Ferber GmbH, Cagliostrostrasse 14, 4125 Riehen, Switzerland
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Chhabra N, Aks SE. Treatment of acute naloxone-precipitated opioid withdrawal with buprenorphine. Am J Emerg Med 2019; 38:691.e3-691.e4. [PMID: 31753622 DOI: 10.1016/j.ajem.2019.09.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/24/2019] [Indexed: 11/18/2022] Open
Abstract
Naloxone is a frequently utilized and effective treatment to reverse the life-threatening effects of illicit opioid intoxication. Excessive naloxone dosing in these circumstances, however, may lead to naloxone-precipitated opioid withdrawal in individuals with opioid dependence. Buprenorphine, a partial mu-opioid agonist, is increasingly utilized in the Emergency Department (ED) for the treatment of opioid withdrawal syndrome but little is known regarding its utility in cases of naloxone-precipitated opioid withdrawal. We report a case of naloxone-precipitated opioid withdrawal that was effectively treated with sublingual buprenorphine. An older male was brought into the ED with signs and symptoms of opioid toxicity that was successfully treated with pre-hospital naloxone by Emergency Medical Services. He had a clinical opioid withdrawal scale (COWS) or 10 with abdominal cramping and unintentional defecation. After a discussion of treatment options and possible adverse effects with the patient, the decision was made to administer 4 mg/1 mg of sublingual buprenorphine/naloxone film. The patient reported a rapid improvement in symptoms and at 30 min posttreatment, his COWS was 4. His COWS decreased to 3 at 1 h and this was sustained for 4 h of observation. The patient was subsequently discharged to a treatment facility for opioid use disorder. This case highlights the potential of buprenorphine as a treatment modality for acute naloxone-precipitated opioid withdrawal. Due to the risks of worsening or sustained buprenorphine-precipitated opioid withdrawal, further research is warranted to identify patients who may benefit from this therapy.
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Affiliation(s)
- Neeraj Chhabra
- Cook County Health, Department of Emergency Medicine, Division of Medical Toxicology, 1950 West Polk Street, 7th floor, cubicle 85, Chicago, IL 60612, United States.
| | - Steven E Aks
- Cook County Health, Department of Emergency Medicine, Division of Medical Toxicology, Chicago, IL, United States
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Levin CJ, Wai JM, Jones JD, Comer SD. Changes in cardiac vagal tone as measured by heart rate variability during naloxone-induced opioid withdrawal. Drug Alcohol Depend 2019; 204:107538. [PMID: 31513980 PMCID: PMC7017784 DOI: 10.1016/j.drugalcdep.2019.06.040] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/03/2019] [Accepted: 06/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Heart rate variability (HRV) is of interest to researchers due to its potential utility as a marker for both physiological and psychological stress. Sympatholytics are used to treat opioid withdrawal, but little information about the parasympathetic system's role in mediating withdrawal symptoms exists. The goal of the current study was to evaluate changes in HRV during opioid withdrawal to provide a better understanding of the autonomic effects of opioid withdrawal. METHODS Ten male participants (mean age = 46.4 years) received intramuscular naloxone (mean dose =0.26 mg) to confirm opioid dependence. The presence and severity of withdrawal symptoms were assessed using subjective and objective measures (Wang et al., 1974). Electrocardiography (ECG) was measured continuously, and HRV was analyzed in 2-minute segments before naloxone injection (at baseline) and after participants were in moderate withdrawal (Wang Test score ≥10). Heart rate, blood pressure, pupil diameter, and respiratory rate were also examined. RESULTS Pupil diameter significantly increased after naloxone administration relative to baseline (t(9) = 5.562, p = 0.000). Both high frequency (HF) HRV (Z = -2.803, p = 0.005) and root mean square of successive differences (RMSSD) HRV (Z = -2.090, p = 0.037) were significantly lower during withdrawal relative to baseline. Increases in heart rate (Z = -2.090, p = 0.032) and systolic pressure (t(9) = 8.099, p = 0.0000) from baseline to withdrawal also were significant. CONCLUSIONS These preliminary data indicate that a large reduction in cardiac vagal tone occurs during naloxone-induced withdrawal. This finding underscores the need for further research into the role of the parasympathetic nervous system in opioid withdrawal.
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Affiliation(s)
- Charles J Levin
- Division on Substance Use Disorders, New York State Psychiatric Institute and Columbia University Vagelos College of Physicians and Surgeons, 1051 Riverside Drive, New York, NY, 10032, USA.
| | - Jonathan M Wai
- Division on Substance Use Disorders, New York State Psychiatric Institute and Columbia University Vagelos College of Physicians and Surgeons, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Jermaine D Jones
- Division on Substance Use Disorders, New York State Psychiatric Institute and Columbia University Vagelos College of Physicians and Surgeons, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Sandra D Comer
- Division on Substance Use Disorders, New York State Psychiatric Institute and Columbia University Vagelos College of Physicians and Surgeons, 1051 Riverside Drive, New York, NY, 10032, USA
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Bergeria CL, Huhn AS, Tompkins DA, Bigelow GE, Strain EC, Dunn KE. The relationship between pupil diameter and other measures of opioid withdrawal during naloxone precipitated withdrawal. Drug Alcohol Depend 2019; 202:111-114. [PMID: 31336328 PMCID: PMC6745696 DOI: 10.1016/j.drugalcdep.2019.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 04/29/2019] [Accepted: 05/03/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Understanding mechanisms of physiological opioid withdrawal symptoms can inform treatment strategies. This secondary analysis evaluated the association between mydriasis (dilated pupils), a commonly-assessed opioid withdrawal metric, with self- and observer-rated opioid withdrawal severity. METHOD Ninety-five participants with opioid physical dependence were stabilized with morphine before receiving an injection of the opioid antagonist naloxone to precipitate withdrawal. Pupil diameter, the Subjective Opiate Withdrawal Scale (SOWS), and the Clinical Opiate Withdrawal Scale (COWS) were collected at baseline and in 15-minute intervals for 120 min following naloxone administration. Pearson product-moment correlations and linear regressions characterized the relationships between pupil measurements (baseline and peak naloxone-induced) and self- and observer-rated measures of withdrawal. Repeated-measures ANOVAs tested whether self and observer-rated withdrawal severity corresponded to unique patterns in pupil changes. RESULTS Baseline pupil diameter significantly correlated with SOWS and COWS peak scores. Peak naloxone-induced pupil diameter significantly correlated with SOWS scores only. Peak changes in pupil from baseline did not correspond to peak changes in self- and observer-rated withdrawal scales. CONCLUSIONS This study suggests that pupil diameter measurements were more closely associated with acute opioid withdrawal severity than changes in pupil diameter. Prospective research examining the mechanisms underlying the relationship between pupil diameter and opioid withdrawal severity are warranted.
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Affiliation(s)
- Cecilia L Bergeria
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - D Andrew Tompkins
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - George E Bigelow
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Pergolizzi JV, Varrassi G, Paladini A, LeQuang J. Stopping or Decreasing Opioid Therapy in Patients on Chronic Opioid Therapy. Pain Ther 2019; 8:163-76. [PMID: 31378000 DOI: 10.1007/s40122-019-00135-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Indexed: 12/19/2022] Open
Abstract
With the rising concerns about long-term opioid use, particularly in patients with chronic noncancer pain, more and more patients are being considered for decreased doses or discontinuation of opioid therapy. This is a challenging clinical situation for both patient and clinician and should be presented in a shared decision-making model so that the patient understands the risks of opioid therapy and how the therapy will be discontinued. The patient should be aware of the long-range plan and its milestones. It is imperative that alternate pain control treatments be made available to the patient early, and that the patient never feels abandoned by the healthcare team. There can be many barriers in shared decision-making and multiple discussions between patient and provider may be required. Opioid use should not be decreased sharply or discontinued abruptly, but should be gradually decremented in a process known as tapering. Tapering should be systematic and planned in advance with the patient knowing the steps. Slow tapers (over months) are more comfortable for the patients but may not always be appropriate. There is guidance for planning the taper and the patient should be closely monitored throughout this process. If withdrawal symptoms occur, they can be managed, for example, with lofexidine. Patients should get full support as they explore new pain control options. For patients who have opioid use disorder, addiction counseling may be appropriate. Navigating opioid discontinuation can be slow work, but optimal results occur when the healthcare team works together and respectfully with the patient.
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Abstract
The neuropeptide Oxytocin (ΟΤ) is involved as a neurohormone, a neurotransmitter, or a neuromodulator in an extensive range of central and peripheral effects, complex emotional and social human behaviors, memory and learning processes. It is implicated in homeostatic, neuroadaptive processes associated with stress responses and substance use via interactions with the hypothalamic-pituitary-adrenal (HPA) axis and the dopamine mesolimbic reward stress system. This chapter reviews the preclinical and clinical literature on the complicated relationships between endogenous and exogenous opioids and ΟΤ systems and attempts to highlight key findings to date on the effectiveness of intranasal OT administration to treat opioid use disorders. OΤ seems to attenuate, even inhibit, the development of opioid use disorders in preclinical models but is still under clinical research as a promising pharmacological agent in the treatment of opioid use related behaviors. Evidence suggests a role for OT as an adjunctive or stand-alone treatment of behavioral, cognitive and emotional deficits associated with substance use, which may be responsible for seeking behavior and relapse. The mechanisms by which oxytocin acts to reverse the neural substrates of these deficits, partially due to substance induced alterations of the endogenous OT system, and thus modify the behavioral response to substance use are discussed. Other clinically relevant issues are also discussed.
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Abstract
Fear of withdrawal symptoms has been cited by survey respondents as the main reason that they continued to use opioids. Lofexidine is an α2-adrenergic agonist that decreases the sympathetic outflow that results in the characteristic symptoms of opioid withdrawal. A structural analog of clonidine, lofexidine has a higher affinity and specificity for the α2a receptors and does not reinforce opioid dependence. Withdrawal symptoms correlate approximately to the half-life of the opioid; patient factors such as age, duration of opioid exposure, physical status, and other considerations may influence the nature and duration of withdrawal symptoms. For patients with opioid use disorder and psychiatric comorbidities, withdrawal may be destabilizing and may exacerbate mental health status. Lofexidine has been shown in clinical trials to be safe and effective in helping to manage the symptoms of withdrawal and has been recommended in guidelines for this purpose. Adverse events associated with lofexidine include QT prolongation, hypotension, orthostasis, and bradycardia. The maximum course of treatment is 14 days, and doses should be titrated, with the recommended maximum dose to coincide with the most severe withdrawal symptoms (about 5-7 days after opioid discontinuation).
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Coloma-Carmona A, Carballo JL, Rodríguez-Marín J, Pérez-Carbonell A. Withdrawal symptoms predict prescription opioid dependence in chronic pain patients. Drug Alcohol Depend 2019; 195:27-32. [PMID: 30562677 DOI: 10.1016/j.drugalcdep.2018.11.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 10/24/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The last version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes substantial changes for prescription opioid-use disorder (POUD). After its removal as a criterion, the goal of this study was to estimate the prevalence of withdrawal symptoms in long-term users of prescription opioids and its association with the new DSM-5 POUD classification. METHODS Data were collected from 215 long-term consumers of opioid medication who were chronic non-cancer pain patients. Participants completed sociodemographic, Adjective Rating Scale for Withdrawal (ARSW), opioid treatment characteristics, POUD criteria (DSM-5), and pain intensity measurements. RESULTS 26.6% of the participants were classified with moderate to severe POUD. Higher intensity of withdrawal symptoms was found in patients with moderate/severe POUD, younger age, and higher pain intensity (p < .01). Anxiolytics (p < .01) and antidepressants use (p < .05) and percentage of smokers (p < .05) were significantly higher in patients with severe withdrawal. Logistic regression analyses suggested moderate [odds ratio (OR) = 3.25] and severe (OR = 10.52) withdrawal as the strongest predictor of POUD. Age, anxiolytics use, and smoking were also associated with POUD, but multilevel analysis showed that these variables do not moderate the association between withdrawal intensity and POUD. CONCLUSION Escalation of withdrawal intensity during opioid treatment can be used to identify patients with POUD. Further studies are needed to assess the clinical implications of these findings during long-term opioid therapy for chronic pain.
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Affiliation(s)
- Ainhoa Coloma-Carmona
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, 03202, Elche, Spain.
| | - José L Carballo
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, 03202, Elche, Spain.
| | - Jesús Rodríguez-Marín
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, 03202, Elche, Spain.
| | - Ana Pérez-Carbonell
- University General Hospital of Elche, Camino de la Almazara, 11, 03203, Elche, Spain.
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Abstract
Background Opioid use disorder is one of the most prevalent addiction problems worldwide. Buprenorphine is used as a medication to treat this disorder, but in countries where buprenorphine is unavailable in combination with naloxone, diversion can be a problem if the medication is given outside a hospital setting. Objective The objective of this research is to evaluate the effect of a single, high dose of buprenorphine on craving in opioid-dependent patients over 5 days of abstinence from use of other opioids. The primary goal was to determine the safety and efficacy of buprenorphine during withdrawal in a hospital setting. Methods Ninety men who used opium, heroin, or prescribed opioids and met DSM-5 criteria for opioid use disorder (severe form) were randomized to three groups (n = 30 per group) to receive a single, sublingual dose of buprenorphine (32, 64, or 96 mg). The study was conducted in an inpatient psychiatric ward, with appropriate precautions and monitoring of respiratory and cardiovascular measures. Buprenorphine was administered when the patients were in moderate opiate withdrawal, as indicated by the presence of four to five symptoms. A structured clinical interview was conducted, and urine toxicology testing was performed at baseline. Self-reports of craving were obtained at baseline and on each of the 5 days after buprenorphine administration. Findings Craving decreased from baseline in each of the three groups (p < 0.0001), with a significant interaction between group and time (p < 0.038), indicating that groups with higher doses of buprenorphine had greater reduction. Conclusions A single, high dose of buprenorphine can reduce craving during opioid withdrawal; additional studies with follow-up are warranted to evaluate safety.
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Affiliation(s)
- Jamshid Ahmadi
- Substance Abuse Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | | | - Dara Ghahremani
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, California, USA
| | - Edythe D London
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, California, USA.,Department of Molecular and Medical Pharmacology, University of California at Los Angeles, Los Angeles, California, USA.,Brain Research Institute, University of California at Los Angeles, Los Angeles, California, USA
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Schroeder JR, Phillips KA, Epstein DH, Jobes ML, Furnari MA, Kennedy AP, Heilig M, Preston KL. Assessment of pioglitazone and proinflammatory cytokines during buprenorphine taper in patients with opioid use disorder. Psychopharmacology (Berl) 2018; 235:2957-66. [PMID: 30079432 DOI: 10.1007/s00213-018-4986-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 07/24/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Preliminary evidence suggested that the PPARγ agonist pioglitazone reduces opioid-withdrawal symptoms, possibly by inhibiting increases in proinflammatory cytokines. METHODS A randomized, placebo-controlled clinical trial was conducted utilizing two different study designs (entirely outpatient, and a combination of inpatient and outpatient) to evaluate the safety and efficacy of pioglitazone as an adjunct medication for people with opioid physical dependence undergoing a buprenorphine taper. Participants were stabilized on buprenorphine/naloxone (sublingual, up to 16/4 mg/day), then randomized to receive oral pioglitazone (up to 45 mg/day) or placebo before, during, and after buprenorphine taper. Outcome measures included the Subjective Opiate Withdrawal Scale (SOWS) and Clinical Opiate Withdrawal Scale, use of rescue medications to alleviate opioid withdrawal symptoms, and opioid-positive urine specimens. Cerebrospinal fluid (CSF) and plasma were collected during the taper in a subset of participants for measurement of proinflammatory cytokines. RESULTS The clinical trial was prematurely terminated due to slow enrollment; 40 participants per group were required for adequate statistical power to test study hypotheses. Twenty-four participants enrolled; 17 received at least one dose of study medication (6 pioglitazone, 11 placebo). SOWS scores were higher in the pioglitazone arm than in the placebo arm after adjusting for use of rescue medications; participants in the pioglitazone arm needed more rescue medications than the placebo arm during the post-taper phase. SOWS scores were positively correlated with monocyte chemoattractant protein-1 (MCP-1) in CSF (r = 0.70, p = 0.038) and plasma (r = 0.77, p = 0.015). Participants having higher levels of plasma MCP-1 reported higher SOWS, most notably after the buprenorphine taper ended. CONCLUSIONS Results from this study provide no evidence that pioglitazone reduces opioid withdrawal symptoms during buprenorphine taper. High correlations between MCP-1 and opioid withdrawal symptoms support a role of proinflammatory processes in opioid withdrawal. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT01517165.
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Bisaga A, Mannelli P, Yu M, Nangia N, Graham CE, Tompkins DA, Kosten TR, Akerman SC, Silverman BL, Sullivan MA. Outpatient transition to extended-release injectable naltrexone for patients with opioid use disorder: A phase 3 randomized trial. Drug Alcohol Depend 2018; 187:171-178. [PMID: 29674251 DOI: 10.1016/j.drugalcdep.2018.02.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Injectable extended-release naltrexone (XR-NTX), approved to prevent relapse to opioid dependence, requires initial abstinence. This multisite outpatient clinical trial examined the efficacy and safety of low-dose oral naltrexone (NTX), combined with a brief buprenorphine (BUP) taper and standing ancillary medications, for detoxification and induction onto XR-NTX. METHODS Patients (N = 378) were randomized, stratified by primary short-acting opioid-of-use, to one of three regimens: NTX + BUP; NTX + placebo BUP (PBO-B); placebo NTX (PBO-N) + PBO-B. Patients received 7 days of ascending NTX or placebo, concurrent with a 3-day BUP or placebo taper, and ancillary medications in an outpatient setting. Daily psychoeducational counseling was provided. On Day 8, patients passing a naloxone challenge received XR-NTX. RESULTS Rates of transition to XR-NTX were comparable across groups: NTX/BUP (46.0%) vs. NTX/PBO-B (40.5%) vs. PBO-N/PBO-B (46.0%). Thus, the study did not meet its primary endpoint. Adverse events, reported by 32.5% of all patients, were mild to moderate in severity and consistent with opioid withdrawal. A first, second, and third XR-NTX injection was received by 44.4%, 29.9%, and 22.5% of patients, respectively. Compared with the PBO-N/PBO-B group, the NTX/BUP group demonstrated higher opioid abstinence during the transition and lower post-XR-NTX subjective opioid withdrawal scores. CONCLUSIONS A 7-day detoxification protocol with NTX alone or NTX + BUP provided similar rates of induction to XR-NTX as placebo. For those inducted onto XR-NTX, management of opioid withdrawal symptoms prior to induction was achieved in a structured outpatient setting using a well-tolerated, fixed-dose ancillary medication regimen common to all three groups.
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Affiliation(s)
- Adam Bisaga
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, 1051 Riverside Dr., Unit #120, New York, NY, 10032, USA.
| | - Paolo Mannelli
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 2213 Elba Street, Suite 156, DUMC 3074, Durham, NC, 27705, USA
| | - Miao Yu
- Alkermes, Inc., 852 Winter Street, Waltham, MA, 02451, USA
| | | | | | - D Andrew Tompkins
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
| | - Thomas R Kosten
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | | | | | - Maria A Sullivan
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, 1051 Riverside Dr., Unit #120, New York, NY, 10032, USA; Alkermes, Inc., 852 Winter Street, Waltham, MA, 02451, USA
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Chu LF, Rico T, Cornell E, Obasi H, Encisco EM, Vertelney H, Gamble JG, Crawford CW, Sun J, Clemenson A, Erlendson MJ, Okada R, Carroll I, Clark JD. Ondansetron does not prevent physical dependence in patients taking opioid medications chronically for pain control. Drug Alcohol Depend 2018; 183:176-183. [PMID: 29278818 PMCID: PMC6092026 DOI: 10.1016/j.drugalcdep.2017.06.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 12/19/2016] [Revised: 04/26/2017] [Accepted: 06/01/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES In this study, we investigated the co-administration of ondansetron with morphine, and whether it could prevent the development of physical dependence in patients taking opioids for the treatment of chronic pain. METHODS A total of 48 chronic back pain patients (N = 48) participated in this double-blinded, placebo-controlled, randomized study. Patients were titrated onto sustained-release oral morphine and randomized to take 8 mg ondansetron or placebo three times daily concurrently with morphine during the 30-day titration. Following titration, patients underwent Naloxone induced opioid withdrawal. Opioid withdrawal signs and symptoms were then assessed by a blinded research assistant (objective opioid withdrawal score: OOWS) and by the research participant (subjective opioid withdrawal score: SOWS). RESULTS We observed clinically significant signs of naloxone-precipitated opioid withdrawal in all participants (ΔOOWS = 4.3 ± 2.4, p < 0.0001; ΔSOWS = 14.1 ± 11.7, p < 0.0001), however no significant differences in withdrawal scores were detected between treatment groups. CONCLUSION We hypothesized that ondansetron would prevent the development of physical dependence in human subjects when co-administered with opioids, but found no difference in naloxone-precipitated opioid withdrawal scores between ondansetron and placebo treatment groups. These results suggest that further studies are needed to determine if 5HT3 receptor antagonists are useful in preventing opioid physical dependence.
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Affiliation(s)
- Larry F. Chu
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - Tom Rico
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - Erika Cornell
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - Hannah Obasi
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - Ellen M. Encisco
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - Haley Vertelney
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - Jamison G. Gamble
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - Clayton W. Crawford
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - John Sun
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - Anna Clemenson
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - Matthew J. Erlendson
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - Robin Okada
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - Ian Carroll
- Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Drive, Grant Building Room S268C, Stanford, CA, 94305
| | - J. David Clark
- Veterans Affairs Palo Alto Healthcare System, 3801 Miranda Avenue, Palo Alto, CA 94304
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Rudolf G, Walsh J, Plawman A, Gianutsos P, Alto W, Mancl L, Rudolf V. A novel non-opioid protocol for medically supervised opioid withdrawal and transition to antagonist treatment. Am J Drug Alcohol Abuse 2017; 44:302-309. [PMID: 28795846 DOI: 10.1080/00952990.2017.1334209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The clinical feasibility of a novel non-opioid and benzodiazepine-free protocol was assessed for the treatment of medically supervised opioid withdrawal and transition to subsequent relapse prevention strategies. METHODS A retrospective chart review of DSM-IV diagnosed opioid-dependent patients admitted for inpatient medically supervised withdrawal examined 84 subjects (52 males, 32 females) treated with a 4-day protocol of scheduled tizanidine, hydroxyzine, and gabapentin. Subjects also received ancillary medications as needed, and routine counseling. Primary outcomes were completion of medically supervised withdrawal, and initiation of injectable extended release (ER) naltrexone treatment. Secondary outcomes included the length of hospital stay, Clinical Opiate Withdrawal Scale (COWS) scores, and facilitation to substance use disorder treatment intervention. Ancillary medication use and adverse effects were also assessed. RESULTS A total of 79 (94%) of subjects completed medically supervised withdrawal. A total of 27 (32%) subjects chose to pursue transition to ER naltrexone, and 24 of the 27 (89%) successfully received the injection prior to hospital discharge. The protocol subjects had a mean length of hospital stay of 3.6 days, and the mean COWS scores was 3.3, 3.4, 2.8, and 2.4 on Day 1, 2, 3, and 4, respectively. Furthermore, 71 (85%) engaged in an inpatient or outpatient substance use disorder (SUD) treatment program following protocol completion. CONCLUSION This retrospective chart review suggests the feasibility of a novel protocol for medically supervised opioid withdrawal and transition to relapse prevention strategies, including injectable ER naltrexone. This withdrawal protocol does not utilize opioid agonists or other controlled substances..
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Affiliation(s)
- Gregory Rudolf
- a Department of Pain Services , Swedish Medical Center , Seattle , WA , USA
| | - Jim Walsh
- b Addiction Recovery Service, Swedish Medical Center , Seattle , WA , USA
| | - Abigail Plawman
- b Addiction Recovery Service, Swedish Medical Center , Seattle , WA , USA
| | - Paul Gianutsos
- c Department of Family Medicine , Swedish Medical Center Cherry Hill Campus , Seattle , WA , USA
| | - William Alto
- c Department of Family Medicine , Swedish Medical Center Cherry Hill Campus , Seattle , WA , USA
| | - Lloyd Mancl
- d Department of Biostatistics , University of Washington , Seattle , WA , USA
| | - Vania Rudolf
- b Addiction Recovery Service, Swedish Medical Center , Seattle , WA , USA
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Abstract
The rate of opioid overdose continues to rise, necessitating improved treatment options. Current therapeutic approaches rely on administration of either a blocking agent, such as naloxone, or chronic treatment with replacement drugs, including methadone and/or buprenorphine. Recent findings suggest that males and females respond to these treatments uniquely. In an effort to better understand this sex-specific variation in treatment efficacy, we investigated the effects of acute opioid withdrawal in male and female rats using 18FDG and microPET. These data demonstrate that acute opioid withdrawal produces metabolic alterations in brain regions associated with reward and drug dependence, namely corpus striatum, thalamic nuclei, septum, and frontal cortex. Furthermore, certain changes are unique to males. Specifically, males demonstrated increased metabolism in the anterior cingulate cortex and the ventral hippocampus (CA3) following acute opioid withdrawal. If males and females exhibit sex-specific changes in regional brain metabolism following acute opioid withdrawal, then perhaps it is not surprising that they respond to treatment differently.
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Affiliation(s)
- Giovanni C Santoro
- Center for Neurosciences, Laboratory for Molecular and Behavioral Neuroimaging, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Joseph Carrion
- Center for Neurosciences, Laboratory for Molecular and Behavioral Neuroimaging, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Stephen L Dewey
- Center for Neurosciences, Laboratory for Molecular and Behavioral Neuroimaging, Feinstein Institute for Medical Research, Manhasset, NY, USA
- Psychiatry Department, New York University School of Medicine, NY, USA
- Department of Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY, USA
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Kandasamy R, Lee AT, Morgan MM. Depression of home cage wheel running is an objective measure of spontaneous morphine withdrawal in rats with and without persistent pain. Pharmacol Biochem Behav 2017; 156:10-15. [PMID: 28366799 DOI: 10.1016/j.pbb.2017.03.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 03/03/2017] [Accepted: 03/30/2017] [Indexed: 01/31/2023]
Abstract
Opioid withdrawal in humans is often subtle and almost always spontaneous. In contrast, most preclinical studies precipitate withdrawal by administration of an opioid receptor antagonist such as naloxone. These animal studies rely on measurement of physiological symptoms (e.g., wet dog shakes) in the period immediately following naloxone administration. To more closely model the human condition, we tested the hypothesis that depression of home cage wheel running will provide an objective method to measure the magnitude and duration of spontaneous morphine withdrawal. Rats were allowed access to a running wheel in their home cage for 8days prior to implantation of two 75mg morphine or placebo pellets. The pellets were removed 3 or 5days later to induce spontaneous withdrawal. In normal pain-free rats, removal of the morphine pellets depressed wheel running for 48h compared to rats that had placebo pellets removed. Morphine withdrawal-induced depression of wheel running was greatly enhanced in rats with persistent inflammatory pain induced by injection of Complete Freund's Adjuvant (CFA) into the hindpaw. Removal of the morphine pellets following 3days of treatment depressed wheel running in these rats for over 6days. These data demonstrate that home cage wheel running provides an objective and more clinically relevant method to assess spontaneous morphine withdrawal compared to precipitated withdrawal in laboratory rats. Moreover, the enhanced withdrawal in rats with persistent inflammatory pain suggests that pain patients may be especially susceptible to opioid withdrawal.
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Affiliation(s)
- Ram Kandasamy
- Graduate Program in Neuroscience, Washington State University, Pullman, WA, USA.
| | - Andrea T Lee
- Department of Psychology, Washington State University Vancouver, Vancouver, WA, USA
| | - Michael M Morgan
- Graduate Program in Neuroscience, Washington State University, Pullman, WA, USA; Department of Psychology, Washington State University Vancouver, Vancouver, WA, USA
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Lalanne L, Nicot C, Lang JP, Bertschy G, Salvat E. Experience of the use of Ketamine to manage opioid withdrawal in an addicted woman: a case report. BMC Psychiatry 2016; 16:395. [PMID: 27832755 PMCID: PMC5105239 DOI: 10.1186/s12888-016-1112-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 11/04/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Opioids are good painkillers, but many patients treated with opioids as painkillers developed a secondary addiction. These patients need to stop misusing opioids, but the mild-to-severe clinical symptoms associated with opioid withdrawal risk increasing their existing pain. In such cases, ketamine, which is used by anaesthetists and pain physicians to reduce opioid medication, may be an effective agent for managing opioid withdrawal. CASE PRESENTATION We describe the case of a woman who developed a severe secondary addiction to opioids in the context of lombo-sciatic pain. She presented a severe opioid addiction, and her physicians refused to prescribe such high doses of opioid treatment (oxycontin® extended-release 120 mg daily, oxycodone 60 mg daily, and acetaminophen/codeine 300 mg/25 mg 6 times per day). To assist her with her opioid withdrawal which risked increasing her existing pain, she received 1 mg/kg ketamine oral solution, and two days after ketamine initiation her opioid treatment was gradually reduced. The patient dramatically reduced the dosage of opioid painkillers and ketamine was withdrawn without any withdrawal symptoms. CONCLUSION Ketamine displays many interesting qualities for dealing with all symptoms relating to opioid withdrawal. Accordingly, it could be used instead of many psychotropic treatments, which interact with each other, to help with opioid withdrawal. However, the literature describes addiction to ketamine. All in all, although potentially addictive, ketamine could be a good candidate for the pharmacological management of opioid withdrawal.
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Affiliation(s)
- Laurence Lalanne
- Department of Psychiatry and Addictology, Fédération de Médecine Translationnelle de Strasbourg (FMTS), University Hospital of Strasbourg, Strasbourg, France
- INSERM 1114, Fédération de Médecine Translationnelle de Strasbourg (FTMS), University Hospital of Strasbourg, Strasbourg, France
| | - Chloe Nicot
- Department of Psychiatry and Addictology, Fédération de Médecine Translationnelle de Strasbourg (FMTS), University Hospital of Strasbourg, Strasbourg, France
| | - Jean-Philippe Lang
- Department of Psychiatry and Addictology, Fédération de Médecine Translationnelle de Strasbourg (FMTS), University Hospital of Strasbourg, Strasbourg, France
| | - Gilles Bertschy
- Department of Psychiatry and Addictology, Fédération de Médecine Translationnelle de Strasbourg (FMTS), University Hospital of Strasbourg, Strasbourg, France
- INSERM 1114, Fédération de Médecine Translationnelle de Strasbourg (FTMS), University Hospital of Strasbourg, Strasbourg, France
| | - Eric Salvat
- Centre d’Evaluation et de Traitement de la Douleur, University Hospital of Strasbourg, Strasbourg, France
- Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, Strasbourg, France
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