opioid-use disorder

Objectives. Chronic pain is common, and opioid therapy is frequently prescribed for this condition. This report updates and expands on a prior Comparative Effectiveness Review on long-term (≥1 year) effectiveness and harms of opioid therapy for chronic pain, including evidence on shorter term (1 to 12 months) outcomes.

Data sources. A prior systematic review (searches through January 2014), electronic databases (Ovid MEDLINE®, Embase®, PsycINFO®, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews through August 2019), reference lists, and clinical trials registries.

Review methods. Predefined criteria were used to select studies of patients with chronic pain prescribed opioids that addressed effectiveness or harms versus placebo, no opioid use, or nonopioid pharmacological therapies; different opioid dosing methods; or risk mitigation strategies. Effects were analyzed at short-term (1 to <6 months), intermediate-term (≥6 to <12 months), and long-term (≥12 months) followup. Studies on the accuracy of risk prediction instruments for predicting opioid use disorder or misuse were also included. Random effects meta-analysis was conducted on short-term trials of opioids versus placebo, opioids versus nonopioids, and opioids plus nonopioids versus an opioid or nonopioid alone. Magnitude of effects was classified as small, moderate, or large using predefined criteria, and strength of evidence was assessed.

Results. We included 115 randomized controlled trials (RCTs), 40 observational studies, and 7 studies of predictive accuracy; 134 were new to this update. Opioids were associated with small benefits versus placebo in short-term pain, function, and sleep quality. There was a small dose-dependent effect on pain, and effects were attenuated at longer (3 to 6 month) versus shorter (1 to 3 month) followup. Opioids were associated with increased risk of discontinuation due to adverse events, gastrointestinal adverse events, somnolence, dizziness, and pruritus versus placebo. In observational studies, opioids were associated with increased risk of an opioid abuse or dependence diagnosis, overdose, all-cause mortality, fractures, falls, and myocardial infarction versus no opioid use; there was evidence of a dose-dependent risk for all outcomes except fracture and falls.

There were no differences between opioids and nonopioid medications in pain, function, or other short-term outcomes. Opioid plus nonopioid combination therapy was associated with little improvement in pain at short-term followup versus an opioid alone. Co-prescription of benzodiazepines or gabapentinoids was associated with increased risk of overdose versus an opioid alone. No RCT evaluated intermediate- or long-term benefits of opioids versus placebo. One trial found stepped therapy starting with opioids to be associated with higher pain intensity and no difference in function or other outcomes versus stepped therapy starting with nonopioid therapy.

Limited evidence indicated no differences between long- and short-acting opioids in effectiveness, but long-acting opioids were associated with increased risk of overdose. One RCT found a taper support intervention associated with greater improvement in function but no difference in pain versus usual care.

Estimates of diagnostic accuracy for various risk prediction instruments were highly inconsistent, and there was no evidence on the effectiveness of risk mitigation strategies for improving clinical outcomes, with the exception of one study that found provision of naloxone associated with decreased emergency department visits.

Trials of patients with prescription opioid dependence found buprenorphine maintenance associated with better outcomes than buprenorphine taper and similar effects of methadone versus buprenorphine. Evidence was insufficient to evaluate benefits and harms of opioid therapy in patients at higher risk for opioid use disorder.

Conclusions. At short-term followup, for patients with chronic pain, opioids are associated with small beneficial effects versus placebo but are associated with increased risk of short-term harms and do not appear to be superior to nonopioid therapy. Evidence on intermediate-term and long-term benefits remains very limited, and additional evidence confirms an association between opioids and increased risk of serious harms that appears to be dose-dependent. Research is needed to develop accurate risk prediction instruments, determine effective risk mitigation strategies, clarify risks associated with co-prescribed medications, and identify optimal opioid tapering strategies.

Author/s:

Chou, R, Hartung, D, Turner, J, Blazina, I, Chan, B, Levander, X, McDonagh, M, Selph, S, Fu, Pappas

Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder

John Bayhi — Fri, 07 Feb 2020 13:59:45 +0000

Date Added:

February 7, 2020

Journal/Publication:

JAMA Network Open

Publisher:

American Medical Association

Publication Date:

February 5, 2020

Issue:

Volume:

Pages:

e1920622

URL:

Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2019.20622

Keywords

PMID (1):

32022884

MeSH

retrospective studies

Inpatients

outpatients

Comparative Effectiveness Research

opioid-related disorders

If the goal is to reduce overdoses and ED visits, the best treatment options appear to include buprenorphine or methadone. James W. Mold, MD, MPH

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IMPORTANCE:

Although clinical trials demonstrate the superior effectiveness of medication for opioid use disorder (MOUD) compared with nonpharmacologic treatment, national data on the comparative effectiveness of real-world treatment pathways are lacking.

OBJECTIVE:

To examine associations between opioid use disorder (OUD) treatment pathways and overdose and opioid-related acute care use as proxies for OUD recurrence.

DESIGN, SETTING, AND PARTICIPANTS:

This retrospective comparative effectiveness research study assessed deidentified claims from the OptumLabs Data Warehouse from individuals aged 16 years or older with OUD and commercial or Medicare Advantage coverage. Opioid use disorder was identified based on 1 or more inpatient or 2 or more outpatient claims for OUD diagnosis codes within 3 months of each other; 1 or more claims for OUD plus diagnosis codes for opioid-related overdose, injection-related infection, or inpatient detoxification or residential services; or MOUD claims between January 1, 2015, and September 30, 2017. Data analysis was performed from April 1, 2018, to June 30, 2019.

EXPOSURES:

One of 6 mutually exclusive treatment pathways, including (1) no treatment, (2) inpatient detoxification or residential services, (3) intensive behavioral health, (4) buprenorphine or methadone, (5) naltrexone, and (6) nonintensive behavioral health.

MAIN OUTCOMES AND MEASURES:

Opioid-related overdose or serious acute care use during 3 and 12 months after initial treatment.

RESULTS:

A total of 40 885 individuals with OUD (mean [SD] age, 47.73 [17.25] years; 22 172 [54.2%] male; 30 332 [74.2%] white) were identified. For OUD treatment, 24 258 (59.3%) received nonintensive behavioral health, 6455 (15.8%) received inpatient detoxification or residential services, 5123 (12.5%) received MOUD treatment with buprenorphine or methadone, 1970 (4.8%) received intensive behavioral health, and 963 (2.4%) received MOUD treatment with naltrexone. During 3-month follow-up, 707 participants (1.7%) experienced an overdose, and 773 (1.9%) had serious opioid-related acute care use. Only treatment with buprenorphine or methadone was associated with a reduced risk of overdose during 3-month (adjusted hazard ratio [AHR], 0.24; 95% CI, 0.14-0.41) and 12-month (AHR, 0.41; 95% CI, 0.31-0.55) follow-up. Treatment with buprenorphine or methadone was also associated with reduction in serious opioid-related acute care use during 3-month (AHR, 0.68; 95% CI, 0.47-0.99) and 12-month (AHR, 0.74; 95% CI, 0.58-0.95) follow-up.

CONCLUSIONS AND RELEVANCE:

Treatment with buprenorphine or methadone was associated with reductions in overdose and serious opioid-related acute care use compared with other treatments. Strategies to address the underuse of MOUD are needed.

Author/s:

Wakeman, SE, Larochelle, MR, Ameli, O, Chaisson, CE, McPheeters, JT, Crown, WH, Azocar, F, Sanghavi, DM

Helping patients manage substance use disorder: Tobacco, alcohol, and other drugs

John Bayhi — Mon, 03 Feb 2020 20:04:07 +0000

Date Added:

February 3, 2020

Publisher:

Alosa Health

Publication Date:

January 1, 2020

Type:

Clinical Decision Aids

Format:

Article

Keywords

substance use disorder

alcohol use disorder

opioid-use disorder

tobacco use

This guide was prepared for use in the OPHIC implementation projects involving management of patients with substance use disorders. James W. Mold, MD, MPH

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Author/s:

Oklahoma Department of Mental & Substance Abuse Services, Oklahoma Primary Healthcare Improvement Cooperative, University of Oklahoma Health Sciences Center, Alosa Health

Medication-Assisted Treatment for Opioid Use Disorder Playbook

John Bayhi — Thu, 03 Oct 2019 13:50:59 +0000

Date Added:

October 3, 2019

Journal/Publication:

Agency for Healthcare Research and Quality Website

Publisher:

U.S. Depart of Health & Human Services

URL:

Medication-Assisted Treatment for Opioid Use Disorder Playbook

Type:

Clinical Decision Aids

Format:

Web Page

Keywords

opioid-use disorder

medication-assisted treatment

OUD

MAT

toolkit

This is a step-by-step guide to help practices implement medication-assisted treatment for opioid use disorders.

James W. Mold, MD, MPH

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Purpose

The AHRQ Academy developed the Medication-Assisted Treatment for Opioid Use Disorder Playbook (referred to as the MAT for OUD Playbook), a practical guide for implementing MAT in primary care and other ambulatory care settings. While the Playbook aims to help providers in rural primary care, the information in the Playbook should apply to other ambulatory care settings. This interactive, web-based product has the latest guidance, tools, and resources that address key aspects of implementation.

The MAT for OUD Playbook aims to address the growing need for guidance as more primary care practices and health systems begin to implement MAT. The Playbook’s framework is designed to be useful for practices implementing any array of MAT services.

Author/s:

Moran, G, Snyder, C, OUD Playbook Working Group

Medication-Assisted Treatment for Opioid-Use Disorder

John Bayhi — Tue, 24 Sep 2019 22:22:30 +0000

Date Added:

October 3, 2019

Journal/Publication:

Mayo Clinic Proceedings

Publisher:

Mayo Foundation for Medical Education and Research / Elsevier Inc.

Publication Date:

September 9, 2019

Issue:

Volume:

Pages:

2072-2086

URL:

Medication-Assisted Treatment for Opioid-Use Disorder

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.mayocp.2019.03.029

Keywords

PMID (1):

31543255

MeSH

Buprenorphine

naltrexone

methadone

opioid-related disorders

analgesics, opioid

outpatients

A nice review of how and when to use the three available medications for treating patients with opioid dependency. James W. Mold, MD, MPH

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The United States is in the midst of a national opioid epidemic. Physicians are encouraged both to prevent and treat opioid-use disorders (OUDs). Although there are 3 Food and Drug Administration-approved medications to treat OUD (methadone, buprenorphine, and naltrexone) and there is ample evidence of their efficacy, they are not used as often as they should. We provide a brief review of the 3 primary medications used in the treatment of OUD. Using data from available medical literature, we synthesize existing knowledge and provide a framework for how to determine the optimal approach for outpatient management of OUD with medication-assisted treatments.

Author/s:

Oesterle, TS, Thusius, NJ, Rummans, TA, Gold, MS

Drug Threat Bulletin: DSUVIA (Sufentanil)

Jeffrey Wilson — Tue, 04 Dec 2018 21:45:33 +0000

Date Added:

December 4, 2018

Journal/Publication:

Threat Bulletin

Publisher:

Oklahoma Bureau of Narcotics and Dangerous Drugs

Publication Date:

November 30, 2018

Type:

Public Health Announcements

Format:

Article

Keywords

MeSH

united states food and drug administration

Sufentanil (DSUVIA), an extremely potent opiate has just been approved by the FDA.

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The US Food and Drug Administration (FDA) approved DSUVIA, the synthetic opioid sufentanil in tiny blue tablet form, on Nov. 2, 2018 for single doses ingested under the tongue. Sufentanil is chemically similar to fentanyl (the lethal narcotic showing up as fake oxycodone pills and as a cutting agent in heroin) but estimated to be five to 10 times stronger. The opioid has been administered in solution form via IV and epidural injection since 1984, and typically employed as an anesthesia during major surgery (high dose) and in low-dosages as part of pain-relieving regimen for general surgery. (ROCIC Drug Publication)

Author/s:

Oklahoma Bureau of Narcotics and Dangerous Drugs

Buprenorphine to Treat Opioid Use Disorder: A Practical Guide

Jeffrey Wilson — Sat, 29 Sep 2018 20:41:15 +0000

Date Added:

November 1, 2018

Journal/Publication:

Journal of Family Practice

Publisher:

Oxford University Press

Publication Date:

September 1, 2018

Issue:

Volume:

Pages:

544-548

URL:

Buprenorphine to treat opioid use disorder: A practical guide

Type:

Meta-analyses, Reviews, and Guidelines, Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

MeSH

opioid-related disorders

This is a practical summary of how to diagnose opioid use disorder and how to treat patients who have it with buprenorphine.

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Opioids were involved in 42,249 deaths in the United States in 2016, and opioid overdoses have quintupled since 1999.1 Among the causes behind these statistics is increased opiate prescribing by physicians—with primary care providers accounting for about one half of opiate prescriptions.2 As a result, the Centers for Disease Control and Prevention has issued a 4-part response for physicians,3 which includes careful opiate prescribing, expanded access to naloxone, prevention of opioid use disorder (OUD), and expanded use of medication-assisted treatment (MAT) of addiction— with the goal of preventing and managing OUD.

Author/s:

Nissly, Tanner, Levy, Robert