Buprenorphine

Importance: Opioid use disorder (OUD) involves compulsive opioid use that causes substantial distress or impairment at work, school, or home. OUD, which is the third most prevalent substance use disorder worldwide, affected an estimated 3.7% of US adults (9 367 000) in 2022 and caused 53 774 deaths in the US in 2024. Medications for opioid use disorder (MOUD) reduce morbidity and mortality. Individuals with OUD also benefit from medications to treat opioid withdrawal and reverse acute opioid overdose.

Observations: Methadone, buprenorphine, and naltrexone are medications approved by the US Food and Drug Administration (FDA) to reduce unregulated opioid use. Methadone and buprenorphine reduce the risks of overdose and all-cause mortality. However, only 25.1% of people in the US with OUD were treated with these medications in 2022. MOUD should be selected based on shared decision-making that considers availability and convenience of treatment options and patient preferences. Buprenorphine and naltrexone are prescribed in office-based settings and can be taken at home. Outpatients with OUD in the US can only obtain methadone in person at federally regulated clinics. After stopping or substantially reducing use of opioids, individuals with OUD develop symptoms of opioid withdrawal, such as anxiety, insomnia, pain, nausea, vomiting, and diarrhea. Medications for opioid withdrawal include opioid agonists (eg, methadone and buprenorphine), α2-receptor agonists (eg, lofexidine and clonidine), and medications to treat pain (ibuprofen) and nausea (ondansetron). Individuals being treated for acute withdrawal should also be prescribed MOUD to decrease the risk of all-cause mortality (adjusted hazard ratio, 0.52; 95% CI, 0.42-0.63 for MOUD vs no MOUD). Individuals who use opioids may develop opioid overdose, which can cause respiratory depression, stupor, and, if severe, coma and death. Opioid overdose can be treated or can be reversed with naloxone, an opioid antagonist that is FDA approved and should be administered at the lowest dose needed to restore a normal respiratory rate (eg, naloxone 0.4 mg intramuscularly or 2-4 mg intranasally). Community-wide distribution of naloxone to people who use opioids and their social networks has been associated with 25% to 46% lower community opioid overdose rates.

Conclusions and relevance: All individuals with OUD should be offered treatment with MOUD to reduce opioid use. Methadone and buprenorphine decrease opioid-associated and all-cause mortality in patients with OUD. Opioid withdrawal symptoms may be treated with opioid agonists, α2-receptor agonists, and medications for pain and nausea. All individuals with OUD should have access to opioid antagonists, such as naloxone, to treat opioid overdose.

Author/s:

Miriam T H Harris, Zoe M Weinstein, Alexander Y Walley

Nurse Standing Orders for Buprenorphine Follow-Up Care in a Community Health Center Network

Rowan Hutchins — Sun, 15 Oct 2023 05:00:00 +0000

Date Added:

October 15, 2023

Journal/Publication:

JABFM

Publisher:

American Board of Family Medicine

Publication Date:

October 1, 2023

Issue:

Volume:

Pages:

723-730

URL:

Nurse Standing Orders for Buprenorphine Follow-Up Care in a Community Health Center Network

Type:

Best Local Practices

Format:

Article

DOI (1):

10.3122/jabfm.2022.220426R1

Keywords

PMID (1):

37775321

MeSH

Field-tested nurse standing orders for follow-up visits with patients taking buprenorphine for opioid use disorder. James W. Mold, MD, MPH

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Background: Less than 20% of individuals with opioid use disorder (OUD) are receiving a medication treatment for OUD in the United States. Though nurses can assume critical roles in outpatient models of OUD care, there are no published reports of buprenorphine standing orders for nurses that guide a nuanced response for patients returning as expected versus those re-engaging after a treatment lapse, without requiring real-time prescriber consultation.

Methods: Standing orders for buprenorphine were created with multiple stakeholders within an urban community health center that includes traditional clinics as well as non-traditional homeless care sites. After more than two years of use, an anonymous survey assessed staff perception of usability and safety of the standing orders using the validated system usability scale (SUS) and a 5-item Likert scale. Patient retention rates at 12 and 18 months were compared for sites that were early- and late-adopters of the standing orders.

Results: Of 24 clinicians and 7 nurses who responded to the survey, 46% had used the standing orders. More than 85% reported a perception that the standing orders improved team-based care and increased access to buprenorphine refills. None reported any safety concerns. The median SUS score was 75.0 (SD 15.4), rated as “excellent”. There was no statistically significant difference in 12- or 18-month retention rates between early- and late-adopter sites of the standing orders.

Conclusions: Nurse standing orders for buprenorphine follow-up and re-engagement care are feasible, usable and perceived as safe in varied community health center settings.

Author/s:

Richard C. Waters, Meaghan Mugleston, Anina Terry, Carrie Reinhart, Megan Wilson

Mobile Telemedicine for Buprenorphine Treatment in Rural Populations With Opioid Use Disorder

Bethie Seay — Fri, 03 Sep 2021 05:00:00 +0000

Date Added:

September 3, 2021

Type:

Clinical Research Results

DOI (1):

10.1001/jamanetworkopen.2021.18487

A report and description of the use of telemedicine and mobile services to help people in rural areas with substance abuse challenges.

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Importance
The demand for medications for opioid use disorder (MOUD) in rural US counties far outweighs their availability. Novel approaches to extend treatment capacity include telemedicine (TM) and mobile treatment on demand; however, their combined use has not been reported or evaluated.

Objective
To evaluate the use of a TM mobile treatment unit (TM-MTU) to improve access to MOUD for individuals living in an underserved rural area.

Design, Setting, and Participants
This quality improvement study evaluated data collected from adult outpatients with a diagnosis of OUD enrolled in the TM-MTU initiative from February 2019 (program inception) to June 2020. Program staff traveled to rural areas in a modified recreational vehicle equipped with medical, videoconferencing, and data collection devices. Patients were virtually connected with physicians based more than 70 miles (112 km) away. Data analysis was performed from June to October 2020.

Intervention
Patients received buprenorphine prescriptions after initial teleconsultation and follow-up visits from a study physician specialized in addiction psychiatry and medicine.

Main Outcomes and Measures
The primary outcome was 3-month treatment retention, and the secondary outcome was opioid-positive urine screens. Exploratory outcomes included use of other drugs and patients’ travel distance to treatment.

Results
A total of 118 patients were enrolled in treatment, of whom 94 were seen for follow-up treatment predominantly (at least 2 of 3 visits [>50%]) on the TM-MTU; only those 94 patients’ data are considered in all analyses. The mean (SD) age of patients was 36.53 (9.78) years, 59 (62.77%) were men, 71 (75.53%) identified as White, and 90 (95.74%) were of non-Hispanic ethnicity. Fifty-five patients (58.51%) were retained in treatment by 3 months (90 days) after baseline. Opioid use was reduced by 32.84% at 3 months, compared with baseline, and was negatively associated with treatment duration (F = 12.69; P = .001). In addition, compared with the nearest brick-and-mortar treatment location, TM-MTU treatment was a mean of 6.52 miles (range, 0.10-58.70 miles) (10.43 km; range, 0.16-93.92 km) and a mean of 10 minutes (range, 1-49 minutes) closer for patients.

Conclusions and Relevance
These data demonstrate the feasibility of combining TM with mobile treatment, with outcomes (retention and opioid use) similar to those obtained from office-based TM MOUD programs. By implementing a traveling virtual platform, this clinical paradigm not only helps fill the void of rural MOUD practitioners but also facilitates access to underserved populations who are less likely to reach traditional medical settings, with critical relevance in the context of the COVID-19 pandemic.

Author/s:

Weintraub, E., Seneviratne, C., Anane, J.

Responding to Unsafe Opioid Use: Abandon the Drug, Not the Patient

Devin Evans — Wed, 24 Mar 2021 05:00:00 +0000

Date Added:

March 24, 2021

Journal/Publication:

Journal of General Internal Medicine

Publication Date:

October 9, 2020

Issue:

Volume:

Pages:

790-791

URL:

Responding to Unsafe Opioid Use: Abandon the Drug, Not the Patient

Type:

Best Local Practices

Format:

Article

DOI (1):

10.1007/s11606-020-06281-4

Keywords

Opioid Use

opioids

RISEOK

Opioid-Related Disorders

2019-nCOV

PMID (1):

33037590

MeSH

opioid-related disorders

Prejudice

An argument for not firing patients for opioid misuse. James W. Mold, MD, MPH

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Physicians have a legal and ethical duty to protect their patients and support them during times of clinical need; the decision to end a doctor-patient relationship should not be made lightly. However, in a recent survey of 794 primary care practices, 90% reported discharging patients in the previous two years, often for opioid-related issues.1 Disruptive or inappropriate behavior was the most common reason for discharge (81%), but 78% reported dismissing patients for violations of a chronic pain or controlled substance agreement. We find this practice worrisome, particularly since many controlled substance agreements use coercive and stigmatizing language that patients may reluctantly sign or have trouble understanding.2 Although violent, threatening, or disruptive behavior may be a valid reason to discharge patients in certain circumstances, opioid misuse should rarely rise to this threshold

Author/s:

Tobin, Daniel G., Holt, Stephen R., Doolittle, Benjamin R.

Creation of an algorithm for clinical decision support for treatment of opioid use disorder with buprenorphine in primary care

Devin Evans — Wed, 03 Mar 2021 06:00:00 +0000

Date Added:

March 3, 2021

Journal/Publication:

Addiction Science and Clinical Practice

Publication Date:

February 19, 2021

Issue:

Volume:

URL:

Creation of an algorithm for clinical decision support for treatment of opioid use disorder with buprenorphine in primary care

Type:

Practice Management Reviews and Guidelines, Practice Management Research Results

Format:

Article

DOI (1):

10.1186/s13722-021-00222-0

Keywords

Clinical decision support

Measurement based care

PMID (1):

33608060

MeSH

physicians, primary care

opioid-related disorders

Medication Adherence

Opiate Substitution Treatment

aged

Buprenorphine

A potentially useful algorithm for identifying and managing patients with opioid use disorders. James W. Mold, MD,. MPH

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Background: The treatment capacity for opioid use disorder (OUD) lags far behind the number of patients in need of treatment. Capacity is limited, in part, by the limited number of physicians who offer office based OUD treatment with buprenorphine. Measurement based care (MBC) has been proposed as a means to support primary care physicians in treating OUD. Here, we propose a set of measures and a clinical decision support algorithm to provide MBC for the treatment of OUD.

Methods: We utilized literature search and expert consensus to identify measures for universal screening and symptom tracking. We used expert consensus to create the clinical decision support algorithm.

Results: The Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) tool was selected as the best published measure for universal screening in primary care. No published measure was identified as appropriate for symptom tracking or medication adherence; therefore, we created the OUD Symptom Checklist from the DSM-5 criteria for OUD and the Patient Adherence Questionnaire for Opioid Use Disorder Treatment (PAQ-OUD) to assess medication adherence. We developed and present a clinical decision support algorithm to provide direct guidance regarding treatment interventions during the first 12 weeks of buprenorphine treatment.

Conclusion: Creation of these tools is the necessary first step for implementation of MBC for the treatment of OUD with buprenorphine in primary care. Further work is needed to test the feasibility and acceptability of these tools. Trial Registration ClinicalTrials.gov; NCT04059016; 16 August 2019; retrospectively registered; https://clinicaltrials.gov/ct2/show/NCT04059016.

Author/s:

Dela Cruz, Adriane M., Walker, Robrina, Pipes, Ronny, Wakhlu, Sidarth, Trivedi, Madhukar H.

Weekly and Monthly Subcutaneous Buprenorphine Depot Formulations vs Daily Sublingual Buprenorphine With Naloxone for Treatment of Opioid Use Disorder: A Randomized Clinical Trial

Devin Evans — Thu, 14 Jan 2021 06:00:00 +0000

Date Added:

January 14, 2021

Journal/Publication:

Journal of the American Medical Association Internal Medicine

Publication Date:

June 1, 2018

Issue:

Volume:

178

Pages:

764-773

URL:

Weekly and Monthly Subcutaneous Buprenorphine Depot Formulations vs Daily Sublingual Buprenorphine With Naloxone for Treatment of Opioid Use Disorder: A Randomized Clinical Trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamainternmed.2018.1052

Keywords

opioids

Opioid Use Disorder

Buprenorphine

Buprenorphine-naloxone

PMID (1):

29799968

MeSH

Delayed-Action Preparations

opioid-related disorders

Long-acting buprenorphine, given weekly or monthly seem to work as well as daily SL buprenorphine for opioid use disorder. James W. Mold, MD, MPH

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Importance: Buprenorphine treatment for opioid use disorder may be improved by sustained-release formulations.

Objective: To determine whether treatment involving novel weekly and monthly subcutaneous (SC) buprenorphine depot formulations is noninferior to a daily sublingual (SL) combination of buprenorphine hydrochloride and naloxone hydrochloride in the treatment of opioid use disorder.

Design, setting, and participants: This outpatient, double-blind, double-dummy randomized clinical trial was conducted at 35 sites in the United States from December 29, 2015, through October 19, 2016. Participants were treatment-seeking adults with moderate-to-severe opioid use disorder.

Interventions: Randomization to daily SL placebo and weekly (first 12 weeks; phase 1) and monthly (last 12 weeks; phase 2) SC buprenorphine (SC-BPN group) or to daily SL buprenorphine with naloxone (24 weeks) with matched weekly and monthly SC placebo injections (SL-BPN/NX group).

Main outcomes and measures: Primary end points tested for noninferiority were response rate (10% margin) and the mean proportion of opioid-negative urine samples for 24 weeks (11% margin). Responder status was defined as having no evidence of illicit opioid use for at least 8 of 10 prespecified points during weeks 9 to 24, with 2 of these at week 12 and during month 6 (weeks 21-24). The mean proportion of samples with no evidence of illicit opioid use (weeks 4-24) evaluated by a cumulative distribution function (CDF) was an a priori secondary outcome with planned superiority testing if the response rate demonstrated noninferiority.

Results: A total of 428 participants (263 men [61.4%] and 165 women [38.6%]; mean [SD] age, 38.4 [11.0] years) were randomized to the SL-BPN/NX group (n = 215) or the SC-BPN group (n = 213). The response rates were 31 of 215 (14.4%) for the SL-BPN/NX group and 37 of 213 (17.4%) for the SC-BPN group, a 3.0% difference (95% CI, -4.0% to 9.9%; P < .001). The proportion of opioid-negative urine samples was 1099 of 3870 (28.4%) for the SL-BPN/NX group and 1347 of 3834 (35.1%) for the SC-BPN group, a 6.7% difference (95% CI, -0.1% to 13.6%; P < .001). The CDF for the SC-BPN group (26.7%) was statistically superior to the CDF for the SL-BPN/NX group (0; P = .004). Injection site adverse events (none severe) occurred in 48 participants (22.3%) in the SL-BPN/NX group and 40 (18.8%) in the SC-BPN group.

Conclusions and relevance: Compared with SL buprenorphine, depot buprenorphine did not result in an inferior likelihood of being a responder or having urine test results negative for opioids and produced superior results on the CDF of no illicit opioid use. These data suggest that depot buprenorphine is efficacious and may have advantages.

Author/s:

Lofwall, Michelle R., Walsh, Sharon L., Nunes, Edward V., Bailey, Genie L., Sigmon, Stacey C., Kampman, Kyle M., Frost, Michael, Tiberg, Fredrik, Linden, Marareta, Sheldon, Behshad, Oosman, Sonia, Peterson, Stefan, Chen, Michael, Kim, Sonnie

Interventions for Substance Use Disorders in Adolescents: A Systematic Review

Brian Desmarais — Fri, 05 Jun 2020 18:28:32 +0000

Date Added:

June 5, 2020

Journal/Publication:

Comparative Effectiveness Review

Publisher:

Agency for Healthcare Research and Quality

Publication Date:

May 21, 2020

Volume:

225

URL:

Interventions for Substance Use Disorders in Adolescents: A Systematic Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.23970/AHRQEPCCER225

Keywords

MeSH

Family Characteristics

An AHRQ systematic review of substance abuse disorders in adolescents. James W. Mold, MD, MPH

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Structured Abstract

Objectives. This systematic review (SR) synthesizes the literature on behavioral, pharmacologic, and combined interventions for adolescents ages 12 to 20 years with problematic substance use or substance use disorder. We included interventions designed to achieve abstinence, reduce use quantity and frequency, improve functional outcomes, and reduce substance-related harms.

Data sources. We conducted literature searches in MEDLINE, the Cochrane CENTRAL Trials Registry, Embase, CINAHL, and PsycINFO to identify primary studies meeting eligibility criteria through November 1, 2019.

Review methods. Studies were extracted into the Systematic Review Data Repository. We categorized interventions into seven primary intervention components: motivational interviewing (MI), family focused therapy (Fam), cognitive behavioral therapy (CBT), psychoeducation, contingency management (CM), peer group therapy, and intensive case management. We conducted meta-analyses of comparative studies and evaluated the strength of evidence (SoE). The PROSPERO protocol registration number is CRD42018115388 .

Results. The literature search yielded 33,272 citations, of which 118 studies were included. Motivational interviewing reduced heavy alcohol use days by 0.7 days/month, alcohol use days by 1.2 days/month, and overall substance use problems by a standardized mean difference of 0.5, compared with treatment as usual. Brief MI did not reduce cannabis use days (net mean difference of 0). Across multiple intensive interventions, Fam was most effective, reducing alcohol use days by 3.5 days/month compared with treatment as usual. No intensive interventions reduced cannabis use days. Pharmacologic treatment of opioid use disorder led to a more than 4 times greater likelihood of abstinence with extended courses (2 to 3 months) of buprenorphine compared to short courses (14 to 28 days).

Conclusions. Brief interventions: MI reduces heavy alcohol use (low SoE), alcohol use days (moderate SoE), and substance use–related problems (low SoE) but does not reduce cannabis use days (moderate SoE). Nonbrief interventions: Fam may be most effective in reducing alcohol use (low SoE). More research is needed to identify other effective intensive behavioral interventions for alcohol use disorder. Intensive interventions did not appear to decrease cannabis use (low SoE). Some interventions (CBT, CBT+MI, and CBT+MI+CM) were associated with increased cannabis use (low SoE). Both MI and CBT reduce combined alcohol and other drug use (low SoE). Combined CBT+MI reduces illicit drug use (low SoE). Subgroup analyses of interest (male vs. female, racial and ethnic minorities, socioeconomic status, and family characteristics) were sparse, precluding conclusions regarding differential effects. Pharmacological interventions: longer courses of buprenorphine (2–3 months) are more effective than shorter courses (14–28 days) to reduce opioid use and achieve abstinence (low SoE). SRs in the college settings support use of brief interventions for students with any use, heavy or problematic use. More research is needed to identify the most effective combinations of behavioral and pharmacologic treatments for opioid, alcohol, and cannabis use disorders.

Citation

Suggested citation: Steele DW, Becker SJ, Danko KJ, Balk EM, Saldanha IJ, Adam GP, Bagley SM, Friedman C, Spirito A, Scott K, Ntzani EE, Saeed I, Smith B, Popp J, Trikalinos TA. Interventions for Substance Use Disorders in Adolescents: A Systematic Review. Comparative Effectiveness Review No. 225. (Prepared by the Brown Evidence-based Practice Center under Contract No. 290-2015-00002-I.) AHRQ Publication No. 20-EHC014. Rockville, MD: Agency for Healthcare Research and Quality. May 2020. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCCER225 .

Author/s:

Steele, D.W., Becker, S.J., Danko, K.J., Balk, E.M., Saldanha, I.J., Adam, G.P., Bagley, S.M., Friedman, C., Spirito, A., Scott, K., Ntzani, E.E., Saeed, I., Smith, B., Popp J., Trikalinos, T.A.

Opioid Treatments for Chronic Pain. Comparative Effectiveness Review No. 229

John Bayhi — Fri, 17 Apr 2020 17:45:13 +0000

Date Added:

April 17, 2020

Journal/Publication:

AHRQ Publication No. 20-EHC011

Publisher:

Agency for Healthcare Research and Quality

Publication Date:

April 16, 2020

URL:

Opioid Treatments for Chronic Pain. Comparative Effectiveness Review No. 229

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.23970/AHRQEPCCER229

Keywords

MeSH

opioid-related disorders

drug overdose

analgesics, non-narcotic

AHRQ evidence review of opioids for relief of chronic pain. James W. Mold, MD, MPH

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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

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

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.

Free full text

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