opioid-related disorders

Opioid-Induced Adrenal Insufficiency

Endocarditis

The most recent guideline for management of opioid use disorder from the American Society of Addiction Medicine. James W. Mold, MD, MPH

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The American Society of Addiction Medicine (ASAM) developed this National Practice Guideline for the Treatment of Opioid Use Disorder to provide information on evidence-based treatment of opioid use disorder. This guideline is an update and replacement of the 2015 ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use.

Opioid-Induced Adrenal Insufficiency

Erin Blanchette — Wed, 22 May 2024 23:12:22 +0000

Date Added:

May 22, 2024

Journal/Publication:

JAMA International Medicine

Publisher:

American Medical Association

Publication Date:

May 13, 2024

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2024.0687

Keywords

Methicillin-Resistant Staphylococcus aureus

Opioid Use

Hyponatremia

methadone

Diabetes and Endocrinology

Endocrinology

PMID (1):

38739374

MeSH

Methicillin-Resistant Staphylococcus aureus

Hyponatremia

methadone

Chronic use of opioids can result in suppression of the hypothalamic, pituitary, adrenal axis causing adrenal insufficiency in up to 15% of patients. James W. Mold, MD, MPH

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A woman in her 40s with opioid use disorder receiving methadone (70 mg daily) was admitted for extended antibiotic treatment for methicillin-resistant Staphylococcus aureus bacteremia. She had been taking methadone at varying doses (ranging from 15 to 70 mg daily) for 15 years.

Following the resolution of bacteremia, she experienced unexplained persistent hyponatremia (129 mEq/L) and dizziness, with her urine sodium levels exceeding 40 mEq/L. A high dose, 250-μg cosyntropin stimulation test was performed, which revealed her cortisol levels were 6.6, 17.2, and 19.2 μg/mL (to convert to nmol/L, multiply by 27.6) at baseline, 30 minutes, and 60 minutes, respectively. A serum adrenocorticotropic hormone (ACTH) level was not measured.

Author/s:

Douglas Rice, Hirofumi Yoshida

Managing Opioid Use Disorder in Primary Care: PEER Simplified Guide

Bethie Seay — Mon, 13 Sep 2021 05:00:00 +0000

Date Added:

September 13, 2021

Type:

Meta-analyses, Reviews, and Guidelines

PMID (1):

31088869

MeSH

decision making

disease management

Humans

Opiate Substitution Treatment

Trajectories of Opioid Use Following First Opioid Prescription in Opioid-Naive Youths and Young Adults

primary health care

A easy-to-use, primary care-oriented opioid use disorder management guideline from the College of Family Physicians of Canada.

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Objective: To use the best available evidence and principles of shared, informed decision making to develop a clinical practice guideline for a simplified approach to managing opioid use disorder (OUD) in primary care.

Methods: Eleven health care and allied health professionals representing various practice settings, professions, and locations created a list of key questions relevant to the management of OUD in primary care. These questions related to the treatment setting, diagnosis, treatment, and management of comorbidities in OUD. The questions were researched by a team with expertise in evidence evaluation using a series of systematic reviews of randomized controlled trials. The Guideline Committee used the systematic reviews to create recommendations.

Recommendations: Recommendations outline the role of primary care in treating patients with OUD, as well as pharmacologic and psychotherapy treatments and various prescribing practices (eg, urine drug testing and contracts). Specific recommendations could not be made for management of comorbidities in patients with OUD owing to limited evidence.

Conclusion: The recommendations will help simplify the complex management of patients with OUD in primary care. They will aid clinicians and patients in making informed decisions regarding their care.

Author/s:

Korownyk, C., Perry, D, Kolber, M. R., Garrision, S., Thomas, B., Allan, G. M., Bateman, C., de Queiroz, R., Kennedy, D., Lamba, W., Marlinga, J., Mogus, T., Nickonchuk, T., Orrantia, E., Reich, K., Wong, N., Dugré, N., Lindblad, A. J.

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.

Trajectories of Opioid Use Following First Opioid Prescription in Opioid-Naive Youths and Young Adults

Devin Evans — Thu, 29 Apr 2021 05:00:00 +0000

Date Added:

May 19, 2021

Journal/Publication:

Journal of the American Medical Association Network Open

Publication Date:

April 1, 2021

Issue:

Volume:

URL:

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2021.4552

Keywords

PMID (1):

33885777

MeSH

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

prescriptions

Very interesting study showing two distinct patterns of opioid use behaviors among adolescents after being given a first opioid prescription for pain. Predictors of subsequent misuse were identified. James W. Mold, MD, MPH

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Importance: Although prescription opioids are the most common way adolescents and young adults initiate opioid use, many studies examine population-level risks following the first opioid prescription. There is currently a lack of understanding regarding how patterns of opioid prescribing following the first opioid exposure may be associated with long-term risks.

Objective: To identify distinct patterns of opioid prescribing following the first prescription using group-based trajectory modeling and examine the patient-, clinician-, and prescription-level factors that may be associated with trajectory membership during the first year.

Design, setting, and participants: This cohort study examined Pennsylvania Medicaid enrollees' claims data from 2010 through 2016. Participants were aged 10 to 21 years at time of first opioid prescription. Data analysis was performed in March 2020.

Main outcomes and measures: This study used group-based trajectory modeling and defined trajectory status by opioid fill.

Results: Among the 189 477 youths who received an initial opioid prescription, 107 562 were female (56.8%), 81 915 were non-Latinx White (59.6%), and the median age was 16.9 (interquartile range [IQR], 14.6-18.8) years. During the subsequent year, 47 477 (25.1%) received at least one additional prescription. Among the models considered, the 2-group trajectory model had the best fit. Of those in the high-risk trajectory, 65.3% (n = 901) filled opioid prescriptions at month 12, in contrast to 13.1% (n = 6031) in the low-risk trajectory. Median age among the high-risk trajectory was 19.0 years (IQR, 17.1-20.0 years) compared with the low-risk trajectory (17.8 years [IQR, 15.8-19.4 years]). The high-risk trajectory received more potent prescriptions compared with the low-risk trajectory (median dosage of the index month for high-risk trajectory group: 10.0 MME/d [IQR, 5.0-21.2 MME/d] vs the low-risk trajectory group: 4.7 MME/d [IQR, 2.5-7.8 MME/d]; P < .001). The trajectories showed persistent differences with more youths in the high-risk trajectory going on to receive a diagnosis of opioid use disorder (30.0%; n = 412) compared with the low-risk group (10.1%; n = 4638) (P < .001).

Conclusions and relevance: This study's results identified 2 trajectories associated with elevated risk for persistent opioid receipt within 12 months following first opioid prescription. The high-risk trajectory was characterized by older age at time of first prescription, and longer and more potent first prescriptions. These findings suggest even short and low-dose opioid prescriptions can be associated with risks of persistent use for youths.

Author/s:

Wilson, J.D., Zbebe, K.Z., Kraemer, K., Liebschutz, J., Merlin, J., Miller, E., D., Donohue, 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:

Type:

Best Local Practices

Format:

Article

DOI (1):

10.1007/s11606-020-06281-4

Keywords

Opioid Use

RISEOK

2019-nCOV

PMID (1):

33037590

MeSH

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

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:

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

Opiate Substitution Treatment

Medication Adherence

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.

Association of Current Opioid Use With Serious Adverse Events Among Older Adult Survivors of Breast Cancer

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

Date Added:

March 3, 2021

Journal/Publication:

Journal of the American Medical Association Network Open

Publication Date:

September 1, 2020

Issue:

Volume:

URL:

Association of Current Opioid Use With Serious Adverse Events Among Older Adult Survivors of Breast Cancer

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2020.16858

Keywords

RISEOK

aged

elderly

pain management

PMID (1):

32930779

MeSH

The opioid crisis: a contextual, social-ecological framework

This study documented a wide range of serious adverse events in older breast cancer patients prescribed opioids after surgery. James W. Mold, MD, MPH

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Importance: National efforts to improve safe opioid prescribing focus on preventing misuse, overdose, and opioid use disorder. This approach overlooks opportunities to better prevent other serious opioid-related harms in complex populations, such as older adult survivors of cancer. Little is known about the rates and risk factors for comprehensive opioid-related harms in this population.

Objective: To determine rates of multiple opioid-related adverse drug events among older adults who survived breast cancer and estimate the risk of these events associated with opioid use in the year after completing cancer treatment.

Design, setting, and participants: This retrospective cohort study used 2007 to 2016 Surveillance, Epidemiology and End Results-Medicare data from fee-for-service Medicare beneficiaries with first cancer diagnosis of stage 0 to III breast cancer at age 66 to 90 years from January 1, 2008, through December 31, 2015, who completed active breast cancer treatment. Data were analyzed from October 31, 2019, to June 10, 2020.

Exposures: Repeated daily measure indicating possession of any prescription opioid supply in Medicare Part D prescription claims.

Main outcomes and measures: Adjusted risk ratios (aRRs), estimated using modified Poisson generalized estimating equation models, for adverse drug events related to substance misuse (ie, diagnosed opioid abuse, dependence, or poisoning), other adverse drug events associated with opioid use (ie, gastrointestinal events, infections, falls and fractures, or cardiovascular events), and all-cause hospitalization associated with opioid supply the prior day, controlling for patient characteristics.

Conclusions and relevance: These findings suggest that among older adults who survived breast cancer, continued prescription opioid use in the year after completing active cancer treatment was associated with an immediate increased risk of a broad range of serious adverse drug events related to substance misuse and other adverse drug events associated with opioid use. Clinicians should consider the comprehensive risks of managing cancer pain with long-term opioid therapy.

Author/s:

Winn, Aaron N., Check, Devon K., Farkas, Amy, Fergestrom, Nicole M., Neuner, Joan M., Roberts, Andrew W.

The opioid crisis: a contextual, social-ecological framework

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

Date Added:

March 3, 2021

Journal/Publication:

Health Research Policy and Systems

Publication Date:

August 6, 2020

Issue:

Volume:

URL:

Type:

Community-Based Research Results

Format:

Article

DOI (1):

10.1186/s12961-020-00596-8

Keywords

Opioid Use Disorder

social-ecological framework

RISEOK

Opioid Epidemic

PMID (1):

32762700

MeSH

analgesics, opioid

public health

Opioid Epidemic

Challenges and Approaches to Population Management of Long-Term Opioid Therapy Patients

This resources is being added primarily for those participating in a study of opioid management in the elderly. It presents a socioecological view of the opioid crisis. James W. Mold, MD, MPH

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The prevalence of opioid use and misuse has provoked a staggering number of deaths over the past two and a half decades. Much attention has focused on individual risks according to various characteristics and experiences. However, broader social and contextual domains are also essential contributors to the opioid crisis such as interpersonal relationships and the conditions of the community and society that people live in. Despite efforts to tackle the issue, the rates of opioid misuse and non-fatal and fatal overdose remain high. Many call for a broad public health approach, but articulation of what such a strategy could entail has not been fully realised. In order to improve the awareness surrounding opioid misuse, we developed a social-ecological framework that helps conceptualise the multivariable risk factors of opioid misuse and facilitates reviewing them in individual, interpersonal, communal and societal levels. Our framework illustrates the multi-layer complexity of the opioid crisis that more completely captures the crisis as a multidimensional issue requiring a broader and integrated approach to prevention and treatment.

Author/s:

Jalali, Mohammad S., Botticelli, Michael, Hwang, Rachael C., Koh, Howard K., McHugh, R. Kathryn

Challenges and Approaches to Population Management of Long-Term Opioid Therapy Patients

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

Date Added:

March 3, 2021

Journal/Publication:

Journal of the American Board of Family Medicine

Publication Date:

February 1, 2021

Issue:

Volume:

Pages:

89-98

URL:

Type:

Best Local Practices, Practice Management Research Results

Format:

Article

DOI (1):

10.3122/jabfm.2021.01.190100

Keywords

PMID (1):

33452086

MeSH

analgesics, opioid

Focus Groups

Capacity Building

Medication Therapy Management

chronic pain

Mind-Body Therapies for Opioid-Treated Pain: A Systematic Review and Meta-analysis

prescriptions

Useful tips from a multi-practice initiative to improve management of opioids in primary care. James W. Mold, MD, MPH

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Purpose: Primary care is challenged with safely prescribing opioids for patients with chronic noncancer pain (CNCP), specifically to address risks for overdose, opioid use disorder, and death. We identify sociotechnical challenges, approaches, and recommendations in primary care to effectively track and monitor patients on long-term opioid therapy, a key component for supporting adoption of opioid prescribing guidelines.

Methods: We examined qualitative data (field notes and postintervention interview and focus group transcripts) from 6 rural and rural-serving primary care organizations with 20 clinic locations enrolled in a study evaluating a practice redesign program to improve opioid medication management for CNCP patients. Two independent researchers used content analysis to categorize data into key themes to develop an understanding of sociotechnical factors critical to creating and implementing an approach to tracking and monitoring of patients on long-term opioid therapy in primary care practices.

Results: Four factors were critical to developing a tracking and monitoring system. For each we describe common challenges and approaches used by the clinics to overcome then. The first factor, buy-in and participation, was essential for accomplishing the other 3. The other factors occurred sequentially: 1) cohort identification-finding the right patients, 2) data collection and extraction-tracking the right data, and 3) data use-monitoring patients and adjusting care processes.

Conclusions: We identified common challenges and approaches to tracking and monitoring patients using long-term opioid therapy for CNCP in primary care. Based on these findings we provide recommendations to build capacity for tracking and monitoring for organizations that are engaged in improving safe opioid-prescribing practices for CNCP in primary care.

Author/s:

Stephens, Kari A., Ike, Brooke, Baldwin, Laura-Mae, Packer, Christine, Parchman, Michael

Mind-Body Therapies for Opioid-Treated Pain: A Systematic Review and Meta-analysis

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:

November 4, 2019

Issue:

Volume:

180

Pages:

91-105

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2019.4917

Keywords

Mind-Body Therapies

meditation

hypnosis

cognitive behavioral therapy

pain reduction

Cognitive Behavioral Therapy

Opioid Epidemic

PMID (1):

31682676

MeSH

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

Adult

In this meta-analysis, moderate to large improvements in pain outcomes were found for meditation, hypnosis, suggestion, and cognitive behavioral therapy. James W. Mold, MD, MPH

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Importance: Mind-body therapies (MBTs) are emerging as potential tools for addressing the opioid crisis. Knowing whether mind-body therapies may benefit patients treated with opioids for acute, procedural, and chronic pain conditions may be useful for prescribers, payers, policy makers, and patients.

Objective: To evaluate the association of MBTs with pain and opioid dose reduction in a diverse adult population with clinical pain.

Data sources: For this systematic review and meta-analysis, the MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Cochrane Library databases were searched for English-language randomized clinical trials and systematic reviews from date of inception to March 2018. Search logic included (pain OR analgesia OR opioids) AND mind-body therapies. The gray literature, ClinicalTrials.gov, and relevant bibliographies were also searched.

Study selection: Randomized clinical trials that evaluated the use of MBTs for symptom management in adults also prescribed opioids for clinical pain.

Data extraction and synthesis: Independent reviewers screened citations, extracted data, and assessed risk of bias. Meta-analyses were conducted using standardized mean differences in pain and opioid dose to obtain aggregate estimates of effect size with 95% CIs.

Main outcomes and measures: The primary outcome was pain intensity. The secondary outcomes were opioid dose, opioid misuse, opioid craving, disability, or function.

Results: Of 4212 citations reviewed, 60 reports with 6404 participants were included in the meta-analysis. Overall, MBTs were associated with pain reduction (Cohen d = -0.51; 95% CI, -0.76 to -0.26) and reduced opioid dose (Cohen d = -0.26; 95% CI, -0.44 to -0.08). Studies tested meditation (n = 5), hypnosis (n = 25), relaxation (n = 14), guided imagery (n = 7), therapeutic suggestion (n = 6), and cognitive behavioral therapy (n = 7) interventions. Moderate to large effect size improvements in pain outcomes were found for meditation (Cohen d = -0.70), hypnosis (Cohen d = -0.54), suggestion (Cohen d = -0.68), and cognitive behavioral therapy (Cohen d = -0.43) but not for other MBTs. Although most meditation (n = 4 [80%]), cognitive-behavioral therapy (n = 4 [57%]), and hypnosis (n = 12 [63%]) studies found improved opioid-related outcomes, fewer studies of suggestion, guided imagery, and relaxation reported such improvements. Most MBT studies used active or placebo controls and were judged to be at low risk of bias.

Conclusions and relevance: The findings suggest that MBTs are associated with moderate improvements in pain and small reductions in opioid dose and may be associated with therapeutic benefits for opioid-related problems, such as opioid craving and misuse. Future studies should carefully quantify opioid dosing variables to determine the association of mind-body therapies with opioid-related outcomes.

Author/s:

Garland, Eric L., Brintz, Carrie E., Hanley, Adam W., Roseen, Eric J., Atchley, Rachel M., Gaylord, Susan A., Faurot, Keturah R., Yaffe, Joanne, Fiander, Michelle, Keefe, Francis J.

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:

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamainternmed.2018.1052

Keywords

Delayed-Action Preparations

Opioid Use Disorder

Buprenorphine

Buprenorphine-naloxone

PMID (1):

29799968

MeSH

Prevention, Diagnosis, and Management of Opioids, Opioid Misuse and Opioid Use Disorder in Older Adults

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

Prevention, Diagnosis, and Management of Opioids, Opioid Misuse and Opioid Use Disorder in Older Adults

Brian Desmarais — Sat, 07 Nov 2020 21:37:46 +0000

Date Added:

January 21, 2021

Journal/Publication:

U.S. Department of Health and Human Services

Publication Date:

November 3, 2020

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

MeSH

analgesics, non-narcotic

Prescription Drug Monitoring Programs

analgesics, opioid

An AHRQ evidence review on the prevention, diagnosis, and management of opioid misuse. James W. Mold, MD, MPH

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Structured Abstract

Background. Opioid-related harms are increasing among older adults. Until we better understand the factors contributing to this trend, we will be unable to design and implement effective interventions to optimally manage opioid use and its potential harms among older adults. Although considerable research has been done in younger or mixed-age populations, the degree to which it is directly applicable to older adults is uncertain.

Objectives. To provide a framework for understanding how to reduce adverse outcomes of opioid use among older adults, and to describe the evidence available for different factors associated with and interventions to reduce adverse outcomes related to opioid use in this population.

Approach. With input from a diverse panel of content experts and other stakeholders, we developed a conceptual framework and evidence map to characterize empirical studies of factors associated with opioid-related outcomes and interventions to reduce opioid-related harms in older adults. We identified relevant literature among older adults (age ≥60 years) for an evidence map by systematically searching PubMed, PsycINFO, and CINAHL for studies published in English between 2000 and May 6, 2020.

Findings. We identified 5,933 citations, from which we identified 41 studies with multivariable models of factors associated with opioid-related outcomes and 16 studies of interventions in older adults. More than half (22/41) of the multivariable analysis studies evaluated factors associated with long-term opioid use (which, though not a harm per se, may increase the risk of harms if not appropriately managed). Prior or early postoperative opioid use, or greater amounts of prescribed opioids (high number of opioid prescriptions or higher opioid dose), were consistently (100% agreement) and strongly (measure of association ≥2.0) associated with long-term opioid use. Back pain, depression, concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs), and fibromyalgia also had consistent, but weaker, associations with long-term opioid use. Several factors were mostly associated (>75% agreement) with long-term opioid use, including benzodiazepine use, comorbidity scores, (generally undefined) substance misuse, tobacco use, and low income. However, studies were mostly consistent that alcohol abuse and healthcare utilization were not associated with long-term opioid use. Gender, age among older adults, Black race, dementia, rural/nonurban residence, prescription of long-acting opioids, unmarried status, and use of muscle relaxants were variably associated (<75% agreement) with long-term opioid use.

Six studies examined factors associated with opioid-related disorders, although only one study evaluated factors associated with opioid use disorder. Alcohol misuse and gender were variably associated with opioid misuse (examined by three studies each).

All other evaluations of specific pairs of associated factors and outcomes of interest were evaluated by only one or two studies each. These included analyses of factors associated with multiple opioid prescribers, mental health outcomes, physical health outcomes, all-cause hospitalization, opioid-related hospitalization, nonopioid-specific hospitalization, emergency department visits, opioid overdose, all-cause death, opioid-related death, and nonopioid-related death.

The evidence on interventions directed at older adults is sparse. Of the 16 studies of opioid-related interventions in older adults, six examined screening tools to predict opioid-related harms, but none of these tools was tested in clinical practice to assess real-world results. Two studies found that prescription drug monitoring programs are associated with less opioid use in communities. Other studied interventions include multidisciplinary pain education for patients, an educational pamphlet for patients, implementation of an opioid safety initiative, provision of patient information and pain management training for clinicians, a bundle of educational modalities for clinicians, free prescription acetaminophen, a nationally mandated tamper-resistant opioid formulation, and motivational interview training for nursing students. Few intervention studies evaluated pain or other patient-centered outcomes such as disability and functioning.

Conclusions. The evidence base that is directly applicable to older adults who are prescribed opioids or have opioid-related disorders is limited. Fundamental research is necessary to determine which factors may predict clinically important, patient-centered, opioid-related outcomes. Studies to date have identified numerous possible factors associated with long-term opioid use (whether appropriate or not), but analyses of other opioid-related outcomes in older adults are relatively sparse. Research is also needed to identify interventions to reduce opioid prescribing where harms outweigh benefits (including screening tools), reduce opioid-related harms and disorders, and treat existing misuse or opioid use disorder among older adults.

Author/s:

Agency for Healthcare Research and Quality

Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations

Carly Hughes — Tue, 06 Oct 2020 13:44:48 +0000

Date Added:

October 6, 2020

Journal/Publication:

Mayo Clinic Proceedings

Publisher:

Mayo Clinic

Publication Date:

October 2, 2020

Issue:

Volume:

Pages:

2155-2171

URL:

Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.mayocp.2020.04.025

Keywords

MeSH