Opioid Use Disorder

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

Integrating Buprenorphine for Opioid Use Disorder into Rural, Primary Care Settings

Alex Haga — Mon, 09 Sep 2024 23:06:07 +0000

Date Added:

September 9, 2024

Journal/Publication:

Journal of General Internal Medicine

Publication Date:

July 2, 2024

Volume:

Pages:

2142–2149

URL:

Integrating Buprenorphine for Opioid Use Disorder into Rural, Primary Care Settings

Type:

Best Local Practices

Format:

Article

DOI (1):

10.1007/s11606-024-08898-1

Keywords

PMID (1):

38955895

MeSH

Buprenorphine* / therapeutic use

narcotic antagonists

Opiate Substitution Treatment* / methods

Rural Health Services / organization & administration

Rural Population

United States Department of Veterans Affairs

A qualitative study of methods used by rural VA-owned primary care practices to implement buprenorphine treatment of patients with opioid use disorders.

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Background: Medications for opioid use disorder (MOUD) including buprenorphine are effective, but underutilized. Rural patients experience pronounced disparities in access. To reach rural patients, the US Department of Veterans Affairs (VA) has sought to expand buprenorphine prescribing beyond specialty settings and into primary care.

Objective: Although challenges remain, some rural VA health care systems have begun offering opioid use disorder (OUD) treatment with buprenorphine in primary care. We conducted interviews with clinicians, leaders, and staff within these systems to understand how this outcome had been achieved.

Design: Using administrative data from the VA Corporate Data Warehouse (CDW), we identified rural VA health care systems that had improved their rate of primary care-based buprenorphine prescribing over the period 2015-2020. We conducted qualitative interviews (n = 30) with staff involved in implementing or prescribing buprenorphine in these systems to understand the processes that had facilitated implementation.

Participants: Clinicians, staff, and leaders embedded within rural VA health care systems located in the Northwest, West, Midwest (2), South, and Northeast.

Approach: Qualitative interviews were analyzed using a mixed inductive/deductive approach.

Key results: Interviews revealed the processes through which buprenorphine was integrated into primary care, as well as processes insufficient to enact change. Implementation was often initially catalyzed through a targeted hire. Champions then engaged clinicians and leaders one-on-one to "pitch" the case, describe concordance between buprenorphine prescribing and existing goals, and delineate the supportive role that they could provide. Sites were prepared for implementation by developing new clinical teams and redesigning clinical processes. Each of these processes was made possible with the active, instrumental support of leadership.

Conclusions: Results suggest that rural systems seeking to improve buprenorphine accessibility in primary care may need to alter primary care structures to accommodate buprenorphine prescribing, whether through new hires, team development, or clinical redesign.

Author/s:

Jessica J Wyse, Alison Eckhardt, Summer Newell, Adam J Gordon, Benjamin J Morasco

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.

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:

The opioid crisis: a contextual, social-ecological framework

Type:

Community-Based Research Results

Format:

Article

DOI (1):

10.1186/s12961-020-00596-8

Keywords

Opioid Use Disorder

opioids

social-ecological framework

RISEOK

Opioid Epidemic

PMID (1):

32762700

MeSH

analgesics, opioid

public health

Opioid Epidemic

opioid-related disorders

drug overdose

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

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