Medications for management of opioid use disorder

2019 ◽  
Vol 76 (15) ◽  
pp. 1097-1103 ◽  
Author(s):  
Jennifer L Koehl ◽  
David E Zimmerman ◽  
Patrick J Bridgeman
Keyword(s):  
Illicit Drugs ◽  
Symptom Control ◽  
Opioid Use Disorder ◽  
Opioid Use ◽  
Life Saving ◽  
Fentanyl Analogs ◽  
Initiation Of Therapy ◽  
Long Acting ◽  
Illicit Opioid Use

Abstract Purpose The use of buprenorphine, methadone, and long-acting naltrexone for treatment of opioid use disorder (OUD) is discussed, including a review of current literature detailing treatment approaches and action steps to optimize treatment in acute care and office-based settings. Summary The U.S. epidemic of opioid-related deaths has been driven by misuse of prescription opioids and, increasingly, illicit drugs such as heroin, fentanyl, and fentanyl analogs, necessitating a refocusing of treatment efforts on expanding access to life-saving, evidence-based OUD pharmacotherapy. Inpatient treatment of opioid withdrawal includes acute symptom control through a combination of nonopioid medications and long-term pharmacotherapy to lessen opioid craving and facilitate stabilization and recovery. Methadone and buprenorphine reduce opioid craving, increase treatment retention, reduce illicit opioid use, and increase overall survival. Buprenorphine has logistical advantages over methadone, such as greater flexibility of treatment setting and less risk of adverse effects. Studies have shown the efficacy of long-acting injectable naltrexone to be comparable to that of buprenorphine if patients are detoxified prior to initiation of therapy; however, patients with active OUD are often not able to complete the week-long period of opioid abstinence needed prior to initiation of naltrexone injections. Although buprenorphine is preferred by many patients and can be prescribed in office-based settings, there remains a paucity of physicians certified to prescribe it. Conclusion Buprenorphine has become the medication of choice for many patients with OUD, but its use is limited by the low number of physicians certified to prescribe the agent. Other agents studied for treatment of OUD include methadone and naltrexone.

Methadone for Opioid Use Disorder

2020 ◽  
pp. 139-154
Author(s):  
Dennis J. Hand
Keyword(s):  
Addiction Treatment ◽  
Methadone Treatment ◽  
Opioid Use Disorder ◽  
Term Treatment ◽  
Opioid Use ◽  
Opioid Agonist ◽  
Long Term Treatment ◽  
Long Acting ◽  
Practical Factors

Methadone is a long-acting full opioid agonist that has a long history in the treatment of opioid use disorder (OUD). It was the first opioid agonist with OUD as an indication for use. Methadone was developed for OUD during a time of prohibition and criminalization of both addiction and the use of opioid agonists for addiction treatment, which resulted in methadone being heavily regulated at multiple levels. Methadone is frequently used in short-term withdrawal management (i.e., detoxification) and in long-term treatment, with the latter producing better treatment outcomes. This chapter explores the basic pharmacology of methadone and the development of methadone for OUD and its accompanying regulations, discusses the place of methadone in treatment for OUD, reviews the effectiveness of methadone treatment, and visits some practical factors related to methadone as part of treatment for OUD.

Opioids

2020 ◽  
pp. 109-148
Author(s):  
Darius A. Rastegar
Keyword(s):  
Respiratory Depression ◽  
Opioid Use Disorder ◽  
Opioid Antagonist ◽  
Opioid Use ◽  
Opioid Agonist ◽  
Level Of Consciousness ◽  
Long Acting ◽  
Self Help Groups ◽  
Prescription Pain Relievers

Opioids are a class of drugs that include heroin and prescription pain relievers that produce analgesia and euphoria. More than 2 million Americans have an opioid use disorder. Acute effects include analgesia, respiratory depression, miosis, and euphoria. Overdose is a serious complication of opioid use, characterized by depressed level of consciousness and respiratory depression. It can be treated with naloxone. Withdrawal symptoms include dysphoria, yawning, tearing, diarrhea, cramps, nausea, and piloerection. Buprenorphine, methadone, clonidine, and lofexidine can be used to ameliorate the symptoms of withdrawal. However, supervised withdrawal alone rarely leads to long-term abstinence. There are a number of psychosocial treatments, including self-help groups, outpatient therapy, and residential treatment; the data on their effectiveness are limited. Pharmacotherapy with an opioid agonist (methadone or buprenorphine) is the most effective treatment. Long-acting injectable naltrexone, an opioid antagonist, is also effective, but it is more difficult to initiate.

Initiation of Long-Acting Opioids Following Hospital Discharge Among Medicare Beneficiaries

2021 ◽  
Author(s):  
Bhushan R Deshpande ◽  
Ellen P McCarthy ◽  
Yoojin Jung ◽  
Timothy S Anderson ◽  
Shoshana J Herzig
Keyword(s):  
Hospital Discharge ◽  
Hospice Care ◽  
Opioid Use Disorder ◽  
High Dose ◽  
Medicare Beneficiaries ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Short Acting ◽  
Long Acting

Guidelines recommend against initiating long-acting opioids during acute hospitalization, owing to higher risk of overdose and morbidity compared to short-acting opioid initiation. We investigated the incidence of long-acting opioid initiation following hospitalization in a retrospective cohort of Medicare beneficiaries with an acute care hospitalization in 2016 who were ≥65 years old, did not have cancer or hospice care, and had not filled an opioid prescription within the preceding 90 days. Among 258,193 hospitalizations, 47,945 (18.6%) were associated with a claim for a new opioid prescription in the week after hospital discharge: 817 (0.3%) with both short- and long-acting opioids, 125 (0.1%) with long-acting opioids only, and 47,003 (18.2%) with short-acting opioids only. Most long-acting opioid claims occurred in surgical patients (770 out of 942; 81.7%). Compared with beneficiaries prescribed short-acting opioids only, beneficiaries prescribed long-acting opioids were younger, had a higher prevalence of diseases of the musculoskeletal system and connective tissue, and had more known risk factors for opioid-related adverse events, including anxiety disorders, opioid use disorder, prior long-term high-dose opioid use, and benzodiazepine co-prescription. These findings may help target quality-improvement initiatives.

Identification of Distinct Etiologies across Prescription Misuse and Illicit Drug Use: Opioids and Stimulants Compared

2020 ◽  
Author(s):  
Genevieve Fullerton Dash ◽  
Nicholas G. Martin ◽  
Arpana Agrawal ◽  
Michael Lynskey ◽  
Wendy S. Slutske
Keyword(s):  
Illicit Drugs ◽  
Genetic Influence ◽  
Prescription Opioid ◽  
Future Research ◽  
Opioid Use ◽  
Stimulant Use ◽  
Drug Classes ◽  
Illicit Use ◽  
Prescription Opioid Misuse ◽  
Illicit Opioid Use

Background. Drug classes are grouped based on their chemical and pharmacological properties, but prescription and illicit drugs differ in other important ways. Opioid and stimulant classes contain prescription and illicit forms differentially associated with salient risk factors (common route of administration, legality), making them useful comparators for examining the potential differences in the etiological influences on (mis)use of prescription and illicit drugs. Methods. 2,410 individual Australian twins (Mage=31.77 [SD=2.48]; 67% women) were interviewed about prescription misuse and illicit use of opioids and stimulants. Univariate and bivariate biometric models partitioned variances and covariances into additive genetic, shared environmental, and unique environmental influences across drug types. Results. Variation in the propensity to misuse prescription opioids was primarily attributable to genes (37%) and unique environment (59%). Illicit opioid use was attributable to shared (71%) and unique (29%) environment. Prescription stimulant misuse was primarily attributable to genes (78%) and unique environment (21%). Illicit stimulant use was influenced by genes (48%), and shared (29%) and unique environment (23%). There was evidence for genetic influence common to both stimulant types, but limited evidence for genetic influence common to both opioid types. Conclusions. Prescription opioid misuse may share little genetic influence with illicit opioid use. Future research may consider avoiding unitary drug classifications, particularly when examining genetic influences.

scholarly journals Prior National Drug Abuse Treatment Clinical Trials Network (CTN) opioid use disorder trials as background and rationale for NIDA CTN-0100 “optimizing retention, duration and discontinuation strategies for opioid use disorder pharmacotherapy (RDD)”

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Matisyahu Shulman ◽  
Roger Weiss ◽  
John Rotrosen ◽  
Patricia Novo ◽  
Elizabeth Costello ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Extended Release ◽  
Primary Outcome ◽  
Opioid Use Disorder ◽  
Drug Abuse Treatment ◽  
Opioid Use ◽  
National Drug ◽  
Retention In Treatment ◽  
Abuse Treatment

AbstractOpioid use disorder continues to be a significant problem in the United States and worldwide. Three medications—methadone, buprenorphine, and extended-release injectable naltrexone,— are efficacious for treating opioid use disorder (OUD). However, the utility of these medications is limited, in part due to poor rates of retention in treatment. In addition, minimum recovery milestones and other factors that influence when and whether individuals can safely discontinue medications are unknown. The National Drug Abuse Treatment Clinical Trials Network (CTN) study “Optimizing Retention, Duration, and Discontinuation Strategies for Opioid Use Disorder Pharmacotherapy” (RDD; CTN-0100) will be among the largest clinical trials on treatment of OUD yet conducted, consisting of two phases, the Retention phase, and the Duration-Discontinuation phase. The Retention phase, open to patients initiating treatment, will test different doses and formulations of buprenorphine (standard dose sublingual, high dose sublingual, or extended-release injection), and a digital therapeutic app delivering contingency management and cognitive behavioral counseling on the primary outcome of retention in treatment. The Discontinuation phase, open to patients in stable remission from OUD and choosing to discontinue medication (including participants from the Retention phase or from the population of patients treated at the clinical site, referred by an outside prescriber or self-referred) will study different tapering strategies for buprenorphine (sublingual taper vs taper with injection buprenorphine), and a digital therapeutic app which provides resources to promote recovery, on the primary outcome of relapse-free discontinuation of medication. This paper describes how the RDD trial derives from two decades of research in the CTN. Initial trials (CTN-0001; CTN-0002; CTN-0003) focused on opioid detoxification, showing buprenorphine-naloxone was effective for detoxification, but that acute detoxification did not appear to be an effective treatment strategy. Trials on comparative effectiveness of medications for opioid use disorder (MOUD) (CTN-0027; CTN-0030; and CTN-0051) highlighted the problem of dropout from treatment and few trials defined retention on MOUD as the primary outcome. Long-term follow-up studies on those patient samples demonstrated the importance of long-term continuation of medication for many patients to sustain remission. Overall, these trials highlight the potential of a stable research infrastructure such as CTN to advance treatment effectiveness through a programmatic succession of large clinical trials.

scholarly journals Assessing the Relationships Between COVID-19 Stay-at-Home Orders and Opioid Overdoses in the State of Pennsylvania

2021 ◽  
pp. 002204262110063
Author(s):  
Brian King ◽  
Ruchi Patel ◽  
Andrea Rishworth
Keyword(s):  
Age Groups ◽  
The United States ◽  
Opioid Use Disorder ◽  
Opioid Overdose ◽  
Policy Recommendations ◽  
Opioid Use ◽  
Fentanyl Analogs ◽  
Measure Change ◽  
Using Data ◽  
At Home

COVID-19 is compounding opioid use disorder throughout the United States. While recent commentaries provide useful policy recommendations, few studies examine the intersection of COVID-19 policy responses and patterns of opioid overdose. We examine opioid overdoses prior to and following the Pennsylvania stay-at-home order implemented on April 1, 2020. Using data from the Pennsylvania Overdose Information Network, we measure change in monthly incidents of opioid-related overdose pre- versus post-April 1, and the significance of change by gender, age, race, drug class, and naloxone doses administered. Findings demonstrate statistically significant increases in overdose incidents among both men and women, White and Black groups, and several age groups, most notably the 30–39 and 40–49 ranges, following April 1. Significant increases were observed for overdoses involving heroin, fentanyl, fentanyl analogs or other synthetic opioids, pharmaceutical opioids, and carfentanil. The study emphasizes the need for opioid use to be addressed alongside efforts to mitigate and manage COVID-19 infection.

scholarly journals Patient Experiences with the Transition to Telephone Counseling during the COVID-19 Pandemic

Healthcare ◽  
2021 ◽  
Vol 9 (6) ◽  
pp. 663
Author(s):  
Augustine W. Kang ◽  
Mary Walton ◽  
Ariel Hoadley ◽  
Courtney DelaCuesta ◽  
Linda Hurley ◽  
...  
Keyword(s):  
Patient Outcomes ◽  
Interrater Reliability ◽  
Telephone Counseling ◽  
Patient Experiences ◽  
Opioid Use Disorder ◽  
Opioid Use ◽  
Therapeutic Experience ◽  
Perceived Impact

Background: To identify and document the treatment experiences among patients with opioid use disorder (OUD) in the context of the rapid move from in-person to telephone counseling due to the COVID-19 pandemic. Methods: Participants (n = 237) completed a survey with open-ended questions that included the following domains: (1) satisfaction with telephone counseling, (2) perceived convenience, (3) changes to the therapeutic relationship, (4) perceived impact on substance use recovery, and (5) general feedback. Responses were coded using thematic analysis. Codes were subsequently organized into themes and subthemes (covering 98% of responses). Interrater reliability for coding of participants’ responses ranged from 0.89 to 0.95. Results: Overall, patients reported that telephone counseling improved the therapeutic experience. Specifically, 74% of respondents were coded as providing responses consistently indicating “positive valency”. “Positive valency” responses include: (1) feeling supported, (2) greater comfort and privacy, (3) increased access to counselors, and (4) resolved transportation barriers. Conversely, “negative valency” responses include: (1) impersonal experience and (2) reduced privacy. Conclusions: Telephone counseling presents its own set of challenges that should be investigated further to improve the quality of care and long-term patient outcomes.

Are prescription misuse and illicit drug use etiologically distinct? A genetically-informed analysis of opioids and stimulants

2021 ◽  
pp. 1-8
Author(s):  
Genevieve F. Dash ◽  
Nicholas G. Martin ◽  
Arpana Agrawal ◽  
Michael T. Lynskey ◽  
Wendy S. Slutske
Keyword(s):  
Illicit Drugs ◽  
Environmental Influences ◽  
Genetic Influence ◽  
Prescription Opioid ◽  
Future Research ◽  
Shared Environment ◽  
Opioid Use ◽  
Stimulant Use ◽  
Prescription Opioid Misuse ◽  
Illicit Opioid Use

Abstract Background Drug classes are grouped based on their chemical and pharmacological properties, but prescription and illicit drugs differ in other important ways. Potential differences in genetic and environmental influences on the (mis)use of prescription and illicit drugs that are subsumed under the same class should be examined. Opioid and stimulant classes contain prescription and illicit forms differentially associated with salient risk factors (common route of administration, legality), making them useful comparators for addressing this etiological issue. Methods A total of 2410 individual Australian twins [Mage = 31.77 (s.d. = 2.48); 67% women] were interviewed about prescription misuse and illicit use of opioids and stimulants. Univariate and bivariate biometric models partitioned variances and covariances into additive genetic, shared environmental, and unique environmental influences across drug types. Results Variation in the propensity to misuse prescription opioids was attributable to genes (41%) and unique environment (59%). Illicit opioid use was attributable to shared (71%) and unique (29%) environment. Prescription stimulant misuse was attributable to genes (79%) and unique environment (21%). Illicit stimulant use was attributable to genes (48%), shared environment (29%), and unique environment (23%). There was evidence for genetic influence common to both stimulant types, but limited evidence for genetic influence common to both opioid types. Bivariate correlations suggested that prescription opioid use may be more genetically similar to prescription stimulant use than to illicit opioid use. Conclusions Prescription opioid misuse may share little genetic influence with illicit opioid use. Future research may consider avoiding unitary drug classifications, particularly when examining genetic influences.

Perceived Benefits and Harms of Involuntary Civil Commitment for Opioid Use Disorder

2020 ◽  
Vol 48 (4) ◽  
pp. 718-734
Author(s):  
Elizabeth A. Evans ◽  
Calla Harrington ◽  
Robert Roose ◽  
Susan Lemere ◽  
David Buchanan
Keyword(s):  
Civil Commitment ◽  
Opioid Use Disorder ◽  
Opioid Use ◽  
Treatment Access ◽  
Evidence Based Treatment ◽  
Ethics Framework ◽  
Vulnerable Patients ◽  
Underserved Patients ◽  
Legal Consequences

Involuntary civil commitment (ICC) to treatment for opioid use disorder (OUD) prevents imminent overdose, but also restricts autonomy and raises other ethical concerns. Using the Kass Public Health Ethics Framework, we identified ICC benefits and harms. Benefits include: protection of vulnerable, underserved patients; reduced legal consequences; resources for families; and “on-demand” treatment access. Harms include: stigmatizing and punitive experiences; heightened family conflict and social isolation; eroded patient self-determination; limited or no provision of OUD medications; and long-term overdose risk. To use ICC ethically, it should be recognized as comprising vulnerable patients worthy of added protections; be a last resort option; utilize consensual, humanizing processes; provide medications and other evidence-based-treatment; integrate with existing healthcare systems; and demonstrate effective outcomes before diffusion. ICC to OUD treatment carries significant potential harms that, if unaddressed, may outweigh its benefits. Findings can inform innovations for ensuring that ICC is used in an ethically responsible way.

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