Opioid withdrawal symptoms, a consequence of chronic opioid use and opioid use disorder: Current understanding and approaches to management

Abstract Background Neuropsychopharmacologic effects of long-term opioid therapy (LTOT) in the context of chronic pain may result in subjective anhedonia coupled with decreased attention to natural rewards. Yet, there are no known efficacious treatments for anhedonia and reward deficits associated with chronic opioid use. Mindfulness-Oriented Recovery Enhancement (MORE), a novel behavioral intervention combining training in mindfulness with savoring of natural rewards, may hold promise for treating anhedonia in LTOT. Methods Veterans receiving LTOT (N = 63) for chronic pain were randomized to 8 weeks of MORE or a supportive group (SG) psychotherapy control. Before and after the 8-week treatment groups, we assessed the effects of MORE on the late positive potential (LPP) of the electroencephalogram and skin conductance level (SCL) during viewing and up-regulating responses (i.e. savoring) to natural reward cues. We then examined whether these neurophysiological effects were associated with reductions in subjective anhedonia by 4-month follow-up. Results Patients treated with MORE demonstrated significantly increased LPP and SCL to natural reward cues and greater decreases in subjective anhedonia relative to those in the SG. The effect of MORE on reducing anhedonia was statistically mediated by increases in LPP response during savoring. Conclusions MORE enhances motivated attention to natural reward cues among chronic pain patients on LTOT, as evidenced by increased electrocortical and sympathetic nervous system responses. Given neurophysiological evidence of clinical target engagement, MORE may be an efficacious treatment for anhedonia among chronic opioid users, people with chronic pain, and those at risk for opioid use disorder.

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Lofexidine for acute opioid withdrawal: A clinical case series

Mental Health Clinician ◽

10.9740/mhc.2020.09.259 ◽

2020 ◽

Vol 10 (5) ◽

pp. 259-263

Author(s):

Mandy L. Renfro ◽

Lindsey J. Loera ◽

Carlos F. Tirado ◽

Lucas G. Hill

Keyword(s):

Addiction Treatment ◽

Case Series ◽

Retrospective Chart Review ◽

The United States ◽

Opioid Withdrawal ◽

Withdrawal Symptoms ◽

Total Daily Dose ◽

Opioid Use ◽

Management Protocol ◽

Patient Reported

Abstract Introduction Maintaining abstinence through the opioid withdrawal period is a substantial barrier to treatment for patients with opioid use disorder. The alpha-2 agonist lofexidine has demonstrated efficacy and safety in clinical trials, but pragmatic studies describing its use in clinical practice are lacking. This case series describes the use of lofexidine for opioid withdrawal symptoms in an inpatient addiction treatment facility. Methods Seventeen patients receiving at least 1 dose of lofexidine during inpatient treatment for opioid withdrawal were included in this study. A retrospective chart review was conducted for clinical, subjective, and objective data. Adverse events, total daily dose, clinical opioid withdrawal scale (COWS) scores, vital signs, and reasons for early discontinuation of lofexidine are reported. Results Patients treated with lofexidine experienced mild withdrawal symptoms throughout treatment. Most patients (65%) experienced a decrease in their average daily COWS scores from intake to discharge. Two patients (12%) left treatment against medical advice, and 5 patients (29%) discontinued treatment prior to day 7 due to resolution of symptoms. Average daily blood pressure readings remained stable, and daily average heart rate decreased over time. Discussion Lofexidine can be successfully incorporated into a conventional withdrawal management protocol. The cost of lofexidine and its recent introduction to the market remain barriers to accessibility in the United States. Studies evaluating patient-reported outcomes as well as direct comparisons with other alpha-2 agonists are needed to inform optimal clinical use of lofexidine.

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Elective Naloxone-Induced Opioid Withdrawal for Rapid Initiation of Medication-Assisted Treatment of Opioid Use Disorder

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2019.01.006 ◽

2019 ◽

Vol 74 (3) ◽

pp. 430-432 ◽

Cited By ~ 6

Author(s):

Reid H. Phillips ◽

Matthew Salzman ◽

Rachel Haroz ◽

Rachel Rafeq ◽

Anthony J. Mazzarelli ◽

...

Keyword(s):

Opioid Use Disorder ◽

Opioid Withdrawal ◽

Opioid Use ◽

Medication Assisted Treatment

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A double-edged sword of using opioids and COVID-19: a toxicological view

Substance Abuse Treatment Prevention and Policy ◽

10.1186/s13011-020-00333-y ◽

2020 ◽

Vol 15 (1) ◽

Cited By ~ 1

Author(s):

Mahshid Ataei ◽

Farshad M. Shirazi ◽

Roland J. Lamarine ◽

Samaneh Nakhaee ◽

Omid Mehrpour

Keyword(s):

Organ Damage ◽

Opioid Use Disorder ◽

Opioid Use ◽

Inflammatory Phase ◽

Clinical Support ◽

Increased Risk ◽

The World ◽

Chronic Opioid Use ◽

High Doses ◽

World Information

AbstractToday, COVID-19 is spreading around the world. Information about its mechanism, prognostic factors, and management is minimal. COVID-19, as a human disease, has several identifying phases. Physicians of patients with COVID-19 may be interested in knowing whether opioid use disorder may affect their patients’ course or prognosis. This information may be crucial when considering the opioid epidemic in the US and other parts of the world. Opioid use at high doses and over several months duration can mitigate the immune system’s function, which may complicate the course of COVID-19 disease. Potential suppression of parts of the immune response may be important in prevention, clinical support, and therapeutic use of medications in various phases of the COVID-19. Specifically, opioid use disorders via an inhalation route may enhance the “late hyper-inflammatory phase” or result in end-organ damage. It is well established that opioids decrease ventilation as their effect on the medullary respiratory centers increases the risk of pneumonia. This increased risk has been associated with immune-suppressive opioids. The ultimate role of opioids in COVID-19 is not clear. This paper endorses the need for clinical studies to decipher the role and impact of chronic opioid use on viral diseases such as COVID-19.

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Psychoeducational Strategies During Outpatient Transition to Extended-Release Naltrexone for Patients With Opioid Use Disorder

Journal of the American Psychiatric Nurses Association ◽

10.1177/1078390318820124 ◽

2018 ◽

Vol 25 (4) ◽

pp. 272-279

Author(s):

Abigail Zavod ◽

Sarah C. Akerman ◽

Martha M. Snow ◽

Matt Tierney ◽

Maria A. Sullivan

Keyword(s):

Treatment Adherence ◽

Extended Release ◽

The United States ◽

Opioid Use Disorder ◽

Opioid Withdrawal ◽

Opioid Use ◽

Major Barrier ◽

Supportive Interventions ◽

Outpatient Utilization ◽

Withdrawal Management

BACKGROUND: The United States is experiencing an opioid epidemic. Better approaches to encourage outpatient utilization of Food and Drug Administration–approved medications for the treatment of opioid use disorder, including extended-release naltrexone (XR-NTX), are needed. Withdrawal management before initiation of XR-NTX is challenging for clinicians and patients and represents a major barrier to treatment. AIMS: To review psychoeducational strategies that support patients during outpatient withdrawal management and transition to XR-NTX. METHOD: We reviewed the literature on psychoeducational strategies used during opioid withdrawal management and described the role that nurses can play in facilitating transition to XR-NTX in a Phase 3, placebo-controlled, outpatient trial comparing induction regimens. RESULTS: Supportive interventions include general psychoeducation on addiction, overcoming ambivalence, treatment adherence, anticipating XR-NTX induction, managing psychological and physiological aspects of opioid withdrawal, risks of opioid use, and sources of support during recovery. CONCLUSIONS: Psychoeducational strategies led by nurses can promote treatment adherence during withdrawal management and induction onto XR-NTX.

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Buprenorphine therapy in the setting of induced opioid withdrawal from oral naltrexone: a case report

Harm Reduction Journal ◽

10.1186/s12954-020-00417-9 ◽

2020 ◽

Vol 17 (1) ◽

Author(s):

Laura M. Szczesniak ◽

Vincent J. Calleo ◽

Ross W. Sullivan

Keyword(s):

Emergency Department ◽

Acute Treatment ◽

Opioid Use Disorder ◽

Opioid Withdrawal ◽

Opioid Use ◽

Accidental Ingestion ◽

Heroin Use ◽

Case Presentation ◽

Acute Withdrawal ◽

Oral Naltrexone

Abstract Background Patients with opioid use disorder (OUD) frequently present to the emergency department for acute treatment of overdose and withdrawal. Case presentation A 29-year-old male presented to the emergency room after intravenous heroin use followed by accidental ingestion of naltrexone. He was treated with buprenorphine with significant improvement in his Clinical Opioid Withdrawal Score, from moderately severe to mild withdrawal symptoms within a few hours. Conclusion Buprenorphine and minimal supportive care can be used to treat acute withdrawal precipitated by oral naltrexone in patients with OUD.

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The Role of Quality of Education in Neurocognitive Functioning in a Diverse Sample with Chronic Opioid Use Disorder

Archives of Clinical Neuropsychology ◽

10.1093/arclin/acz029.36 ◽

2019 ◽

Vol 34 (7) ◽

pp. 1269-1269

Author(s):

J Olsen ◽

J Arnsten ◽

T Scott ◽

F Arias ◽

C Zhang ◽

...

Keyword(s):

Executive Functioning ◽

Opioid Use Disorder ◽

Reading Level ◽

Quality Of Education ◽

Opioid Use ◽

Significant Group ◽

Wide Range ◽

Chronic Opioid Use

Abstract Objective Literacy is a proxy for quality of education (QoE) and mediates ethnicity-related differences in neurocognitive (NC) performance in some populations (Manly et al., 2002; Rivera Mindt et al., 2008). However, it is unknown whether this relationship exists in the context of chronic opioid use disorder (OUD). This study examined the role of ethnicity, QoE, opioid use severity, and depression in predicting NC performance in a diverse sample of persons with OUD. Participants and Method This cross-sectional study included 74 adults with OUD (Age M = 40.3 [SD = 10.5]; Education M = 11.3 [2.5]; 24% female; 68% Latinx and 32% Non-Latinx White [NLW]). All participants completed comprehensive NC testing and psychiatric/substance use questionnaires. Variables included ethnicity (Latinx vs. Non-Latinx White), years of education, QoE (Wide Range Achievement Test, Third Edition; WRAT-3 Reading Standard Scores), opioid use severity (high vs. low OAT dose), current depression (Beck Depression Inventory, Second Edition; BDI-II Total Score), and demographically-corrected NC T-scores were computed and used for average domain T-scores (e.g., learning, memory, verbal fluency, executive function). Bivariate and ANCOVA analyses were used to compare ethnic groups. Results There were no significant group differences on opioid use severity or current depression (p’s > .05). However, compared to the NLW group, the Latinx group had lower years of education (M = 10.9 [SD = 1.7] vs. M = 12.2 [SD = 3.5]; t[72)] = 2.1, p < .05), QoE (M = 83.1 [SD = 13.6] vs. M = 94.8 [SD = 9.4]; t[72] = 3.8, p < .001), executive functioning (M = 42.0 [SD = 6.5] vs. M = 45.8 [SD = 8.5]; t[72) = 2.1, p < .05), and learning (M = 32.2 [SD = 8.2] vs. M = 37.8 [SD = 8.7]; t[72)] = 2.7, p < .05), with medium to large effect sizes (Cohen’s d > .50). The overall effect of ethnicity became non-significant for executive functioning after accounting for QoE (F[2,70] = 10.0, p = .002) and years of education (F[2,70)] = 16.8, p < .001). Conclusions The current study found that accounting for years of education and QoE attenuates some differences in NC performance between Latinx and Non-Latinx participants. References Manly, J. J., Jacobs, D. M., Touradji, P., Small, S. A., & Stern, Y. (2002). Reading level attenuates differences in neuropsychological test performance between African American and White elders. Journal of the International Neuropsychological Society, 8(3), 341-348. Mindt, M. R., Arentoft, A., Germano, K. K., D’Aquila, E., Scheiner, D., Pizzirusso, M., ... & Gollan, T. H. (2008). Neuropsychological, cognitive, and theoretical considerations for evaluation of bilingual individuals. Neuropsychology review, 18(3), 255-268.

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Kratom Use Within the Context of the Evolving Opioid Crisis and the COVID-19 Pandemic in the United States

Frontiers in Pharmacology ◽

10.3389/fphar.2021.729220 ◽

2021 ◽

Vol 12 ◽

Author(s):

Walter C. Prozialeck ◽

Peter C. Lamar ◽

Michael Krupp ◽

Matthew Moon ◽

Laura E. Phelps ◽

...

Keyword(s):

United States ◽

Chronic Pain ◽

Southeast Asia ◽

The United States ◽

Opioid Use Disorder ◽

Opioid Withdrawal ◽

Opioid Use ◽

Potential Harm ◽

History Of ◽

Chronic Pain Conditions

Kratom (Mitragyna speciosa, Korth.) is an evergreen tree that is indigenous to Southeast Asia. When ingested, kratom leaves or decoctions from the leaves have been reported to produce complex stimulant and opioid-like effects. For generations, native populations in Southeast Asia have used kratom products to stave off fatigue, improve mood, alleviate pain and manage symptoms of opioid withdrawal. Despite the long history of kratom use in Asia, it is only within the past 10–20 years that kratom has emerged as an important herbal agent in the United States, where it is being used for the self-treatment of pain, opioid withdrawal symptoms, and mood disorders. The increase in the use of kratom in the United States has coincided with the serious epidemic of opioid abuse and dependence. Since 2015, efforts to restrict access to prescription opioids have resulted in a marked increase in the use of “street” opioids such as heroin and illicit fentanyl. At the same time, many patients with chronic pain conditions or opioid use disorder have been denied access to appropriate medical help. The lack of access to care for patients with chronic pain and opioid use disorder has been magnified by the emergence of the COVID-19 pandemic. In this report, we highlight how these converging factors have led to a surge in interest in kratom as a potential harm reduction agent in the treatment of pain and opioid use disorder.

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Novel treatment of opioid use disorder using ibogaine and iboga in two adults

Journal of Psychedelic Studies ◽

10.1556/2054.2020.00133 ◽

2020 ◽

Author(s):

Claire Wilson ◽

Trevor Millar ◽

Zak Matieschyn

Keyword(s):

Addiction Treatment ◽

Case Series ◽

Opioid Use Disorder ◽

Opioid Withdrawal ◽

Opioid Use ◽

Opioid Agonist ◽

Opioid Agonist Therapy ◽

Safety Risks ◽

Short Period ◽

Multiple Treatments

AbstractIbogaine is a naturally occurring psychedelic medicine with anti-addictive properties. While research on ibogaine is limited, several observational studies have shown ibogaine can mitigate opioid withdrawal, as seen with reductions in clinical and subjective opioid withdrawal scores and reduced drug use severity (Noller, Frampton, & Yazar-Klosinski, 2018; Brown & Alper 2018). Furthermore, the psychoactive experience may help individuals to realign their values, purpose and sense of connection, as seen with post treatment reductions in depression scores (Noller et al., 2018; Mash et al., 2000).Case seriesThis case series describes two cases of individuals accessing ibogaine through private unregulated clinics in the Vancouver area to treat their opioid use disorder.ConclusionsIn case 1, the client achieved total abstinence from all opioids within 5–6 days of starting ibogaine treatment, did not experience any opioid withdrawal symptoms after ibogaine treatment and maintained abstinence from opioids for 3 years. In case 2, the patient took ibogaine/iboga in multiple treatments over a short period of time (<4 months). The patient stopped all non-medical opioids after the first iboga treatment and then used ibogaine to aid with further dose reductions of her opioid agonist therapy (OAT) and has maintained abstinence from opioids for 2 years. Ibogaine offers a unique and novel therapeutic approach to treating opioid use disorder. Further studies are needed to establish the safety, risks and potential role for ibogaine as a mainstream, evidence-based addiction treatment.

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