A qualitative examination of the current management of opioid use disorder and barriers to prescribing buprenorphine in a Canadian emergency department

Abstract Background Emergency departments (EDs) across Canada are increasingly prescribing buprenorphine for opioid use disorder (OUD). The objective of this study was to identify the current knowledge, attitudes, and behaviours of ED physicians on the management of OUD in the ED, including barriers and facilitators to prescribing buprenorphine. Methods We purposefully selected emergency physicians from one ED in Toronto which had recently received education on OUD management and had a new addiction medicine follow-up clinic, to participate in semi-structured interviews. We used semi-structured interviews to explore experiences with patients with OUD, conceptions of role of the ED in addressing OUD, and specifically ask about perceptions and experience on using buprenorphine for opioid withdrawal. Our analysis was informed by constructivist grounded theory to help uncover contextualized social processes and focus on what people do and why they do it. Two researchers independently coded transcripts using an iterative constant comparative and interpretative approach. Results Results fell broadly into facilitators and barriers. Generally, management of OUD in the ED varied significantly. Physician-level facilitators to treating opioid withdrawal with buprenorphine included: knowledge about OUD an7d buprenorphine, positive experiences with substitution therapy in the past, and the presence of physician champions. Systems-level facilitators included timely access to follow-up care and pre-printed order sets. Barriers included provider inexperience, lack of feedback on treatment effectiveness, limited time to counsel patients, and pressure to discharge patients quickly. Additional barriers included concerns about precipitating withdrawal, prescribing a chronic medication in acute care, and patient attitudes. Conclusion This study describes barriers and facilitators to addressing OUD and prescribing buprenorphine in a Canadian ED. These findings suggest a role for additional provider education, involvement of allied health professionals in counseling, and mentorship by physician champions in the department.

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P138: Management of opioid withdrawal: A qualitative examination of current practices and barriers to prescribing buprenorphine in a Canadian emergency department

CJEM ◽

10.1017/cem.2019.329 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S114

Author(s):

D. Wiercigroch ◽

P. Hoyeck ◽

H. Sheikh ◽

J. Hulme

Keyword(s):

Medical Education ◽

Continuing Medical Education ◽

Current Knowledge ◽

Opioid Withdrawal ◽

Barriers And Facilitators ◽

Opioid Use ◽

Structured Interviews ◽

Allied Health Professionals ◽

Chronic Medication

Introduction: The opioid crisis persists, and in the context of this urgency and new practice guidelines, the practice of buprenorphine (BUP) prescription is expanding across Canadian emergency departments (EDs). The objective of this study was to identify current knowledge, attitudes and behaviours to managing opioid use disorder (OUD) in the ED, including barriers and facilitators to prescribing BUP. Methods: Forty ED staff physicians were randomly invited to participate from an urban Toronto ED which recently received continuing medical education in addictions, and whose hospital established an addictions follow-up clinic. Individual semi-structured interviews with the 19 physicians who self-selected to participate were grounded in phenomenology, allowing for in-depth accounts of participants’ lived experience and viewpoints on their role in addressing OUD. Thematic analysis was achieved through multiple readings; themes were coded using Dedoose software by two researchers. Themes were further organized as facilitators, barriers, and proposed solutions. Results: Opioid withdrawal management in the ED varied significantly between these practitioners in the same practice group. Facilitators to treating withdrawal and initiating BUP in the ED were rooted in three contributors to physician empowerment: knowledge about OUD and BUP, positive patient and provider experience with substitution therapy in the past, and exposure to physician champions to guide their practice. Systems-level facilitators included timely access to follow-up care and an available order set. Barriers included provider inexperience: missing subtle presentations of withdrawal, lacking feedback on treatment effectiveness, and reported uncertainty about the protocol from nursing staff. The ED environment also limits time to counsel effectively and discourages taking up a bed both to wait for withdrawal onset and for BUP induction. Other barriers were concerns about precipitating withdrawal, prescribing a chronic medication in acute care, and patient attitudes. Conclusion: This is the first study describing barriers and facilitators to addressing OUD and prescribing BUP in the ED. These findings suggest a role for home induction, involvement of allied health professionals in BUP counseling, and heightened continuing medical education. Results will inform departmental efforts across Canada to implement BUP prescribing as standard of care for patients in opioid withdrawal.

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Captagon use in a patient with iatrogenic opioid use disorder

Current Psychopharmacologye ◽

10.2174/2211556010666210701163649 ◽

2021 ◽

Vol 10 ◽

Author(s):

Mohammed Hamdan ◽

Samer El Hayek ◽

Maya Bizri

Keyword(s):

Middle Eastern ◽

Opioid Use Disorder ◽

Opioid Withdrawal ◽

Psychotic Symptoms ◽

Patient Counseling ◽

Opioid Use ◽

Case Presentation ◽

Recreational Use ◽

Reducing Properties

Background: Captagon or Fenethylline is a synthetic theophylline derivative of amphetamine that is widely available for recreational use in the Middle East. It has pain-reducing properties and is known to induce restlessness, irritability, and psychotic symptoms. Case presentation: A middle-aged man with iatrogenic opioid use disorder was admitted for acute cholecystitis. A week following cholecystectomy, the patient used Captagon while hospitalized to manage opioid withdrawal pain. He experienced waxing and waning episodes of irritability, aggressiveness, disorganized behaviors, delusions, and hallucinations, all concurrent with his Captagon intake. These episodes were managed similarly to intoxication with other stimulant types. Conclusion: Careful patient counseling and close follow-up are essential when opioids are prescribed. Captagon’s pain-reducing properties make it an attractive and dangerous option for Middle Eastern patients suffering from opioid withdrawal. Captagon intoxication is currently managed similarly to other stimulant types, but more studies are needed to develop management guidelines specific to this substance.

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The Effect of Single High-dose Buprenorphine on Opioid Craving and Relapse

10.21203/rs.2.214/v1 ◽

2019 ◽

Author(s):

Jamshid Ahmadi ◽

Mina SefidfardJahromi ◽

Dara Ghahremani ◽

Edythe D. London

Keyword(s):

Statistical Significance ◽

Opioid Use Disorder ◽

Opioid Withdrawal ◽

High Dose ◽

Opioid Use ◽

Single High Dose ◽

High Doses ◽

Long Acting ◽

Drug Free

Abstract Background: Buprenorphine, a treatment for Opioid Use Disorder, has liability for diversion and abuse. Use of single high doses of buprenorphine that are supervised avoid issues with diversion that occur with unsupervised or take home doses. Such doses have the potential to act as an initial opioid detox, facilitate transition to opioid antagonists or drug free treatments, as well as to maintenance treatment. Objective: To assess effects of a single, physician-administered high dose of buprenorphine on craving and on early relapse. Method: Sixty men who used heroin, opium or prescription opioids and met DSM-5 criteria for Opioid Use Disorder received a single, sublingual dose of buprenorphine (32 mg, 64 mg or 96 mg; n’s = 20, 21, and 19) as inpatients on a psychiatric unit. Buprenorphine was administered when patients were in moderate opioid withdrawal (4-5 symptoms). Self-reports of craving were taken at baseline and daily for the next 13 days, and relapse was assessed 1 and 2 months. Findings: Craving was reduced from baseline in each of the three groups (p < 0.0005), but the doseXtime interaction did not reach statistical significance (p= 0.069). Follow-up assessments at 1- and 2-months indicated significantly lower relapse rates for the higher-dose groups than for the low-dose group (p < 0.05). Conclusions: A single high dose of buprenorphine provides rapid relief of opioid craving and positively impacts relapse rate in the initial 1- and 2-months of outpatient treatment. Further investigation of single high-dose buprenorphine for early treatment of patients with Opioid Use Disorder is warranted as an alternative when buprenorphine/naloxone or long-acting buprenorphine dosage forms are not available. Keywords: Buprenorphine; opioid dependence; opioid withdrawal; craving

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Syringe service program-based telemedicine linkage to opioid use disorder treatment: protocol for the STAMINA randomized control trial

BMC Public Health ◽

10.1186/s12889-021-10669-0 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Dennis P. Watson ◽

James A. Swartz ◽

Lisa Robison-Taylor ◽

Mary Ellen Mackesy-Amiti ◽

Kim Erwin ◽

...

Keyword(s):

Study Protocol ◽

Randomized Control Trial ◽

Treatment Protocol ◽

Opioid Use Disorder ◽

Additional Treatment ◽

Initial Assessment ◽

Opioid Use ◽

Structured Interviews ◽

Randomized Control ◽

Opioid Users

Abstract Background A key strategy for mitigating the current opioid epidemic is expanded access to medications for treating opioid use disorder (MOUD). However, interventions developed to expand MOUD access have limited ability to engage opioid users at higher levels of overdose risk, such as those who inject opioids. This paper describes the study protocol for testing STAMINA (Syringe Service Telemedicine Access for Medication-assisted Intervention through NAvigation), an intervention that engages high-risk opioid users at community-based syringe service programs (SSP) and quickly links them to MOUD using a telemedicine platform. Methods This randomized control trial will be conducted at three SSP sites in Chicago. All participants will complete an initial assessment with a provider from a Federally Qualified Health Center who can prescribe or refer MOUD services as appropriate. The control arm will receive standard referral to treatment and the intervention arm will receive immediate telemedicine linkage to the provider and (depending on the type of MOUD prescribed) provided transportation to pick up their induction prescription (for buprenorphine or naltrexone) or attend their intake appointment (for methadone). We aim to recruit a total of 273 participants over two years to provide enough power to detect a difference in our primary outcome of MOUD treatment linkage. Secondary outcomes include treatment engagement, treatment retention, and non-MOUD opioid use. Data will be collected using structured interviews and saliva drug tests delivered at baseline, three months, and six months. Fixed and mixed effects generalized linear regression analyses and survival analysis will be conducted to compare the probabilities of a successful treatment linkage between the two arms, days retained in treatment, and post-baseline opioid and other drug use. Discussion If successful, STAMINA’s telemedicine approach will significantly reduce the amount of time between SSP clients’ initial indication of interest in the medication and treatment initiation. Facilitating this process will likely lead to stronger additional treatment- and recovery-oriented outcomes. This study is also timely given the need for more rigorous testing of telemedicine interventions in light of temporary regulatory changes that have occurred during the COVID-19 pandemic. Trial registration ClinicalTrials.gov (Clinical Trials ID: NCT04575324 and Protocol Number: 1138–0420). Registered 29 September 2020. The study protocol is also registered on the Open Science Framework (DOI 10.17605/OSF.IO/4853 M).

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Maternal opioid use disorder: Placental transcriptome analysis for neonatal opioid withdrawal syndrome

Genomics ◽

10.1016/j.ygeno.2021.08.001 ◽

2021 ◽

Author(s):

Uppala Radhakrishna ◽

Swapan K. Nath ◽

Sangeetha Vishweswaraiah ◽

Lavanya V. Uppala ◽

Ariadna Forray ◽

...

Keyword(s):

Transcriptome Analysis ◽

Withdrawal Syndrome ◽

Opioid Use Disorder ◽

Opioid Withdrawal ◽

Opioid Use ◽

Opioid Withdrawal Syndrome

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A national survey of barriers and facilitators to medications for opioid use disorder among legal-involved veterans in the Veterans Health Administration

Substance Abuse ◽

10.1080/08897077.2021.1975867 ◽

2021 ◽

pp. 1-8

Author(s):

Emmeline N. Taylor ◽

Christine Timko ◽

Ingrid A. Binswanger ◽

Alex H. S. Harris ◽

Matthew Stimmel ◽

...

Keyword(s):

National Survey ◽

Veterans Health Administration ◽

Opioid Use Disorder ◽

Barriers And Facilitators ◽

Veterans Health ◽

Health Administration ◽

Opioid Use

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Addiction Medicine Consultations Reduce Readmission Rates for Patients With Serious Infections From Opioid Use Disorder

Clinical Infectious Diseases ◽

10.1093/cid/ciy924 ◽

2018 ◽

Vol 68 (11) ◽

pp. 1935-1937 ◽

Cited By ~ 44

Author(s):

Laura R Marks ◽

Satish Munigala ◽

David K Warren ◽

Stephen Y Liang ◽

Evan S Schwarz ◽

...

Keyword(s):

Opioid Use Disorder ◽

Opioid Use ◽

Addiction Medicine ◽

Readmission Rates ◽

Serious Infections

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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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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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