Rapid microinduction of sublingual buprenorphine from methadone in an outpatient setting: “A case series”

Buprenorphine (BPN), FDA approved for opioid use disorder (OUD), requires an induction protocol for the patient in mild to moderate withdrawal. This can be problematic in outpatient practice due to complicated medical management. An emerging technique in literature uses a novel approach, called microinduction. In this method, escalating microdoses of BPN are administered, without requiring the patient to stop the opioid agonist.Our addiction treatment center used a microdosing technique to transit patients from methadone to BPN, without requiring opioid abstinence. Our case series is novel as it was outpatient microinduction from methadone to BPN in 7 days or less.

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Neurofeedback for Opioid Dependent Patients in an Outpatient Setting: A Pilot Feasibility Study

10.21203/rs.3.rs-966830/v1 ◽

2021 ◽

Author(s):

Helena A. Rempala ◽

Justin A. Barterian

Keyword(s):

Large Scale ◽

The United States ◽

Outpatient Setting ◽

Opioid Use Disorder ◽

High Rate ◽

Treatment Center ◽

Opioid Use ◽

Treatment As Usual ◽

Factors Affecting ◽

Study Approach

Abstract Background: Neurofeedback (NF) has been described as “probably efficacious” when used in conjunction with other interventions for substance use disorders, including the most recent studies in population of individuals with opioid use disorder. Despite these promising outcomes, the seriousness of the opioid epidemic, and the high rate of relapse even with the most effective medication-assisted maintenance treatments NF continues to be an under-researched treatment modality. This article explores factors that affected the feasibility of adding Alpha/Theta Neurofeedback to treatment as usual for opioid dependence in an outpatient urban treatment center. The study strived to replicate previous research completed in Iran that found benefits of NF for opioid dependence.Methods: Out of approximately two dozen patients eligible for Alpha/Theta NF, about 60% (n=15) agreed to participate; however, only 2 participants completed treatment. The rates of enrollment in response to active treatment were monitored. Results: The 4 factors affecting feasibility were: 1) the time commitment required of participants, 2) ineffectiveness of standard incentives to promote participation, 3) delayed effects of training, and 4) the length and number of treatments required.Conclusion: The findings indicate a large scale study examining the use of NF for the treatment of opioid use disorder in the United States will likely be difficult to accomplish without modification to the traditional randomized control study approach and suggests challenges to the implementation of this treatment in an outpatient setting.

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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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Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation

Addiction Science & Clinical Practice ◽

10.1186/s13722-019-0176-y ◽

2019 ◽

Vol 14 (1) ◽

Cited By ~ 1

Author(s):

Randi Sokol ◽

Mark Albanese ◽

Aaronson Chew ◽

Jessica Early ◽

Ellie Grossman ◽

...

Keyword(s):

Conceptual Framework ◽

Best Practice ◽

Case Series ◽

Implementation Strategies ◽

Outpatient Setting ◽

Opioid Use Disorder ◽

Clinical Environment ◽

Opioid Use ◽

Opioid Treatment ◽

Study Sites

Abstract Background Group-Based Opioid Treatment (GBOT) has recently emerged as a mechanism for treating patients with opioid use disorder (OUD) in the outpatient setting. However, the more practical “how to” components of successfully delivering GBOT has received little attention in the medical literature, potentially limiting its widespread implementation and utilization. Building on a previous case series, this paper delineates the key components to implementing GBOT by asking: (a) What are the core components to GBOT implementation, and how are they defined? (b) What are the malleable components to GBOT implementation, and what conceptual framework should providers use in determining how to apply these components for effective delivery in their unique clinical environment? Methods To create a blueprint delineating GBOT implementation, we integrated findings from a previously conducted and separately published systematic review of existing GBOT studies, conducted additional literature review, reviewed best practice recommendations and policies related to GBOT and organizational frameworks for implementing health systems change. We triangulated this data with a qualitative thematic analysis from 5 individual interviews and 2 focus groups representing leaders from 5 different GBOT programs across our institution to identify the key components to GBOT implementation, distinguish “core” and “malleable” components, and provide a conceptual framework for considering various options for implementing the malleable components. Results We identified 6 core components to GBOT implementation that optimize clinical outcomes, comply with mandatory policies and regulations, ensure patient and staff safety, and promote sustainability in delivery. These included consistent group expectations, team-based approach to care, safe and confidential space, billing compliance, regular monitoring, and regular patient participation. We identified 14 malleable components and developed a novel conceptual framework that providers can apply when deciding how to employ each malleable component that considers empirical, theoretical and practical dimensions. Conclusion While further research on the effectiveness of GBOT and its individual implementation components is needed, the blueprint outlined here provides an initial framework to help office-based opioid treatment sites implement a successful GBOT approach and hence potentially serve as future study sites to establish efficacy of the model. This blueprint can also be used to continuously monitor how components of GBOT influence treatment outcomes, providing an empirical framework for the ongoing process of refining implementation strategies.

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The association between cannabis use and outcome in pharmacological treatment for opioid use disorder

Harm Reduction Journal ◽

10.1186/s12954-021-00468-6 ◽

2021 ◽

Vol 18 (1) ◽

Author(s):

Tea Rosic ◽

Raveena Kapoor ◽

Balpreet Panesar ◽

Leen Naji ◽

Darren B. Chai ◽

...

Keyword(s):

Side Effects ◽

Pharmacological Treatment ◽

Addiction Treatment ◽

Age Of Onset ◽

Opioid Use Disorder ◽

Cannabis Use ◽

Self Report ◽

Opioid Use ◽

Differential Outcomes ◽

Urine Drug

Abstract Background With the ongoing opioid crisis and policy changes regarding legalization of cannabis occurring around the world, it is necessary to consider cannabis use in the context of opioid use disorder (OUD) and its treatment. We aimed to examine (1) past-month cannabis use in patients with OUD, (2) self-reported cannabis-related side effects and craving, and (3) the association between specific characteristics of cannabis use and opioid use during treatment in cannabis users. Methods Participants receiving pharmacological treatment for OUD (n = 2315) were recruited from community-based addiction treatment clinics in Ontario, Canada, and provided information on past-month cannabis use (self-report). Participants were followed for 3 months with routine urine drug screens in order to assess opioid use during treatment. We used logistic regression analysis to explore (1) the association between any cannabis use and opioid use during treatment, and (2) amongst cannabis-users, specific cannabis use characteristics associated with opioid use. Qualitative methods were used to examine responses to the question: “What effect does marijuana have on your treatment?”. Results Past-month cannabis use was reported by 51% of participants (n = 1178). Any cannabis use compared to non-use was not associated with opioid use (OR = 1.03, 95% CI 0.87–1.23, p = 0.703). Amongst cannabis users, nearly 70% reported daily use, and half reported experiencing cannabis-related side effects, with the most common side effects being slower thought process (26.2%) and lack of motivation (17.3%). For cannabis users, daily cannabis use was associated with lower odds of opioid use, when compared with occasional use (OR = 0.61, 95% CI 0.47–0.79, p < 0.001) as was older age of onset of cannabis use (OR = 0.97, 95% CI 0.94, 0.99, p = 0.032), and reporting cannabis-related side effects (OR = 0.67, 95% CI 0.51, 0.85, p = 0.001). Altogether, 75% of cannabis users perceived no impact of cannabis on their OUD treatment. Conclusion Past-month cannabis use was not associated with more or less opioid use during treatment. For patients who use cannabis, we identified specific characteristics of cannabis use associated with differential outcomes. Further examination of characteristics and patterns of cannabis use is warranted and may inform more tailored assessments and treatment recommendations.

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Sublingual Buprenorphine-Naloxone Compared With Injection Naltrexone for Opioid Use Disorder: Potential Utility of Patient Characteristics in Guiding Choice of Treatment

American Journal of Psychiatry ◽

10.1176/appi.ajp.2020.20060816 ◽

2021 ◽

pp. appi.ajp.2020.2

Author(s):

Edward V. Nunes ◽

Jennifer M. Scodes ◽

Martina Pavlicova ◽

Joshua D. Lee ◽

Patricia Novo ◽

...

Keyword(s):

Patient Characteristics ◽

Opioid Use Disorder ◽

Potential Utility ◽

Opioid Use ◽

Sublingual Buprenorphine ◽

Choice Of Treatment ◽

Disorder Potential

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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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Use of Buprenorphine for the Treatment of Opioid Use Disorder

Substance Use Disorders ◽

10.1093/med/9780190920197.003.0009 ◽

2020 ◽

pp. 155-168

Author(s):

Paul J. Fudala ◽

Anne Cramer Andorn

Keyword(s):

Opioid Dependence ◽

Addiction Treatment ◽

Partial Agonist ◽

The United States ◽

Opioid Use Disorder ◽

Sublingual Administration ◽

Opioid Use ◽

The Us ◽

Monthly Administration ◽

Drug Addiction Treatment

Buprenorphine is a mu-opioid partial agonist that was first developed as a parenteral analgesic and subsequently as a treatment for opioid dependence. In the United States, the first two products approved by the US Food and Drug Administration (in 2002) for the latter indication were buprenorphine (Subutex) and buprenorphine/naloxone (Suboxone) tablet formulations for sublingual administration. Since that time, additional products for both sublingual and buccal administration have also been approved, as well as a subcutaneous injection for once-monthly administration for the treatment of moderate or severe opioid use disorder (OUD) and a subdermal implant for the maintenance treatment of opioid dependence that delivers buprenorphine over a 6-month period. Under the Drug Addiction Treatment Act of 2000 (DATA 2000), qualified practitioners may apply for waivers to treat opioid dependence/OUD with approved buprenorphine products in any setting in which they are qualified to practice. Like other opioids, buprenorphine has the potential for being misused and abused.

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