Treatment for opioid dependence and suicide prevention

A new study has shed light on the need for better treatment for opioid dependency in people who are at increased risk of suicide and self-harm

Shaping and delivering services in primary care: benzodiazepine and opiate withdrawal service

This article looks at the development of the benzodiazepine and opiate withdrawal service (BOWS) based in addiction services in London. The service was created to implement a manageable and sustainable model that would treat patients with benzodiazepine and codeine-based dependencies. It was envisaged the service would effectively treat patients in GP practices in two boroughs in London. The article outlines what is possible in terms of treatment for patients with issues of opioid dependency, by examining two in-depth case studies. It also illustrates what is possible for nurses in the modern NHS and can be used as a resource to shape and deliver services with positive patient outcomes. Nurses should be seen as shaping and delivering care in the NHS. This is a role that should be promoted to a greater degree, wherever possible.

Shaping and delivering services in primary care: benzodiazepine and opiate withdrawal service

Dependency on benzodiazepine and opiates is an increasing problem. Jeff Fernandez uses case studies to show how a nurse-led addiction service based in primary care can improve patient outcomes This article looks at the development of the benzodiazepine and opiate withdrawal service (BOWS) based in addiction services in London. The service was created to implement a manageable and sustainable model that would treat patients with benzodiazepine and codeine-based dependencies. It was envisaged the service would effectively treat patients in GP practices in two boroughs in London. The article outlines what is possible in terms of treatment for patients with issues of opioid dependency, by examining two in-depth case studies. It also illustrates what is possible for nurses in the modern NHS and can be used as a resource to shape and deliver services with positive patient outcomes. Nurses should be seen as shaping and delivering care in the NHS. This is a role that should be promoted to a greater degree, wherever possible.

Classification of Patients for whom benefit no longer outweighs harm of long-term opioid therapy: Protocol for a Delphi study (Preprint)

UNSTRUCTURED Introduction: Patients with chronic pain who have been prescribed long term opioid therapies often come to a point where the benefits of their therapy are out weighted by the risks associated with taking such a high dose of opioid medication. These patients need to taper off their opioid therapy while simultaneously treating their chronic pain. At the 2019 Veterans' Health Administration State of the Art Conference, there was an acknowledgment of a lack of clinical guidance with regards to treating this subset of patients. Some of the participants believed clinicians and patients would both benefit from a new diagnostic entity describing this situation where patients needed to have their opioid dependency and chronic pain simultaneously treated. Given the ability of a Delphi method to synthesize input from a broad range of experts, we felt this technique could be used to determine if a new diagnostic entity was needed and what the criteria of the diagnostic entity would be. Methods: This would be a modified Delphi technique involving three rounds. The first round would be a series of open ended questions asking about the necessity of this diagnostic entity, how this condition is different from OUD, and what it's possible diagnostic criteria would be. After synthesizing the responses collected, a second round would be conducted to ask participants to rate the different responses offered by their peers. These ratings would be collected, analyzed, and would generate a final potential definition for this clinical phenomena. In the third round we would circulate this definition and would hopefully gain consensus. Dissemination: This protocol has been approved by the Internal Review Board at the Connecticut VA and the study is in process. We hope that other researchers can use this protocol to conduct similar studies and further explore how patients with concurrent chronic pain and opioid dependency can be best served.

Opioid-Dependency and Sleep

The article's abstract is not available.

Intra-muscular administration of autologous bone marrow mononuclear cells reduces opioid dependency in patients with critical limb threatening ischemia.

Background and Hypothesis Critical limb-threatening ischemia (CLTI) is a severe limitation in perfusion of the lower extremities. It is the most advanced stage of peripheral arterial disease. Characterized by unremitting rest pain and/or gangrene, the CLTI patient population has an excessively high rate of opioid use and addiction. The MOBILE Trial was a Phase II multi-center, double-blinded placebo controlled trial designed to assess the safety and efficacy of autologous bone marrow cells (ABMC) in treating patients with CLTI. Our central hypothesis is that cell therapy may provide trophic effects in the treated limb that may decrease opioid requirements. Project Methods The primary endpoint of the MOBILE Trial was amputation-free survival at 52 weeks. Secondary endpoints included limb perfusion measures, ambulatory function, quality of life (VascuQol), pain assessment with a visual analog score, and opioid requirements, as tabulated by prescriptions reported to us. A post-hoc statistical analysis using ANOVA was conducted to describe changes in pain and quality of life measures along the study, and Fisher’s test to compare the incidence of new opioid prescriptions between treatment groups. Results There were no differences in quality of life and visual analog pain measures between the ABMC and placebo groups (P= 0.42). There was however a 36% decrease in new opioid prescriptions in the ABMC groups as compared to placebo (P = 0.058, HR: -0.44-1.012). This reduction did not correlate with changes in limb perfusion measures, gender, age, diagnosis of diabetes, or Rutherford score. Discussion The results of this analysis demonstrate an effect of ABMC in reducing opioid use in a high-risk addiction patient population. These findings are consistent with other studies assessing mesenchymal stem cells in chronic pain syndromes. The effect of ABMC did not correlate with changes in limb perfusion suggesting other beneficial trophic effects of cells in ischemic induced neuropathies. This discovery suggests a potential therapeutic strategy for reducing opioid dependency.

Factors influencing recovery in opioid substitution treatment: a systematic review and thematic synthesis

Background and Aims Recovery outcomes for opioid substitution treatment are poorer than those for alcohol and other drugs. In order to understand why this is and to synthesise the findings of a large number of qualitative studies, we conducted a systematic review and thematic synthesis to understand facilitators of and barriers to recovery from opioid dependency. Methods Electronic databases (Pubmed, PsychInfo, CINAHL and Embase) were searched. English language studies exploring the views of adult service user and stakeholders with experiences of opioid substitution treatment were considered for inclusion. Included studies were inductively analysed using thematic synthesis. During analysis, the socioecological model was selected as an analytical framework for organising and making links between themes as it captured the complexity of the topic well. ResultsFrom 3646 screened papers, we included 37 studies reporting the views of 1212 staff and service users. Studies highlighted complex interactions between factors influencing recovery across the five levels of the socioecological model (intrapersonal, inter-personal, organisational, community and policy). Early life experiences of trauma were common; lack of support (both psychological and social) was also a recurring theme resulting in feelings of disconnection and isolation. Stigma played a particularly important role in an individual’s capacity to recover from opioid dependency and cut-across all levels of the socioecological model. Conclusions Interventions targeted at the individual level fail to take account of the complexity of recovery within opioid substitution treatment and may ignore the complex socio-political context that service users and services exist within. Stigma permeates all levels of the opioid substitution treatment system; we suggest that addressing this is likely to improve healthcare encounters, help-seeking, increase access to social support and facilitate community reintegration for individuals receiving opioid substitution treatment.

Meeting demand for opioid dependency in an Inner London borough

This paper is looking at the development of the Benzodiazepine and Opiate Withdrawal Service (BOWS) in the borough in Inner London to implement a model that would treat patients effectively in GP practices. It is to illustrate what can be achieved with experienced nurse prescribers in treating an emerging group of patients in primary care. Often patients are aware of their dependency on opiate medications and do want to reduce and come off their medications. This paper describes the BOWS service and its approach, illustrating what can be possible, in terms of treatment for patients in general practice. It also shows what can be designed in NHS services to address the growing issue of dependency on prescribed drugs and argues that services having experience in addictive behaviours can play a very large role in achieving this.

Opioid tapering after surgery: a qualitative study of patients’ experiences

Background and aimsPatients usually receive a prescription for morphine or another opioid at discharge after surgery. Several studies have shown that many patients do not step down but develop persistent opioid use following surgery. The purpose of this study was to gain insight of patients’ experiences with opioid tapering after surgery and to propose recommendations for clinicians to assist patients in opioid tapering.MethodsUsing a qualitative study design, 15 adult patients who took opioids before surgery and still had a daily consumption of opioids 6 months following spine surgery were interviewed.ResultsAnalyses of the transcripts identified three major themes and eight subthemes. The major themes were as follows: (1) The patients’ experienced that their whole life revolved around pain and opioids and felt stigmatized and suspected of being drug addicts by their social circle and health care professionals (2) Barriers for opioid tapering were increased pain, opioid dependency and fear of withdrawal symptoms (3) Motivational factors for opioid tapering were fear of dependency, the prospect of a better health, patient involvement in opioid tapering and a trusting relationship between patient and clinician.ConclusionsThe results of this study highlight that opioid tapering is challenging and may be influenced by many different factors. Some patients find opioid tapering particularly difficult and therefore need additional assistance in order to taper off successfully.ImplicationsFor opioid tapering to succeed, it is highly important to establish a trustful relationship with the patients, to take each patient’s personal circumstances into account and to address fears of increased pain and withdrawal symptoms. Clinicians should also focus on patient involvement in opioid tapering and consider to offer a follow-up after discharge to patients at risk for prolonged opioid use.