חיפוש מאמרים

Office-Based Buprenorphine for Patients with Opioid Dependence
Sullivan, L. E., & Fiellin, D. A. Annals of internal medicine 148.9 (2008): 662.
The profile of opioid dependence in the United States is changing. Abuse of prescription opioids is more common than thatRead More...

The profile of opioid dependence in the United States is changing. Abuse of prescription opioids is more common than that of illicit opioids. Recent data indicate that there are approximately 1.6 million individuals with prescription opioid abuse or dependence and 323,000 with heroin abuse or dependence. Despite this prevalence, nearly 80% of these individuals go untreated. One option for expanding treatment is the use of buprenorphine and the buprenorphine/naloxone combination. Buprenorphine is a partial opioid agonist that can be prescribed by trained Internists and dispensed at pharmacies.

The case-based discussion in this paper addresses the clinical presentation of a patient with opioid dependence and describes the relatively new practice of office-based treatment with buprenorphine/naloxone. It examines the different components of treatment, the role of the Internist in providing this treatment, and the logistics of treating this growing and multi-faceted patient population.

Read Less
Clonidine Maintenance Prolongs Opioid Abstinence and Decouples Stress From Craving in Daily Life: A Randomized Controlled Trial With Ecological Momentary Assessment
Kowalczyk, W. J., Phillips, K. A., Jobes, M. L., Kennedy, A. P., Ghitza, U. E., Agage, D. A., ... & Preston, K. L. American Journal of Psychiatry 172.8 (2015): 760-767.
Objective: The authors tested whether clonidine blocks stress-induced seeking of heroin and cocaine. The study was also intended to confirmRead More...

Objective:

The authors tested whether clonidine blocks stress-induced seeking of heroin and cocaine. The study was also intended to confirm translational findings from a rat model of drug relapse by using ecological momentary assessment of patients’ stress to test hypotheses about clonidine’s behavioral mechanism of action.

Method:

The authors conducted a randomized double-blind placebo-controlled clinical trial with 208 opioid-dependent patients at an outpatient buprenorphine clinic. The 118 participants (57%) who maintained abstinence during weeks 5–6 were continued on buprenorphine and randomly assigned to receive clonidine (N=61) or placebo (N=57) for 14 weeks. Urine was tested thrice weekly. Lapse was defined as any opioid-positive or missed urine test, and relapse as two or more consecutive lapses. Time to lapse and relapse were examined with Cox regressions; longest period of abstinence was examined with a t test, and ecological momentary assessment data were examined with generalized linear mixed models.

Results:

In an intent-to-treat analysis, clonidine produced the longest duration (in consecutive days) of abstinence from opioids during the intervention phase (34.8 days [SD=3.7] compared with 25.5 days [SD=2.7]; Cohen’s d=0.38). There was no group difference in time to relapse, but the clonidine group took longer to lapse (hazard ratio=0.67, 95% CI=0.45–1.00). Ecological momentary assessment showed that daily-life stress was partly decoupled from opioid craving in the clonidine group, supporting the authors’ hypothesized mechanism for clonidine’s benefits.

Conclusions:

Clonidine, a readily available medication, is useful in opioid dependence not just for reduction of withdrawal signs, but also as an adjunctive maintenance treatment that increases duration of abstinence. Even in the absence of physical withdrawal, it decouples stress from craving in everyday life.

Read Less
Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence – A Randomized Clinical Trial
D’onofrio, G., O’connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens, P. H., & Fiellin, D. A. Jama 313.16 (2015): 1636-1644.
Importance  Opioid-dependent patients often use the emergency department (ED) for medical care. Objective  To test the efficacy of 3 interventions for opioidRead More...

Importance  Opioid-dependent patients often use the emergency department (ED) for medical care.

Objective  To test the efficacy of 3 interventions for opioid dependence: (1) screening and referral to treatment (referral); (2) screening, brief intervention, and facilitated referral to community-based treatment services (brief intervention); and (3) screening, brief intervention, ED-initiated treatment with buprenorphine/naloxone, and referral to primary care for 10-week follow-up (buprenorphine).

Design, Setting, and Participants  A randomized clinical trial involving 329 opioid-dependent patients who were treated at an urban teaching hospital ED from April 7, 2009, through June 25, 2013.

Interventions  After screening, 104 patients were randomized to the referral group, 111 to the brief intervention group, and 114 to the buprenorphine treatment group.

Main Outcomes and Measures  Enrollment in and receiving addiction treatment 30 days after randomization was the primary outcome. Self-reported days of illicit opioid use, urine testing for illicit opioids, human immunodeficiency virus (HIV) risk, and use of addiction treatment services were the secondary outcomes.

Results  Seventy-eight percent of patients in the buprenorphine group (89 of 114 [95% CI, 70%-85%]) vs 37% in the referral group (38 of 102 [95% CI, 28%-47%]) and 45% in the brief intervention group (50 of 111 [95% CI, 36%-54%]) were engaged in addiction treatment on the 30th day after randomization (P < .001). The buprenorphine group reduced the number of days of illicit opioid use per week from 5.4 days (95% CI, 5.1-5.7) to 0.9 days (95% CI, 0.5-1.3) vs a reduction from 5.4 days (95% CI, 5.1-5.7) to 2.3 days (95% CI, 1.7-3.0) in the referral group and from 5.6 days (95% CI, 5.3-5.9) to 2.4 days (95% CI, 1.8-3.0) in the brief intervention group (P < .001 for both time and intervention effects; P = .02 for the interaction effect). The rates of urine samples that tested negative for opioids did not differ statistically across groups, with 53.8% (95% CI, 42%-65%) in the referral group, 42.9% (95% CI, 31%-55%) in the brief intervention group, and 57.6% (95% CI, 47%-68%) in the buprenorphine group (P = .17). There were no statistically significant differences in HIV risk across groups (P = .66). Eleven percent of patients in the buprenorphine group (95% CI, 6%-19%) used inpatient addiction treatment services, whereas 37% in the referral group (95% CI, 27%-48%) and 35% in the brief intervention group (95% CI, 25%-37%) used inpatient addiction treatment services (P < .001).

Conclusions and Relevance  Among opioid-dependent patients, ED-initiated buprenorphine treatment vs brief intervention and referral significantly increased engagement in addiction treatment, reduced self-reported illicit opioid use, and decreased use of inpatient addiction treatment services but did not significantly decrease the rates of urine samples that tested positive for opioids or of HIV risk. These findings require replication in other centers before widespread adoption.

Read Less
Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence (Review)
Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. Cochrane database of systematic reviews 2 (2014).
Background Buprenorphine maintenance treatment has been evaluated in randomised controlled trials against placebo medication, and separately as an alternative toRead More...

Background

Buprenorphine maintenance treatment has been evaluated in randomised controlled trials against placebo medication, and separately as an alternative to methadone for management of opioid dependence.

Objectives

To evaluate buprenorphine maintenance compared to placebo and to methadone maintenance in the management of opioid dependence, including its ability to retain people in treatment, suppress illicit drug use, reduce criminal activity, and mortality.

Search methods

We searched the following databases to January 2013: Cochrane Drugs and Alcohol Review Group Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Current Contents, PsycLIT, CORK, Alcohol and Drug Council of Australia, Australian Drug Foundation, Centre for Education and Information on Drugs and Alcohol, Library of Congress, reference lists of identified studies and reviews. We sought published/unpublished randomised controlled trials (RCTs) from authors.

Selection criteria

Randomised controlled trials of buprenorphine maintenance treatment versus placebo or methadone in management of opioid‐dependent persons.

Data collection and analysis

We used Cochrane Collaboration methodology.

Main results

We include 31 trials (5430 participants), the quality of evidence varied from high to moderate quality.

There is high quality of evidence that buprenorphine was superior to placebo medication in retention of participants in treatment at all doses examined. Specifically, buprenorphine retained participants better than placebo: at low doses (2 ‐ 6 mg), 5 studies, 1131 participants, risk ratio (RR) 1.50; 95% confidence interval (CI) 1.19 to 1.88; at medium doses (7 ‐ 15 mg), 4 studies, 887 participants, RR 1.74; 95% CI 1.06 to 2.87; and at high doses (≥ 16 mg), 5 studies, 1001 participants, RR 1.82; 95% CI 1.15 to 2.90. However, there is moderate quality of evidence that only high‐dose buprenorphine (≥ 16 mg) was more effective than placebo in suppressing illicit opioid use measured by urinanalysis in the trials, 3 studies, 729 participants, standardised mean difference (SMD) ‐1.17; 95% CI ‐1.85 to ‐0.49, Notably, low‐dose, (2 studies, 487 participants, SMD 0.10; 95% CI ‐0.80 to 1.01), and medium‐dose, (2 studies, 463 participants, SMD ‐0.08; 95% CI ‐0.78 to 0.62) buprenorphine did not suppress illicit opioid use measured by urinanalysis better than placebo.

There is high quality of evidence that buprenorphine in flexible doses adjusted to participant need,was less effective than methadone in retaining participants, 5 studies, 788 participants, RR 0.83; 95% CI 0.72 to 0.95. For those retained in treatment, no difference was observed in suppression of opioid use as measured by urinalysis, 8 studies, 1027 participants, SMD ‐0.11; 95% CI ‐0.23 to 0.02 or self report, 4 studies, 501 participants, SMD ‐0.11; 95% CI ‐0.28 to 0.07, with moderate quality of evidence.

Consistent with the results in the flexible‐dose studies, in low fixed‐dose studies, methadone (≤ 40 mg) was more likely to retain participants than low‐dose buprenorphine (2 ‐ 6 mg), (3 studies, 253 participants, RR 0.67; 95% CI: 0.52 to 0.87). However, we found contrary results at medium dose and high dose: there was no difference between medium‐dose buprenorphine (7 ‐ 15 mg) and medium‐dose methadone (40 ‐ 85 mg) in retention, (7 studies, 780 participants, RR 0.87; 95% CI 0.69 to 1.10) or in suppression of illicit opioid use as measured by urines, (4 studies, 476 participants, SMD 0.25; 95% CI ‐0.08 to 0.58) or self report of illicit opioid use, (2 studies, 174 participants, SMD ‐0.82; 95% CI ‐1.83 to 0.19). Similarly, there was no difference between high‐dose buprenorphine (≥ 16 mg) and high‐dose methadone (≥ 85 mg) in retention (RR 0.79; 95% CI 0.20 to 3.16) or suppression of self‐reported heroin use (SMD ‐0.73; 95% CI ‐1.08 to ‐0.37) (1 study, 134 participants).

Few studies reported adverse events ; two studies compared adverse events statistically, finding no difference between methadone and buprenorphine, except for a single result indicating more sedation among those using methadone.

Authors' conclusions

Buprenorphine is an effective medication in the maintenance treatment of heroin dependence, retaining people in treatment at any dose above 2 mg, and suppressing illicit opioid use (at doses 16 mg or greater) based on placebo‐controlled trials.

However, compared to methadone, buprenorphine retains fewer people when doses are flexibly delivered and at low fixed doses. If fixed medium or high doses are used, buprenorphine and methadone appear no different in effectiveness (retention in treatment and suppression of illicit opioid use); however, fixed doses are rarely used in clinical practice so the flexible dose results are more relevant to patient care. Methadone is superior to buprenorphine in retaining people in treatment, and methadone equally suppresses illicit opioid use.

Read Less
Association of Mental Health Disorders With Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan
Seal, K. H., Shi, Y., Cohen, G., Cohen, B. E., Maguen, S., Krebs, E. E., & Neylan, T. C. Jama 307.9 (2012): 940-947.
Context Record numbers of Iraq and Afghanistan veterans survive their war injuries and yet continue to experience pain and mentalRead More...

Context

Record numbers of Iraq and Afghanistan veterans survive their war injuries and yet continue to experience pain and mental health problems, particularly posttraumatic stress disorder (PTSD). Little is known about the association of mental health disorders and prescription opioid use.

Objective

To investigate the effect of mental health disorders, particularly PTSD, on risks and adverse clinical outcomes associated with prescription opioid use.

Design

Retrospective cohort study involving 141 029 Iraq and Afghanistan veterans who received at least 1 non–cancer-related pain diagnosis within 1 year of entering the Department of Veterans Affairs (VA) health care system from October 1, 2005, through December 31, 2010.

Main Outcome Measures

Independent association of mental health disorders and the prescription of opioids, higher risk opioid use, and adverse clinical outcomes (eg, accidents and overdose) within 1 year of receiving a pain-related diagnosis.

Results

 A total of 15 676 veterans were prescribed opioids within 1 year of their initial pain diagnosis. Compared with 6.5% of veterans without mental health disorders, 17.8% (adjusted relative risk [RR], 2.58; 95% CI, 2.49-2.67) of veterans with PTSD and 11.7% (adjusted RR, 1.74; 95% CI, 1.67-1.82) with other mental health diagnoses but without PTSD were significantly more likely to receive opioids for pain diagnoses. Of those who were prescribed pain medication, veterans with PTSD were more likely than those without mental health disorders to receive higher-dose opioids (22.7% vs 15.9%, adjusted RR, 1.42; 95% CI, 1.31-1.54), receive 2 or more opioids concurrently (19.8% vs 10.7%, adjusted RR, 1.87; 95% CI, 1.70-2.06), receive sedative hypnotics concurrently (40.7% vs 7.6%, adjusted RR, 5.46; 95% CI, 4.91-6.07), or obtain early opioid refills (33.8% vs 20.4%; adjusted RR, 1.64; 95% CI, 1.53-1.75). Receiving prescription opioids (vs not) was associated with an increased risk of adverse clinical outcomes for all veterans (9.5% vs 4.1%; RR, 2.33; 95% CI, 2.20-2.46), which was most pronounced in veterans with PTSD.

Conclusion

 Among US veterans of Iraq and Afghanistan, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids for pain, high-risk opioid use, and adverse clinical outcomes.

Greater combat exposure coupled with improvements in battlefield medicine and protective gear have resulted in large numbers of veterans of Iraq and Afghanistan surviving injuries that would have been fatal in prior wars. Veterans are returning home with comorbid mental and physical health problems. Posttraumatic stress disorder (PTSD) is the most prevalent mental health disorder among veterans of Operation Enduring Freedom (OEF, principally Afghanistan) and Operation Iraqi Freedom (OIF) who use Veterans Affairs (VA) health care, the largest provider of health care for these veterans. Somatic complaints, especially pain, have been strongly associated with mental health disorders, particularly PTSD, in prior-era veterans, and similarly, high rates of comorbid pain and PTSD diagnoses have been reported in veterans who have returned from Iraq and Afghanistan.

Nationwide, the prescription of opioid analgesics has nearly doubled since 1994 because of a greater recognition of the importance of treating pain. At the same time, rates of prescription opioid misuse and overdose have increased sharply, and prescription opioids are now a leading cause of death in the United States. Iraq and Afghanistan veterans with pain- and PTSD-prescribed opioids may be at particularly high risk of prescription opioid misuse given the high cooccurrence of substance use disorders among veterans with PTSD. Despite media reports of overdose in these veterans with pain- and PTSD-prescribed opioids,little is known about the association of mental health disorders and PTSD with patterns of prescription opioid use and clinical outcomes. We undertook this study in a national sample of Iraq and Afghanistan veterans enrolled in VA health care to investigate the effect of mental health disorders, particularly PTSD, on patterns of opioid prescription, associated risks, and adverse clinical outcomes, such as accidents and overdose.

Read Less
The Prevalence of Childhood Trauma Among Those Seeking Buprenorphine Treatment
Sansone, R. A., Whitecar, P., & Wiederman, M. W. Journal of addictive diseases 28.1 (2009): 64-67.
In this study, the authors examined the prevalence of five types of childhood trauma among a sample of adult patientsRead More...

In this study, the authors examined the prevalence of five types of childhood trauma among a sample of adult patients who were addicted to opioids and seeking treatment with buprenorphine. Using a survey methodology, the authors examined a consecutive sample of 113 participants and found that 20.4% reported having experienced sexual abuse, 39.8% reported having experienced physical abuse, 60.2% reported having experienced emotional abuse, 23.0% reported having experienced physical neglect, and 65.5% reported having witnessed violence. Only 19.5% of the sample denied having experienced any of the five forms of childhood trauma. Most respondents (60.2%) reported having experienced one, two, or three different forms of childhood trauma. A minority reported having experienced four (13.3%) or all five (7.1%) forms of childhood trauma. These data indicate that among individuals with opioid dependence who are seeking treatment with buprenorphine, the prevalence rates of various types of childhood trauma are quite high.

Read Less
New developments in the management of opioid dependence: focus on sublingual buprenorphine–naloxone
Soyka, M. Substance abuse and rehabilitation 6 (2015): 1.
Opioid maintenance therapy is a well-established first-line treatment approach in opioid dependence. Buprenorphine, a partial opioid agonist, has been foundRead More...

Opioid maintenance therapy is a well-established first-line treatment approach in opioid dependence. Buprenorphine, a partial opioid agonist, has been found by numerous studies to be an effective and safe medication in the treatment of opioid dependence. At present, buprenorphine is available as a monodrug or in a fixed 4:1 ratio combination with naloxone. A diminished risk of diversion and abuse for the buprenorphine–naloxone combination is likely but not firmly established. Conventional formulations are given sublingually to avoid the hepatic first-pass effect. A novel film tablet is available only in the US and Australia. Other novel, sustained-release formulations (implant, depot) are currently being developed and tested. Recent studies, including a Cochrane meta-analysis, suggest that the retention with buprenorphine is lower than for methadone, but that buprenorphine may be associated with less drug use. Higher doses of buprenorphine are associated with better retention rates. Buprenorphine has a ceiling effect at the opioid receptor with regard to respiratory depression, and may cause fewer fatal intoxications than methadone. Possible antidepressant effects of buprenorphine and its use in comorbid psychiatric patients has not been studied in much detail. Clinical implications are discussed.

Read Less
Prescription Opioid Misuse, Abuse, and Treatment in the United States: An Update
Brady, K. T., McCauley, J. L., & Back, S. E. American Journal of Psychiatry 173.1 (2015): 18-26.
Objective: Prescription opioid abuse and dependence have escalated rapidly in the United States over the past 20 years, leading toRead More...

Objective:

Prescription opioid abuse and dependence have escalated rapidly in the United States over the past 20 years, leading to high rates of overdose deaths and a dramatic increase in the number of people seeking treatment for opioid dependence. The authors review the scope of the abuse and overdose epidemic, prescription practices, and the assessment, treatment, and prevention of prescription opioid misuse and dependence.

Method:

The authors provide an overview of the literature from 2006 to the present, with the twin goals of highlighting advances in prevention and treatment and identifying remaining gaps in the science.

Results:

A number of policy and educational initiatives at the state and federal government level have been undertaken in the past 5 years to help providers and consumers, respectively, prescribe and use opioids more responsibly. Initial reports suggest that diversion and abuse levels have begun to plateau, likely as a result of these initiatives. While there is a large body of research suggesting that opioid substitution coupled with psychosocial interventions is the best treatment option for heroin dependence, there is limited research focusing specifically on the treatment of prescription opioid dependence. In particular, the treatment of chronic pain in individuals with prescription opioid use disorders is underexplored.

Conclusions:

While policy and educational initiatives appear to be effective in decreasing prescription opioid abuse and misuse, research focusing on the development and evaluation of treatments specific to prescription opioid dependence and its common comorbidities (e.g., chronic pain, depression) is critically needed.

Read Less
Buprenorphine/Naloxone and Methadone Maintenance Treatment Outcomes for Opioid Analgesic, Heroin, and Combined Users: Findings From Starting Treatment With Agonist Replacement Therapies (START)
Potter, J. S., Marino, E. N., Hillhouse, M. P., Nielsen, S., Wiest, K., Canamar, C. P., & Ling, W. Journal of studies on alcohol and drugs 74.4 (2013): 605-613.
Objective: The objective of this secondary analysis was to explore differences in baseline clinical characteristics and opioid replacement therapy treatmentRead More...

The objective of this secondary analysis was to explore differences in baseline clinical characteristics and opioid replacement therapy treatment outcomes by type (heroin, opioid analgesic [OA], or combined [heroin and OA]) and route (injector or non-injector) of opioid use.

Method:

A total of 1,269 participants (32.2% female) were randomized to receive one of two study medications (methadone or buprenorphine/naloxone [BUP]). Of these, 731 participants completed the 24-week active medication phase. Treatment outcomes were opioid use during the final 30 days of treatment (among treatment completers) and treatment attrition.

Results:

Non-opioid substance dependence diagnoses and injecting differentiated heroin and combined users from OA users. Non-opioid substance dependence diagnoses and greater heroin use differentiated injectors from non-injectors. Further, injectors were more likely to be using at end of treatment compared with non-injectors. OA users were more likely to complete treatment compared with heroin users and combined users. Non-injectors were more likely than injectors to complete treatment. There were no interactions between type of opioid used or injection status and treatment assignment (methadone or BUP) on either opioid use or treatment attrition.

Conclusions:

Findings indicate that substance use severity differentiates heroin users from OA users and injectors from non-injectors. Irrespective of medication, heroin use and injecting are associated with treatment attrition and opioid misuse during treatment. These results have particular clinical interest, as there is no evidence of superiority of BUP over methadone for treating OA users versus heroin users.

Read Less
Predictors of opioid misuse in patients with chronic pain: a prospective cohort study
Ives, T. J., Chelminski, P. R., Hammett-Stabler, C. A., Malone, R. M., Perhac, J. S., Potisek, N. M., ... & Pignone, M. P. BMC health services research 6.1 (2006): 46.
Background Opioid misuse can complicate chronic pain management, and the non-medical use of opioids is a growing public health problem.Read More...

Background

Opioid misuse can complicate chronic pain management, and the non-medical use of opioids is a growing public health problem. The incidence and risk factors for opioid misuse in patients with chronic pain, however, have not been well characterized. We conducted a prospective cohort study to determine the one-year incidence and predictors of opioid misuse among patients enrolled in a chronic pain disease management program within an academic internal medicine practice.

Methods

One-hundred and ninety-six opioid-treated patients with chronic, non-cancer pain of at least three months duration were monitored for opioid misuse at pre-defined intervals. Opioid misuse was defined as: 1. Negative urine toxicological screen (UTS) for prescribed opioids; 2. UTS positive for opioids or controlled substances not prescribed by our practice; 3. Evidence of procurement of opioids from multiple providers; 4. Diversion of opioids; 5. Prescription forgery; or 6. Stimulants (cocaine or amphetamines) on UTS.

Results

The mean patient age was 52 years, 55% were male, and 75% were white. Sixty-two of 196 (32%) patients committed opioid misuse. Detection of cocaine or amphetamines on UTS was the most common form of misuse (40.3% of misusers). In bivariate analysis, misusers were more likely than non-misusers to be younger (48 years vs 54 years, p < 0.001), male (59.6% vs. 38%; p = 0.023), have past alcohol abuse (44% vs 23%; p = 0.004), past cocaine abuse (68% vs 21%; p < 0.001), or have a previous drug or DUI conviction (40% vs 11%; p < 0.001%). In multivariate analyses, age, past cocaine abuse (OR, 4.3), drug or DUI conviction (OR, 2.6), and a past alcohol abuse (OR, 2.6) persisted as predictors of misuse. Race, income, education, depression score, disability score, pain score, and literacy were not associated with misuse. No relationship between pain scores and misuse emerged.

Conclusion

Opioid misuse occurred frequently in chronic pain patients in a pain management program within an academic primary care practice. Patients with a history of alcohol or cocaine abuse and alcohol or drug related convictions should be carefully evaluated and followed for signs of misuse if opioids are prescribed. Structured monitoring for opioid misuse can potentially ensure the appropriate use of opioids in chronic pain management and mitigate adverse public health effects of diversion.

Read Less
Opioid Complications and Side Effects
Ricardo Buenaventura, M., Rajive Adlaka, M., & Nalini Sehgal, M. Pain physician 11 (2008): S105-S120.
Medications which bind to opioid receptors are increasingly being prescribed for the treatment of multiple and diverse chronic painful conditions. TheirRead More...

Medications which bind to opioid receptors are increasingly being prescribed for the treatment of multiple and diverse chronic painful conditions. Their use for acute pain or terminal pain is well accepted. Their role in the long-term treatment of chronic noncancer pain is, however, controversial for many reasons. One of the primary reasons is the well-known  henomenon of psychological addiction that can occur with the use of these medications. Abuse and diversion of these medications is a growing problem as the availability of these medications increases and this public health issue confounds their clinical utility. Also, the extent of their efficacy in the treatment of pain when utilized on a chronic basis has not been definitively proven. Lastly, the role of opioids in the treatment of chronic pain is also influenced by the fact that these potent analgesics are associated with a significant number of side effects and complications. It is these phenomena that are the focus of this review.

Common side effects of opioid administration include sedation, dizziness, nausea, vomiting, constipation, physical  dependence, tolerance, and respiratory depression. Physical dependence and addiction are clinical concerns that may prevent proper prescribing and in turn inadequate pain management.Less common side effects may include delayed gastric emptying, hyperalgesia, immunologic and hormonal dysfunction, muscle rigidity, and myoclonus. The most common side effects of opioid usage are constipation (which has a very high incidence) and nausea. These 2 side effects can be difficult to manage and frequently tolerance to them does not develop; this is especially true for constipation. They may be severe enough to require opioid discontinuation, and contribute to under-dosing and inadequate analgesia. Several clinical trials are underway to identify adjunct therapies that may mitigate these side effects. Switching opioids and/or routes of administration may also provide benefits for patients. Proper patient screening, education, and preemptive treatment of potential side effects may aid in maximizing effectiveness while reducing the severity of side effects and adverse events. Opioids can be considered broad spectrum analgesic agents, affecting a wide number of organ systems and influencing a large number of body functions.

Read Less
Opioid agonist treatment for pharmaceutical opioid dependent people – Cochrane systematic review
Nielsen, S., Larance, B., Degenhardt, L., Gowing, L., Kehler, C., & Lintzeris, N. Cochrane Database of Systematic Reviews, 2016, 5.
Background There are increasing concerns regarding pharmaceutical opioid harms including overdose and dependence, with an associated increase in treatment demand.Read More...

Background

There are increasing concerns regarding pharmaceutical opioid harms including overdose and dependence, with an associated increase in treatment demand. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin.

Objectives

To assess the effects of maintenance agonist pharmacotherapy for the treatment of pharmaceutical opioid dependence.

Search methods

The search included the Cochrane Drugs and Alcohol Group's Specialised Register of Trials; the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 5); PubMed (January 1966 to May 2015); EMBASE (Ovid) (January 1974 to May 2015); CINAHL (EBSCOhost) (1982 to May 2015); ISI Web of Science (to May 2014); and PsycINFO (Ovid) (1806 to May 2014).

Selection criteria

We included randomised controlled trials examining maintenance opioid agonist treatments that made the following two comparisons:

1. full opioid agonists (methadone, morphine, oxycodone, levo‐alpha‐acetylmethadol (LAAM), or codeine) versus different full opioid agonists or partial opioid agonists (buprenorphine) for maintenance treatment and

2. full or partial opioid agonist maintenance versus placebo, detoxification only, or psychological treatment (without opioid agonist treatment).

Data collection and analysis

We used standard Cochrane methodological procedures.

Main results

We identified six randomised controlled trials that met inclusion criteria (607 participants).

We found moderate quality evidence from two studies of no difference between methadone and buprenorphine in self reported opioid use (risk ratio (RR) 0.37, 95% confidence interval (CI) 0.08 to 1.63) or opioid positive urine drug tests (RR 0.81, 95% CI 0.56 to 1.18). There was low quality evidence from three studies of no difference in retention between buprenorphine and methadone maintenance treatment (RR 0.69, 95% CI 0.39 to 1.22). There was moderate quality evidence from two studies of no difference between methadone and buprenorphine on adverse events (RR 1.10, 95% CI 0.64 to 1.91).

We found low quality evidence from three studies favouring maintenance buprenorphine treatment over detoxification or psychological treatment in terms of fewer opioid positive urine drug tests (RR 0.63, 95% CI 0.43 to 0.91) and self reported opioid use in the past 30 days (RR 0.54, 95% CI 0.31 to 0.93). There was no difference on days of unsanctioned opioid use (standardised mean difference (SMD) ‐0.31, 95% CI ‐0.66 to 0.04). There was moderate quality evidence favouring buprenorphine maintenance over detoxification or psychological treatment on retention in treatment (RR 0.33, 95% CI 0.23 to 0.47). There was moderate quality evidence favouring buprenorphine maintenance over detoxification or psychological treatment on adverse events (RR 0.19, 95% CI 0.06 to 0.57).

The main weaknesses in the quality of the data was the use of open‐label study designs.

Authors' conclusions

There was low to moderate quality evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. Methadone or buprenorphine appeared equally effective. Maintenance treatment with buprenorphine appeared more effective than detoxification or psychological treatments.

Due to the overall low to moderate quality of the evidence and small sample sizes, there is the possibility that the further research may change these findings.

Read Less
Prevention and Treatment of Opioid Misuse and Addiction – A Review
Volkow, N. D., Jones, E. B., Einstein, E. B., & Wargo, E. M. JAMA psychiatry 76.2 (2019): 208-216.
Importance  More than 42 000 Americans died of opioid overdoses in 2016, and the fatalities continue to increase. This review analyzes theRead More...

Importance  More than 42 000 Americans died of opioid overdoses in 2016, and the fatalities continue to increase. This review analyzes the factors that triggered the opioid crisis and its further evolution, along with the interventions to manage and prevent opioid use disorder (OUD), which are fundamental for curtailing the opioid crisis.

Observations  Opioid drugs are among the most powerful analgesics but also among the most addictive. The current opioid crisis, initially triggered by overprescription of opioid analgesics, which facilitated their diversion and misuse, has now expanded to heroin and illicit synthetic opioids (fentanyl and its analogues), the potency of which further increases their addictiveness and lethality. Although there are effective medications to treat OUD (methadone hydrochloride, buprenorphine, and naltrexone hydrochloride), these medications are underused, and the risk of relapse is still high. Strategies to expand medication use and treatment retention include greater involvement of health care professionals (including psychiatrists) and approaches to address comorbidities. In particular, the high prevalence of depression and suicidality among patients with OUD, if untreated, contributes to relapse and increases the risk of overdose fatalities. Prevention interventions include screening and early detection of psychiatric disorders, which increase the risk of substance use disorders, including OUD.

Conclusions and Relevance  Although overprescription of opioid medications triggered the opioid crisis, improving opioid prescription practices for pain management, although important for addressing the opioid crisis, is no longer sufficient. In parallel, strategies to expand access to medication for OUD and improve treatment retention, including a more active involvement of psychiatrists who are optimally trained to address psychiatric comorbidities, are fundamental to preventing fatalities and achieving recovery. Research into new treatments for OUD, models of care for OUD management that include health care, and interventions to prevent OUD may further help resolve the opioid crisis and prevent it from happening again.

Read Less
Treatment of Opioid-Use Disorders
Schuckit, M. A. New England Journal of Medicine 375.4 (2016): 357-368.
This article provides an overview of the current treatment of opioid-related conditions, including treatments provided by general practitioners and byRead More...

This article provides an overview of the current treatment of opioid-related conditions, including treatments provided by general practitioners and by specialists in substance-use disorders. The recent dramatic increase in misuse of prescription analgesics, the easy accessibility of opioids such as heroin on the streets, and the epidemic of opioid overdoses underscore how important it is for physicians to understand more about these drugs and to be able to tell patients about available treatments for substance-use disorders.

Read Less
Nonmedical Prescription Opioid Use and DSM-5 Nonmedical Prescription Opioid Use Disorder in the United States
Saha, T. D., Kerridge, B. T., Goldstein, R. B., Chou, S. P., Zhang, H., Jung, J., ... & Hasin, D. S. The Journal of clinical psychiatry 77.6 (2016): 772.
Objective The authors present 12-month and lifetime prevalence, correlates, psychiatric comorbidity and treatment of NMPOU and DSM-5 NMPOUD. Method DataRead More...

Objective

The authors present 12-month and lifetime prevalence, correlates, psychiatric comorbidity and treatment of NMPOU and DSM-5 NMPOUD.

Method

Data was derived from the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions – III (NESARC-III) (n = 36,309).

Results

Prevalences of 12-month and lifetime NMPOU were 4.1% and 11.3%, exceeding rates in the 2001–2002 NESARC (1.8%, 4.7%). Twelve-month and lifetime rates of DSM-5 NMPOUD were 0.9% and 2.1%. NESARC-III DSM-IV NMPOUD rates (0.8%, 2.9%) were greater than those observed in the 2001–2002 NESARC (0.4% and 1.4%). Rates of NMPOU were greater among men, but no sex differential was observed for NMPOUD. Prevalences of NMPOU and NMPOUD were generally greater among 18-to-64 year-olds, Whites and Native Americans, and individuals with lower socioeconomic status. Associations were observed between 12-month and lifetime NMPOU and NMPOUD and other drug use disorders, posttraumatic stress disorder and borderline, schizotypal and antisocial personality disorders, persistent depression and major depressive disorder (for NMPOU) and bipolar I disorder (for NMPOUD). Only 5.5% and 17.7% of individuals with 12-month NMPOU and NMPOUD were ever treated.

Conclusions

NMPOU and NMPOUD have considerably increased over the past decade, are associated with a broad array of risk factors and comorbidities, and largely go untreated in the U.S. More information on the determinants, characteristics and outcomes of NMPOU and NMPOUD is needed to support evidence-based interventions and prevention.

Read Less
ברוכים הבאים