Buprenorphine-naloxone Research Articles

A buprenorphine–naloxone induction in the North

A buprenorphine–naloxone induction in the North

An alternative analysis of illicit opioid use during treatment in a randomized trial of extended-release naltrexone versus buprenorphine-naloxone: A per-protocol and completers analysis

BackgroundThe distinct pharmacological properties and clinical uses of extended-release naltrexone (XR-NTX) and sublingual buprenorphine-naloxone (BUP-NX) present challenges in analyzing patient outcomes. MethodsWe conducted a secondary analysis of a multi-site randomized trial comparing XR-NTX with sublingual BUP-NX treatment for opioid use disorder initiated during inpatient detoxification and continued in outpatient treatment. Urine testing data for non-study opioids from the last 22 weeks of the 24-week trial were analyzed in both a per-protocol sample (n = 474 participants who received at least one dose of medication) and a completers sample (n = 211 participants who received all XR-NTX doses or all BUP-NX prescriptions). The present analyses sought to identify differences in the weekly percentages of opioid-positive urine tests between participants treated with the two medications. ResultsThe proportion of opioid-positive tests in both conditions was less than 20 % for 21 of the 22 weeks in the per-protocol sample and all 22 weeks in the completers sample. Generalized linear mixed model analyses revealed a significant treatment (XR-NTX vs. BUP-NX) X week (weeks 3–24) interaction in the per-protocol sample but not the completers sample. In the per-protocol analysis, the BUP-NX, compared to XR-NTX, had significantly greater proportions of opioid-positive tests in 14 out of the 22 weeks. ConclusionsLongitudinal modeling approaches that utilize flexible procedures for handling missing data can offer a different perspective on study findings. Results from the present analyses suggest that XR-NTX appeared to be somewhat more effective than BUP-NX in reducing illicit opioid use in the per-protocol sample.

Opioid agonist and antagonist use and the gut microbiota: associations among people in addiction treatment

Murine models suggest that opioids alter the gut microbiota, which may impact opioid tolerance and psychopathology. We examined how gut microbiota characteristics related to use of opioid agonists and antagonists among people receiving outpatient addiction treatment. Patients (n = 46) collected stool samples and were grouped by use of opioid agonists (heroin, prescription opioids), antagonists (naltrexone), agonist–antagonist combinations (buprenorphine–naloxone), or neither agonists nor antagonists within the month before enrollment. We sequenced the V4 region of the 16S rRNA gene using Illumina MiSeq to examine how alpha diversity, enterotypes, and relative abundance of bacterial genera varied by opioid agonist and antagonist exposures. Compared to 31 participants who used neither agonists nor antagonists, 5 participants who used opioid agonists (without antagonists) had lower microbiota diversity, Bacteroides enterotypes, and lower relative abundance of Roseburia, a butyrate producing genus, and Bilophila, a bile acid metabolizing genus. There were no differences in gut microbiota features between those using agonist + antagonists (n = 4), antagonists only (n = 6), and neither agonists nor antagonists. Similar to murine morphine exposure models, opioid agonist use was associated with lower microbiota diversity. Lower abundance of Roseburia and Bilophila may relate to the gut inflammation/permeability and dysregulated bile acid metabolism observed in opioid-exposed mice.

Tracking Trends in the Opioid Epidemic in North Carolina : Early Results from the Opioid Action Plan Metrics.

BACKGROUND Deaths from unintentional opioid overdose have increased markedly over the last decade in North Carolina. In 2017 the state created a North Carolina Opioid Action Plan, which laid out a multisectoral response to the crisis that included the medical community, law enforcement, emergency medical services, and treatment professionals. It also created a website providing county-level data associated with the crisis. Using this publicly available data, we examine trends and associations between opioid-related mortality and strategies to reduce opioid prescriptions, reduce fatality of overdose, and improve treatment and recovery.METHOD We examine yearly trends from 2010-2017 for statewide unintentional opioid-related death rates, prescription of opioid pills, buprenorphine prescription rates, naloxone administrations, and number of Certified Peer Support Specialists. We compare recent opioid-related death rates for 2015-2017 with an earlier period (2010-2012) at the county level, and examine the association between death rates and rates of the supply, treatment, and recovery metrics.RESULTS Trends for all metrics increased from 2010-2017, although the number of opioid pills per capita has declined since 2015. Between 2010 and 2017, 84 of the state's 100 counties experienced an increase in opioid-related mortality. County-level mortality was positively associated with opioid prescription rate (r = +0.12, P = 0.24) and with naloxone administrations (r = +0.20, P = 0.05). Prescription of buprenorphine was associated with a reduction in opioid mortality (r = -0.27, P = 0.01). The effect of Certified Peer Support Specialists was not discernable.LIMITATIONS Data are available for only eight years and aggregated at the county level. Mortality data are based on death certificates using ICD-10 codes from the North Carolina State Center for Health Statistics, Vital Statistics, which may not capture all opioid-related fatalities. Drug-related deaths may involve multiple non-opioid substances; in addition, determining the intent of the deceased individual may be difficult (suicide versus unintentional). Naloxone administration data only includes data from emergency medical services, not community-administered naloxone, because that data was only available for 2013 and later and is based only on self-reports.CONCLUSIONS The potential efficacy of buprenorphine is promising and should be further explored. All interventions should be monitored.

Patients' perspectives on initiating treatment with extended-release naltrexone (XR-NTX)

BackgroundThe National Drug Abuse Treatment Clinical Trials Network (CTN) multisite comparative-effectiveness study (“X:BOT”) by Lee et al. (2018) found that, once initiated, extended-release naltrexone (XR-NTX) is as similarly safe and effective as sublingual buprenorphine-naloxone (BUP-NX) for the treatment of opioid use disorder (OUD). However, the detoxification hurdle makes XR-NTX much more difficult to initiate than BUP-NX. This hurdle highlights the need to better understand how patients transition from active opioid use to XR-NTX treatment. ObjectiveTo explore patient-identified barriers and facilitators to initiating antagonist treatment (XR-NTX) within the context of an inpatient hospital setting and to reflect postdischarge experiences of those who did and did not initiate XR-NTX treatment. MethodWe used a convenience sampling strategy to identify study candidates, with the intention of recruiting approximately an equal number of medication-initiated and noninitiated patients. Study participants (N = 14) included 13 males and 1 female with OUD randomized to the XR-NTX arm of the X:BOT study at 1 of the 8 study sites. Seven participants in this sample initiated XR-NTX treatment, and seven did not. Each participant completed one semistructured qualitative interview. We analyzed transcripts using deductive and inductive approaches to conventional content analysis. ResultsAlthough the majority of participants viewed opioid blockade, once-monthly dosing, and no dependence or withdrawal as favorable attributes of XR-NTX, participant ambivalence and lack of familiarity with antagonist treatment were barriers to treatment initiation. The long duration of action and the perceived “commitment” to the medication (e.g., “At the time, a month sounded like a year”) compounded the patients' concerns and ambivalence. The majority of those who initiated XR-NTX described it as an effective treatment for OUD, with treatment satisfaction and sustained abstinence emerging as central themes among this population. Some participants who did not successfully initiate XR-NTX expressed regret and a willingness to try XR-NTX in the future. ConclusionAchieving full opioid detoxification is one, but not the only, barrier to initiating treatment with XR-NTX. Additional participant-identified barriers to XR-NTX initiation include fears and ambivalence regarding antagonist treatment. Once initiated, participants perceive XR-NTX to be an effective treatment for maintaining abstinence from opioids. XR-NTX appealed to participants due to the autonomy it affords with once-monthly dosing and no physical dependence.

Risk Factors for Treatment Drop-Out: Implications for Adverse Outcomes When Treating Opioid Use Disorder

ABSTRACT Pathways to resolve the opioid epidemic focus on enhancing addiction treatment. Dropout rates from outpatient buprenorphine-naloxone (BN) treatment remain as high as 35% to 59%, contributing to poor treatment outcomes. Treatment interventions targeting retention require identification of dropout risk factors. This study used the New York State Office of Alcohol and Substance Abuse Services database to analyze patient information from an ancillary withdrawal management program. Binary logistic regression identified dropout trends. Use of alprazolam or cocaine and age (< 26 years old) correlated with increased likelihood of treatment drop-out. In contrast, a history of domestic violence or intimate partner violence, alcohol use, or prior hospitalization for a psychiatric disorder (hospital stay < 30 days) were associated with an increased likelihood of retention. Potentially modifiable dropout risk factors exist in BN treatment. Recommendations for treatment programs using BN treatment are included.

FABRICATION OF AN ABUSE DETERRENT AND MICROEMULSION-BASED SUBLINGUAL FILM OF BUPRENORPHINE HYDROCHLORIDE FOR BREAKTHROUGH PAIN MANAGEMENT

Objective: The present research work aims to develop an abuse deterrent rapidly dissolving buprenorphine microemulsion loaded sublingual film for the treatment of breakthrough pain.&#x0D; Methods: The Buprenorphine microemulsion loaded sublingual films were prepared using Capmul MCM C8 (oil), tween 20 (surfactant) and propylene glycol (co-surfactant) with different grades of film-forming polymer (HPMC) using film casting machine. The films were evaluated for in vitro disintegration and dissolution study, tensile strength, folding endurance, content uniformity, surface pH, thickness and weight variation, % loading of buprenorphine microemulsion in sublingual film, scanning electron microscope, ex vivo permeation study, droplet size and polydispersity index, Zeta potential, % moisture content, stability and abuse deterrent potential were evaluated.&#x0D; Results: The optimized film formulation showed desired mechanical properties with minimum disintegration time of 21s and exhibited 34.45 % loading of Buprenorphine microemulsion. Permeation studies through goat sublingual mucosa, indicated 87% Buprenorphine release, through Buprenorphine microemulsion loaded sublingual film, whereas only 30% Buprenorphine release when it was directly added to film without microemulsion strategy.&#x0D; Conclusion: The present study concludes that abuse deterrent and fast acting buprenorphine microemulsion-incorporated sublingual film of buprenorphine HCL and naloxone HCL is a promising alternative to mostly marketed buprenorphine injectable delivery systems and a non-invasive route of administration for breakthrough pain management.

Young Adults Have Worse Outcomes Than Older Adults: Secondary Analysis of a Medication Trial for Opioid Use Disorder

PurposeYoung adults are disproportionately affected by the current opioid crisis. Although medications for opioid use disorder are broadly effective, with reductions in morbidity and mortality, the particular effectiveness of medications for opioid use disorder among young adults is less well understood. MethodsThis secondary analysis compared young adults (aged 18–25 years) with older adults (aged ≥26 years) in a large comparative effectiveness trial (“XBOT”) that randomized subjects to extended-release naltrexone or sublingual buprenorphine–naloxone for 6 months. Opioid relapse was defined by opioid use over four consecutive weeks or seven consecutive days, using urine testing and self-report. ResultsAmong subjects in the intention-to-treat sample (n = 570, all randomized participants), a main effect of age group was found, with higher relapse rates among young adults (70.3%) compared with older adults (58.2%), with an odds ratio of 1.72 (95% confidence interval = 1.08–2.70), p = .02. In the per-protocol sample (n = 474, only participants who started medication), relapse rates were higher among young adults (66.3%) compared with older adults (50.8%), with an odds ratio of 1.91 (95% confidence interval = 1.19–3.06). Among the intention-to-treat sample, survival analysis revealed a significant time-by-age group interaction (p = .01) with more relapse over time in young adults. No significant interactions between age and medication group were detected. ConclusionsYoung adults have increased rates of relapse compared with older adults, perhaps because of vulnerabilities that increase their risk for treatment dropout and medication nonadherence, regardless of medication assignment. These results suggest that specialized, developmentally informed interventions may be needed to improve retention and successful treatment of opioid use disorder among young adults.

Variants of opioid genes and response to treatment of opioid use disorder with buprenorphine-naloxone versus extended-release naltrexone in Caucasians

ABSTRACT Background: Sublingual buprenorphine-naloxone (BUP-NX), an FDA-approved treatment for opioid use disorder (OUD), combines buprenorphine (a partial mu/kappa agonist) with naloxone (a mu/ kappa antagonist). Extended-release injection naltrexone (XR-NTX; a mu receptor antagonist and kappa receptor partial agonist) is also an FDA-approved treatment for OUD. However, while some patients respond well to these medications, many others leave treatment and relapse. Objectives: Determine whether gene variants in the opioid gene system are associated with better or worse treatment response. Methods: In a 24-week, multisite, randomized, comparative effectiveness trial of daily, sublingual self-administration of BUP-NX versus monthly injection of XR-NTX conducted in the National Drug Abuse Clinical Trials Network, DNA was collected and four opioid gene variants were evaluated: (1) mu opioid receptor 118A>G; (2) 68-bp repeat in prodynorphin; (3) prodynorphin SNP rs910080; and (4) kappa opioid receptor SNP rs6473797. In non-Hispanic Caucasians (N = 334), two outcomes measures were assessed: received first dose (yes/no) and received last dose (yes/no). Separate logistic regressions were used to model each outcome measure as a function of treatment (XR-NTX vs BUP-NX), each gene variant, and their interaction. Results: There were no significant main effects of gene variant on receiving first dose or last dose. There were also no significant gene variant by treatment interactions. Conclusions: The outcome of treatment of OUD with medications is likely a complex function of multiple factors, including environmental, psychosocial, and possibly genetic, such that major effects of genetic variants may be unlikely.

Incidence and factors associated with discontinuation of opioid agonist therapy among people who inject drugs in Australia.

To estimate incidence and predictors of opioid agonist therapy (OAT) discontinuation in a national cohort of people who inject drugs (PWID). Annually repeated cross-sectional serosurveillance among PWID attending ~50 needle-syringe programmes across Australia. Between 1995 and 2018, 2651 PWID who reported current OAT and had subsequent survey participation completed 6739 surveys. Respondents were followed over 11 984 person-years of observation (PYO). Respondents were predominantly male (60%), and the median age was 34years. Heroin was the most commonly reported drug last injected (46%), and methadone was the most commonly prescribed OAT (77%). The primary outcome was discontinuation of OAT (methadone, buprenorphine or buprenorphine-naloxone). Among respondents who reported current OAT, those who did not report current OAT in all subsequent records were defined as discontinued, and those with current OAT at all subsequent records were defined as retained. Predictors of discontinuation included self-reported demographic (sex, location, Indigenous status) and drug use characteristics (drug last injected, frequency of injection). Just fewer than one-third of respondents (29%) reported an OAT discontinuation event. The crude discontinuation rate was 6.3 [95% confidence intervals (CI)=5.9-6.8] per 100 PYO. Discontinuation was significantly higher among respondents who reported last injecting pharmaceutical opioids [adjusted hazard ratio (aHR)=1.75, 95% CI=1.41-2.17, P<0.001], being prescribed buprenorphine (aHR=1.44, 95% CI=1.18-1.76, P=0.001) or buprenorphine-naloxone (aHR=1.68, 95% CI=1.20-2.34, P=0.002), daily or more frequent injection (aHR=1.51, 95% CI=1.23-1.85, P<0.001), recent public injecting (aHR= 1.37, 95% CI=1.17-1.60, P<0.001), incarceration in the previous 12months (aHR= 1.31, 95% CI=1.05-1.64, P=0.017), recent receptive syringe or injection equipment sharing (aHR =1.28, 95% CI=1.10-1.48, P=0.001) and male sex (aHR=1.27, 95% CI=1.09-1.47, P=0.002). People who inject drugs attending needle-syringe programmes in Australia appear to be significantly more likely to discontinue opioid agonist treatment if they were prescribed buprenorphine or buprenorphine-naloxone compared with methadone, are male or report injection risk behaviours and recent incarceration.

Adherence to buprenorphine treatment guidelines among individuals with an opioid use disorder who have private insurance

BackgroundAlthough treatment of opioid use disorders (OUD) with medications is expanding, the extent to which practitioners are prescribing medications following best practices has received little attention. ObjectiveThe aim of this study was to determine the extent to which privately insured patients being treated for OUD with buprenorphine were treated in a manner consistent with practice guidelines. DesignLongitudinal analyses of a large commercial claims dataset from 2012 to 2016. ParticipantsWe analyzed data for 38,517 patients with an OUD diagnosis continuously enrolled for 3 months prior to and 6 months after an initial buprenorphine or buprenorphine–naloxone prescription fill. Main measuresWe evaluated whether practitioners tested patients for hepatitis B, hepatitis C, HIV, and liver function; how often they received urine drug screens; the frequency of outpatient visits; and the extent to which they filled prescriptions for buprenorphine for at least 6 months. Key resultsPractitioners tested approximately 4.7% of patients for hepatitis B, 6.5% for hepatitis C, and 29.3% for HIV; they tested 8.0% for liver functioning; and gave 33.3% urine drug tests. Approximately 76% of patients had at least one outpatient visit for their OUD. Among those with at least one visit, the mean number of visits was 7.38. After the initial prescription, 47.5% stayed on buprenorphine for at least 6 months. ConclusionsA large portion of privately insured patients receiving buprenorphine for OUD did not receive care consistent with guidelines.

Extended-release naltrexone versus buprenorphine-naloxone to treat opioid use disorder among black adults

Few studies examine the effectiveness of treatments for opioid use disorder (OUD) among Black individuals despite recent evidence suggesting opioid overdose death rates are, in some cases, highest and increasing at a faster rate among Black people compared to other racial/ethnic groups. This secondary analysis study investigated treatment preference, retention, and relapse rates amongst a subgroup of 73 Black participants with OUD (81% male, mean age 39.05, SD = 11.80) participating in a 24-week multisite randomized clinical trial (“X:BOT”) comparing the effectiveness of extended-release naltrexone (XR-NTX) and sublingual buprenorphine-naloxone (BUP-NX) between 2014 and 2017. Chi-square analyses were used to investigate treatment preference assessed at baseline, and logistic regression analyses were used to investigate differences in the odds of retention and relapse assessed over the 24-week course of treatment between treatment groups. Our findings suggest no differences in preference for XR-NTX versus BUP-NX. However, similar to the parent trial, there was an induction hurdle such that only 59.5% of those randomized to XR-NTX successfully initiated medication compared to 91.6% of those randomized to BUP-NX (OR = 0.13, 95% CI = 0.04, 0.52). No significant differences were found in treatment retention (intention-to-treat: OR = 1.19, 95% CI = 0.43, 3.28; per-protocol [i.e., those who initiated medication]: OR = 0.60, 95% CI = 0.20, 1.82) or relapse rates between treatment groups (intention-to-treat: OR = 1.53, 95% CI = 0.57, 4.13; per-protocol: OR = 0.69, 95% CI = 0.23, 2.06). Although there is a significant initiation hurdle with XR-NTX, once inducted, both medications appear similar in effectiveness, but as in the main study, dropout rates were high. Future research is needed on how to improve adherence.

Relapse rates among veterans on maintenance doses of combination buprenorphine and naloxone for opioid use disorder.

IntroductionOpioid use disorder (OUD) can cause significant morbidity and mortality with more than 115 people dying from an opioid overdose daily in the United States. Treatment with buprenorphine/naloxone (BUP/NAL) can be effective; however, there is conflicting evidence on the utility of higher doses in preventing relapse. This study was designed to assess BUP/NAL maintenance doses and the rate of relapse in veterans with OUD.MethodsPatients diagnosed with OUD who received a prescription for BUP/NAL through the substance use disorder recovery program were retrospectively evaluated. Patients were categorized into 2 treatment groups: those prescribed ≤16 mg of BUP/NAL daily and those prescribed >16 mg of BUP/NAL daily. The primary outcome was to determine rates of relapse between maintenance doses of BUP/NAL. Secondary outcomes included evaluating the difference in rates of relapse between daily versus take-home dosing, tablets versus films, time to relapse, and use of illicit substances during treatment.ResultsPatients prescribed >16 mg of BUP/NAL daily had statistically significantly lower rates of relapse compared to patients prescribed ≤16 mg of BUP/NAL daily (P = .0018). Regarding secondary outcomes, there was a statistically significant difference in time to relapse (P = .036) and dosage form (P = .0124). Difference in administration of dose and illicit substance use during treatment were not statistically significant.DiscussionThis study identified that rate of relapse can be lowered and time to relapse can be lengthened when doses >16 mg of BUP/NAL are prescribed in the veteran population for OUD.

PMH33 VARIATION IN TREATMENT PERSISTENCE BETWEEN ACUTE AND CHRONIC OPIOID USERS RECEIVING BUPRENORPHINE PRODUCTS FOR OPIOID USE DISORDER

Prior prescription opioid use is common in individuals receiving treatment for opioid use disorder (OUD). The objective of this study was to differentiate the effects of baseline acute and chronic, prescription opioid use on induction and stabilization on buprenorphine/naloxone (BUP/NAL) treatment for OUD.

171 Buprenorphine – A Treatment for Psychic Pain and Suicidal Ideation?

Buprenorphine (BPN) is an opiate medication that is increasingly used in the management of Opioid Use Disorder and pain disorders. This case report highlights the acute efficacy of using buprenorphine-naloxone (BPN-NAL) to reverse anhedonia and suicidal ideation in an individual with OUD, chronic pain and severe suicide attempts.We present a case of a 39-year-old male with a history of bipolar disorder, several lethal suicide attempts and polysubstance abuse, who presented to the hospital after self-immolation, burning 45% total body surface area. He was admitted to the burn unit for three months, reporting continual anhedonia, suicidal ideation, and flashbacks of seeing and feeling himself on fire. He also endorsed chronic pain and hopelessness.Upon transfer to the behavioral health unit, his symptoms persisted, despite trials of quetiapine, mirtazapine, methadone, oxycodone and prazosin. In consultation with pain management, he was initiated on sublingual BPN-NAL 8mg-2mg treatment as a transition from methadone; he immediately reported improvement in depressive symptoms and a reduction in pain. He was titrated on BPN-NAL and continued to report diminished pain and resolution of depression. Furthermore, his irritability was lessened and he newly cooperated with staff, participating in unit activities. Upon discharge, he exhibited stable mood, adequate pain control and the elimination of suicidal thoughts as well as a proactive drive for substance abuse treatment.This case describes the significance of BPN on relieving psychic pain and stabilizing mood in a chronically suicidal patient. We speculate that BPN's pharmacokinetic properties terminate the cycle of short-term opioid-induced analgesia and euphoria with opioid withdrawal-induced hyperalgesia and dysphoria. This results in a steady treatment of pain, as well as maintaining the dopaminergic system, symptomatically translating to mood stabilization and annulling suicidal ideation.

How Motivations for Using Buprenorphine Products Differ From Using Opioid Analgesics: Evidence from an Observational Study of Internet Discussions Among Recreational Users.

BackgroundOpioid use disorder (OUD) poses medical and societal concerns. Although most individuals with OUD in the United States are not in drug abuse treatment, buprenorphine is considered a safe and effective OUD treatment, which reduces illicit opioid use, mortality, and other drug-related harms. However, as buprenorphine prescriptions increase, so does evidence of misused, abused, or diverted buprenorphine. Users’ motivations for extratreatment use of buprenorphine (ie, misuse or abuse of one’s own prescription or use of diverted medication) may be different from the motivations involved in analgesic opioid products. Previous research is based on small sample sizes and use surveys, and none directly compare the motivations for using buprenorphine products (ie, tablet or film) with other opioid products having known abuse potential.ObjectiveThe aim of the study was to describe and compare the motivation-to-use buprenorphine products, including buprenorphine/naloxone (BNX) sublingual film and oxycodone extended-release (ER), as discussed in online forums.MethodsWeb-based posts from 2012 to 2016 were collected from online forums using the Web Informed Services internet monitoring archive. A random sample of posts was coded for motivation to use. These posts were coded into the following motivation categories: (1) use to avoid withdrawal, (2) pain relief, (3) tapering from other drugs, (4) opioid addiction treatment, (5) recreational use (ie, to get high), and (6) other use. Oxycodone ER, an opioid analgesic with known abuse potential, was selected as a comparator.ResultsAmong all posts, 0.81% (30,576/3,788,922) discussed motivation to use one of the target products. The examination of query-selected posts revealed significantly greater discussion of buprenorphine products than oxycodone ER (P<.001). The posts mentioning buprenorphine products were more likely than oxycodone ER to discuss treatment for OUD, tapering down use, and/or withdrawal management (P<.001). Buprenorphine-related posts discussed recreational use (375/1020, 36.76%), although much less often than in oxycodone ER posts (425/508, 83.7%). Despite some differences, the overall pattern of motivation to use was similar for BNX sublingual film and other buprenorphine products.ConclusionsAn analysis of spontaneous, Web-based discussion among recreational substance users who post on online drug forums supports the contention that motivation-to-use patterns associated with buprenorphine products are different from those reported for oxycodone ER. Although the findings presented here are not expected to reflect the actual use of the target products, they may represent the interests and motivations of those posting on the online forums. Buprenorphine-related posts were more likely to discuss treatment for OUD, tapering, and withdrawal management than oxycodone ER. Although the findings are consistent with a purported link between the limited availability of medication-assisted therapies for substance use disorders and use of diverted buprenorphine products for self-treatment, recreational use was a motivation expressed in more than one-third of buprenorphine posts.

Sexual dysfunction in men on buprenorphine - naloxone-based substitution therapy.

Background:The literature on sexual dysfunction in patients on buprenorphine-naloxone (BNX) substitution is limited.Materials and Methods:This research aimed to study the prevalence and correlates of sexual dysfunction in men on BNX substitution therapy. We recruited consecutive forty men from BNX clinic, who had received BNX for at least 6 months, who were free from any recent illicit drug use (confirmed by urine chromatographic immune assay), and who were either married or had a stable sexual partner. Men with other psychiatric and substance use disorders (except tobacco) were excluded from the study. Data for the control group were obtained from a published study (with similar selection criteria) from our center. We assessed sexual dysfunction with two cross-culturally validated instruments: Arizona Sexual Experience Scale (ASEX) and International Index of Erectile Function.Results:The sample had a mean age of 31.6 (±8) years; the mean duration of BNX treatment was 9 (±4.2) months and the mean BNX dose was 4.5 (±1.6) mg. ASEX showed the prevalence of sexual dysfunction to be 40%. The IIEF demonstrated intercourse dissatisfaction (95%) and hypoactive sexual desire (92.5%) as almost universal, while 77.5% of the participants reported erectile dysfunction. In comparison to the published data, these figures were significantly more than among the controls. We found no correlation of sexual dysfunction with marital status, age, duration or dose of BNX, duration of illicit opioid use, the severity of opioid dependence, and tobacco dependence.Conclusion:All men on BNX maintenance therapy must be screened for sexual dysfunction. With the rapid scaling up of office-based BNX substitution, assessment and management of sexual dysfunction ought to be incorporated in the training curriculum.

Multiple suicide attempts in an individual with opioid dependence: Unintended harm of lockdown during the COVID-19 outbreak?

Multiple suicide attempts in an individual with opioid dependence: Unintended harm of lockdown during the COVID-19 outbreak?

PMH20 COST-EFFECTIVENESS OF INCREASING THE EFFICIENCY OF THE DETOXIFICATION PROCESS PRIOR TO INITIATION OF EXTENDED-RELEASE NALTREXONE FOR THE TREATMENT OF OPIOID USE DISORDER

In a US randomized clinical trial testing the effectiveness of preventing opioid relapse among individuals initiating extended-release naltrexone (XR-NTX) compared to buprenorphine-naloxone (BUP-NX) in an inpatient detoxification setting, the additional time required to detoxify from opioids prior to initiating XR-NTX resulted in fewer persons initiating XR-NTX, leading to a higher opioid relapse rate, and higher detoxification costs compared to BUP-NX. The objective of this study was to use trial data to estimate whether an efficient model of inpatient opioid detoxification would improve the economic value of XR-NTX compared to BUP-NX. We identified efficient models of inpatient detoxification for trial participants assigned to XR-NTX using 1) latent class analysis to identify detoxification pharmacotherapy use patterns, 2) a multivariable generalized structural equation model to explore determinants of XR-NTX initiation and detoxification duration, while controlling for endogeneity, and 3) data from the trial on detoxification daily cost by site. We then estimated trial cost-effectiveness outcomes from the healthcare sector perspective assuming alternative detoxification models for trial participants. Five latent pharmacotherapy classes were identified and included in the multivariable model. Site effects were the largest determinants of both XRT-NTX initiation and detoxification duration. The predicted probabilities of successful initiation per detoxification-day ranged from 0.13–0.15 at the four sites with significant effects, and the predicted durations ranged from 5.5 to 6.9 days. The predicted cost/detoxification-day varied from $115–$348, largely due to different staffing models. We estimated that the most efficient site model would result in non-significant cost and effectiveness differences between initiating XR-NTX or BUP-NX. Adopting an efficient model of XR-NTX initiation could result in XR-NTX and BUP-NX having similar economic value from the healthcare sector perspective for the average patient requiring residential detoxification before initiating XR-NTX. The feasibility of implementing more efficient detoxification models needs to be explored.

Trajectory classes of opioid use among individuals in a randomized controlled trial comparing extended-release naltrexone and buprenorphine-naloxone

ObjectivesTo advance our understanding of medication treatments for opioid use disorders (OUDs), identification of distinct subgroups and factors associated with differential treatment response is critical. We examined trajectories of opioid use for patients with OUD who were randomized to (but not in all cases inducted onto) buprenorphine-naloxone (BUP-NX) or extended-release naltrexone (XR-NTX), and identified characteristics associated with each trajectory. MethodsGrowth mixture models (GMMs) were run to identify distinct trajectories of days of opioid use among a subsample of 535 individuals with OUD who participated in a 24-week randomized controlled trial (RCT; 2014–2016) of BUP-NX (n = 281) or XR-NTX (n = 254). ResultsFour distinct opioid use trajectory classes were identified for BUP-NX (near abstinent/no use (59%); low use (13.2%); low use, increasing over time (15%); and moderate use, increasing over time (12.8%)). Three distinct opioid use trajectory classes were found for XR-NTX (near abstinent/no use (59.1%); low use (14.6%); and moderate use, increasing over time (26.4%)). Across both BUP-NX and XR-NTX, the near abstinent/no use class had the highest number of medical management visits. Within BUP-NX, the low use class had a greater proportion of individuals with a previous successful treatment history compared with other classes. Within XR-NTX, the moderate use, increasing over time class had the highest proportion of Hispanic participants compared with other classes. ConclusionsFindings highlight the significant heterogeneity of opioid use during a RCT of BUP-NX and XR-NTX and factors associated with opioid use patterns including medical management visits and history of treatment success.