History Of Opioid Use Disorder Research Articles

Incidence of Postoperative Opioid Overdose and New Diagnosis of Opioid Use Disorder Among US Veterans.

Perioperative exposure to opioids is associated with adverse outcomes. We aim to determine the associations between surgery and subsequent opioid overdose, an acute event, and a new diagnosis of opioid use disorder (OUD), a chronic relapsing disease, in parallel. This retrospective cohort study of US veterans used surgery as exposure and the two outcomes were (1) occurrence of overdose and (2) new diagnosis of OUD in the first postoperative year. Surgical group was matched to the reference controls based on the propensity score of having surgery, and matched logistic regression was used to calculate the odds ratio (OR). A total of 261 208 surgical patients were matched to 479 531 controls. Overdose occurred in 1893 (0.7%) of the surgical patients and in 518 (0.1%) of the matched controls in the first postoperative year (OR, 6.71; 95% confidence interval [CI], 5.80-7.75; P < .001). Among patients with no history of OUD, surgery was also associated with a new diagnosis of OUD in the first postoperative year (OR, 1.13; 95% CI, 1.02-1.24; P = .015). The postoperative period is strongly associated with opioid overdose, but only weakly associated with new diagnosis of OUD. This is likely due to the difficulty of diagnosing OUD in the postoperative period. This is the first study that has examined opioid overdose and new-onset OUD in the postoperative period in parallel. Our analysis suggests different risk factors for each, as well as different strengths of association with surgery. More sensitive diagnostic criteria for postoperative OUD are needed to promptly diagnose and treat this condition. (Am J Addict 2020;00:00-00).

Association of Take-Home Naloxone and Opioid Overdose Reversals Performed by Patients in an Opioid Treatment Program

The US opioid crisis was deemed a public health emergency in 2017. More than 130 individuals in the US die daily as a result of unintentional opioid overdose deaths. To measure use of take-home naloxone for overdose reversals performed by study participants with opioid use disorder receiving treatment at an opioid treatment program. In a year-long cohort study, between April 4, 2016, and May 16, 2017, 395 study participants enrolled at the University of New Mexico Addiction and Substance Abuse Opioid Treatment Program, an outpatient clinic treating substance use disorders. Inclusion criteria included all patients enrolled at University of New Mexico Addiction and Substance Abuse Opioid Treatment Program during the study enrollment period; positive history of opioid use disorder treated with methadone, buprenorphine, or naltrexone; and age 18 years or older. Exclusion criteria included allergy to naloxone and age younger than 18 years. The study closed 1 year after enrollment, on May 17, 2018. Data analysis was performed from May 2018 to July 2019. Two doses of take-home naloxone combined with opioid overdose education were provided to study participants. The primary outcome was to measure the association of take-home naloxone with overdose reversals performed by patients with opioid use disorder enrolled in an opioid treatment program. We enrolled 395 study participants (270 female [68.4%]; mean [SD] age, 35.4 [12.6] years; 260 [65.8%] with Hispanic white race/ethnicity) in the 1-year prospective trial. Sixty-eight female participants (25.2% of all female participants) were pregnant at the time of enrollment. Seventy-three of the 395 study participants (18.0%) performed 114 overdose reversals in the community. All community reversals were heroin related. Most study participants (86.8%) stated that the person on whom they performed an overdose reversal was a friend, relative, acquaintance, or significant other. In the year before enrollment, only 18 study participants (4.5%) had been prescribed naloxone. Take-home naloxone as part of overdose education and naloxone distribution provided to patients in an opioid treatment program may be associated with a strategic targeted harm reduction response for reversing opioid overdose-related deaths. Policy makers may consider regulations to mandate overdose education and naloxone distribution in opioid treatment programs.

The Effects of Opioid Use on Thromboembolic Complications, Readmission Rates, and 90-Day Episode of Care Costs After Total Hip Arthroplasty

BackgroundThe purpose of this study was to investigate whether opioid use disorder (OUD) patients are at greater odds than non–opioid use disorder (NUD) patients in developing (1) thromboembolic complications; (2) readmission rates; and (3) costs of care. MethodsAll patients with a 90-day history of OUD before total hip arthroplasty (THA) were identified from a national database. Patients were matched 1:5 to controls by age, gender, Elixhauser Comorbidity Index scores, and high-risk medical comorbidities, yielding 38,821 patients with (n = 6398) and without (n = 31,883) OUD. Multivariate logistic regression analyses were performed to compare the risks of developing venous thromboembolism (deep vein thrombosis and/or pulmonary embolism) 90 days after the index procedure, 90-day readmission rates, and total global 90-day episode of care costs. ResultsPatients with a history of OUD were found to be at greater risk for 90-day venous thromboembolisms (2.38 vs. 1.07%; OR: 2.25, 95% CI: 1.86-2.73, P < .0001) compared with matched NUD patients. Specifically, OUD patients were at greater risk for both deep vein thromboses (2.13 vs. 0.87%; OR: 2.46, 95% CI: 2.00-3.03, P < .001) and pulmonary embolism (0.61 vs. 0.27%; OR: 2.24, 95% CI: 1.53-3.27, P < .0001). In addition, patients with OUD were at an increased risk for 90-day readmission (28.68 vs. 22.62%; OR: 1.37, 95% CI: 1.29-1.46, P < .0001) compared with controls. Primary THA patients with OUD incurred a 14.72% higher cost of care ($20,610.65 vs. $17,964.58) compared with NUD patients. ConclusionThese findings demonstrate that primary THA patients with a history of OUD are at greater risks for thromboembolic complications, readmissions, and higher costs of care in the 90-day postoperative period.

Mental health conditions and the risk of chronic opioid therapy among patients with rheumatoid arthritis: a retrospective veterans affairs cohort study.

Patients with rheumatoid arthritis (RA) often receive opioid analgesics for pain management. We examined the association between mental health conditions and the risk of chronic opioid therapy. A retrospective cohort of veterans with RA initiating opioid use was assembled using Veterans Health Administration databases (2001-2012). Mental health conditions included anxiety (N = 1108, 12.9%), depression (N = 1912, 22.2%), bipolar disease (N = 131, 1.5%), and post-traumatic stress disorder (N = 768, 8.9%) and were identified by ICD coded diagnoses and use of specific medications. Cohort members were followed from opioid initiation through chronic opioid therapy, defined as the continuous availability of opioids for at least 90days. Multivariable Cox proportional hazard regression models assessed the association between mental health conditions and chronic opioid therapy accounting for relevant covariates. Subgroup analyses examined whether the strength of the observed association varied by the duration of the initial opioid prescription. We identified 14,767 patients with RA with 22,452 episodes of opioid use initiation. Mental health conditions were identified in 8607 (38.3%) patients. Compared with patients without mental health conditions, patients with mental health conditions have a higher risk of developing chronic opioid therapy (469.3 vs 378.1 per 1000 person-years, adjusted hazard ratio [aHR] 1.18, 95% CI 1.09, 1.29). The increased risk was highest for those with a history of opioid use disorder (aHR 1.94, 95% CI 1.09, 3.46) and also elevated for those with other substance use disorders (aHR 1.35, 95% CI 1.05, 1.73). Duration of the initial opioid prescription was independently associated with chronic opioid therapy, regardless of the estimated opioid daily dose. History of mental health conditions and duration of the initial opioid prescription were associated with an increased risk of chronic opioid therapy among patients with RA.Key Points• Approximately a third of patients with RA are exposed to opioid analgesics.• Patients with RA and history of mental health disease, especially substance use disorders, who initiate opioid use have an increased risk of chronic opioid therapy.• This study provides insight in an underrepresented population of mainly male patients with RA.

The labor and birth experience of women with opioid use disorder: A qualitative study

ObjectiveThis study describes the experience of pregnancy and childbirth from the perspective of women with opioid use disorder. MethodsThis qualitative study analyzed semi-structured interviews about the prenatal care and birth experience of nine women with opioid use disorder as a sub-analysis of a qualitative study of women with a history of sexual trauma. Transcripts were analyzed using inductive content analysis. ResultsAnalysis revealed unique interactions with the healthcare system specific to pregnant women with opioid use disorder. Participants identified pregnancy as a reason to enter and maintain recovery and an increased availability of resources when pregnant. Yet during labor and birth, concerns regarding pain control, child protective services involvement and provider stigma led to negative interactions with the healthcare system. ConclusionPregnant woman with opioid use disorder face unique challenges when seeking care. The perspectives of women with a history of opioid use disorder can inform creation of a harm reduction, non-stigmatizing model of prenatal, labor and birth, and postpartum care.

Toxicity of agents used for opioid withdrawal: a case-based approach.

Toxicity of agents used for opioid withdrawal: a case-based approach.

Delivery dose of methadone, but not buprenorphine, is associated with the risk and severity of neonatal opiate withdrawal syndrome

Data on the relationship between the dose of opioid replacement therapy in pregnancy and the risk and severity of neonatal opioid withdrawal syndrome are conflicting and have methodological limitations. To assess the association of methadone and buprenorphine dose at delivery with neonatal opioid withdrawal syndrome in a large cohort. We performed a retrospective cohort study using data from a comprehensive perinatal opioid dependency program from 2000 through 2016. Women with a history of opioid use disorder enrolled in a medication-assisted treatment program were included. Strict neonatal opioid withdrawal syndrome case definition and neonatal treatment guidelines were utilized throughout the study epoch. Comparisons were made between women on methadone and buprenorphine. The dose of opioid replacement at delivery and the risk and severity of neonatal opioid withdrawal syndrome were assessed with univariable analysis and multivariable logistic regression. In all analyses, methadone and buprenorphine dosing were evaluated as a continuous variable. Four hundred eighty two of 709 women (68.0%) met inclusion criteria including 344 on methadone (71.4%) and 138 on buprenorphine (28.6%). Nonopioid polysubstance abuse, body mass index, medication-assisted treatment compliance, birthweight, and other characteristics were similar between groups. Overall, the frequency of neonatal opioid withdrawal syndrome was not significantly different between the methadone and buprenorphine groups (56.8% vs 52.0%, P= .35). Dose at delivery ranged at 0-165 mg for methadone and 0-30 mg for buprenorphine. In a univariable analysis, methadone dose at delivery was associated with neonatal opioid withdrawal syndrome (83.0 ± 34.2 mg vs 71.9 ± 35.8 mg for neonatal opioid withdrawal syndrome vs nonneonatal opioid withdrawal syndrome neonates, P < .001), but buprenorphine dose at delivery was not (8.4 ± 4.4 vs 7.6 ± 4.8 mg for neonatal opioid withdrawal syndrome vs nonneonatal opioid withdrawal syndrome neonates, P= .30). Peak neonatal opioid withdrawal syndrome score, duration of neonatal opioid withdrawal syndrome treatment, and cumulative neonatal morphine exposure were significantly associated with delivery methadone dose but not buprenorphine dose. The association between delivery methadone dose and neonatal opioid withdrawal syndrome persisted in multivariable regression. The dose of methadone at the time of delivery is associated with the frequency and severity of neonatal opioid withdrawal syndrome, with higher doses associated with more severe neonatal opioid withdrawal syndrome when analyzed continuously. These data may inform future prospective studies on methadone dosing in pregnancy. While medication-assisted treatment agent and dose may have an impact on pertinent neonatal outcomes related to neonatal opioid withdrawal syndrome, the provision of medication-assisted treatment in pregnancy should reflect the goal of prevention of recidivism and maternal mortality and utilize an approach that balances fetal and maternal risk to optimize outcomes.

Associations Between the Specialty of Opioid Prescribers and Opioid Addiction, Misuse, and Overdose Outcomes.

To examine associations between opioid prescriber specialty and patient likelihood of opioid use disorder (OUD), opioid misuse, and opioid overdose. Longitudinal retrospective study using Pennsylvania Medicaid data (2007-2015). We constructed an incident cohort of 432,110 enrollees initiating prescription opioid use without a history of OUD or overdose six months before opioid initiation. We attributed patients to one of 10 specialties using the first opioid prescriber's specialty or, alternatively, the specialty of the dominant prescriber writing the majority of the patient's opioid prescriptions. We estimated adjusted rates for OUD, misuse, and overdose, adjusting for demographic variables and medical (including pain) and psychiatric comorbidities. The unadjusted incidence rates of OUD, misuse, and overdose were 7.13, 4.73, and 0.69 per 100,000 person-days, respectively. Patients initiating a new episode of opioid treatment with Pain Medicine/Anesthesiology (6.7 events, 95% confidence interval [CI] = 5.5 to 8.2) or Physical Medicine and Rehabilitation (PM&R; 6.1 events, 95% CI = 5.1 to 7.2) had higher adjusted rates for OUD per 100,000 person-days compared with Primary Care practitioners (PCPs; 4.4 events, 95% CI = 4.1 to 4.7). Patients with index prescriptions from Pain Medicine/Anesthesiology (15.9 events, 95% CI = 13.2 to 19.3) or PM&R (15.8 events, 95% CI = 13.5 to 18.4) had higher adjusted rates for misuse per 100,000 person-days compared with PCPs (9.6 events, 95% CI = 8.8 to 10.6). Findings were largely similar when patients were attributed to specialty based on dominant prescriber. Differences in opioid-related risks by specialty of opioid prescriber may arise from differences in patient risk factors, provider behavior, or both. Our findings inform targeting of opioid risk mitigation strategies to specific practitioner specialties.

The Opioid Epidemic In Veterans Who Were Homeless Or Unstably Housed.

Veterans who are homeless or unstably housed are at increased risk for opioid-related morbidity and mortality. However, there is a limited understanding of the scope of the opioid epidemic and gaps in care for these populations. We conducted a retrospective observational study to examine opioid use disorder (OUD) in a national sample of veterans who accessed specialized homeless programs in the Veterans Health Administration. Additionally, in a subgroup of veterans with a history of OUD, we examined several opioid-related measures: opioid dose, concomitant opioid-benzodiazepine prescribing, and receipt of medication for addiction treatment (MAT) and overdose prevention medication (naloxone). Rates of OUD history varied significantly across age, gender, and program type. Among the subgroup of homeless veterans with an OUD history, prescribing practices and rates of MAT and naloxone receipt varied significantly by age and specialized homeless program. Rates of receipt of MAT and naloxone were moderate and low, respectively, indicating opportunities for program-specific interventions.

Perceptions about mindfulness-based interventions among individuals recovering from opioid and alcohol use disorders: Findings from focus groups

ObjectivesMindfulness-based interventions (MBIs) have been used as an intervention to support recovery from alcohol use disorder (AUD) and opioid use disorder (OUD). We sought to identify attitudes and experiences toward standardized MBIs among individuals recovering from these substance abuse disorders (SUD) through a qualitative approach. DesignWe conducted three 60-minute focus groups among people with history of SUD (6-months to 3 years in recovery): two groups with those with alcohol use disorder (AUD) history and one with individuals with history of opioid use disorder (OUD). Each group had eight participants. ResultsMost participants of the OUD focus group had tried some variations on mindfulness training or meditation-like therapies during treatment. Participants expressed perceived benefits for MBIs’ non-pharmacological property, while expressing concerns related to perceived barriers of cost, scheduling conflicts with work and child/family care needs, and possible lack of provider empathy. Gift cards and other rewards were recognized as useful participation and retention incentives for completing the described program; the training itself was perceived as an “incentive” if able to deliver significant benefits related to supporting continued recovery from SUD. An overarching theme across all groups was that participants reported their own altruistic behavior and social connectedness as important motivators to help them maintain recovery. ConclusionThe importance of perceived provider empathy and the patient’s social connectedness in SUD interventions was underscored as incentives for participation and retention, providing valuable information for the implementation of MBIs among patients recovering from SUD.

Strategies to Identify Patient Risks of Prescription Opioid Addiction When Initiating Opioids for Pain

Although prescription opioid use disorder is associated with substantial harms, strategies to identify patients with pain among whom prescription opioids can be safely prescribed have not been systematically reviewed. To review the evidence examining factors associated with opioid addiction and screening tools for identifying adult patients at high vs low risk of developing symptoms of prescription opioid addiction when initiating prescription opioids for pain. MEDLINE and Embase (January 1946 to November 2018) were searched for articles investigating risks of prescription opioid addiction. Original studies that were included compared symptoms, signs, risk factors, and screening tools among patients who developed prescription opioid addiction and those who did not. Two investigators independently assessed quality to exclude biased or unreliable study designs and extracted data from higher quality studies. The Preferred Reporting Items for Systematic Reviews and Meta-analyses of Diagnostic Accuracy Studies (PRISMA-DTA) reporting guideline was followed. Likelihood ratios (LRs) for risk factors and screening tools were calculated. Of 1287 identified studies, 6 high-quality studies were included in the qualitative synthesis and 4 were included in the quantitative synthesis. The 4 high-quality studies included in the quantitative synthesis were all retrospective studies including a total of 2 888 346 patients with 4470 cases that met the authors' definitions of prescription opioid addiction. A history of opioid use disorder (LR range, 17-22) or other substance use disorder (LR range, 4.2-17), certain mental health diagnoses (eg, personality disorder: LR, 27; 95% CI, 18-41), and concomitant prescription of certain psychiatric medications (eg, atypical antipsychotics: LR, 17; 95% CI, 15-18) appeared useful for identifying patients at high risk of opioid addiction. Among individual findings, only the absence of a mood disorder (negative LR, 0.50; 95% CI, 0.45-0.52) was associated with a lower risk of opioid addiction. Despite their widespread use, most screening tools involving combinations of questions were based on low-quality studies or, when diagnostic performance was assessed among high-quality studies, demonstrated poor performance in helping to identify patients at high vs low risk. While a history of substance use disorder, certain mental health diagnoses, and concomitant prescription of certain psychiatric medications appeared useful for identifying patients at higher risk, few quality studies were available and no symptoms, signs, or screening tools were particularly useful for identifying those at lower risk.

Hepatitis C treatment outcomes among homeless-experienced individuals at a community health centre in Boston

BackgroundHepatitis C virus (HCV) infection prevalence is high among adults who experience homelessness but data on HCV treatment outcomes are limited in this population. We examined HCV treatment engagement and outcomes in a cohort of homeless-experienced adults treated through an innovative community-based primary care program in Boston, Massachusetts, USA. MethodsWe conducted a retrospective chart review of individuals referred for HCV treatment at Boston Health Care for the Homeless Program (BHCHP) from January 2014 to March 2017. We assessed HCV treatment initiation, treatment completion, sustained virologic response (SVR), and reinfection rates. We conducted univariate and multivariable logistic regression analyses to examine the predictors of these outcomes. ResultsOf 510 referred for HCV treatment, 210 (41.1%) did not initiate treatment, principally because of being lost to follow-up (N = 93) or having superseding social issues (N = 49). Of 300 who initiated treatment, 80% were male, 52.3% were non-white, and 29% were homeless. Over half (58.6%) had a history of opioid use disorder (OUD). Twenty percent had cirrhosis. Treatment was completed by 285 (95.0%) individuals, and 255 (85.0%) achieved SVR. In multivariable analyses, individuals with bipolar disorder (OR 0.38, 95% CI 0.15−0.99), treated (OR 0.36, 95% CI 0.14−0.96) or untreated (OR 0.18, 95% CI 0.05−0.57) OUD, or on-treatment insurance change (OR 0.16, 95% CI 0.04−0.67) were less likely to achieve SVR, while individuals living with HIV (OR 10.43, 95% CI 1.33–81.96) were more likely to achieve SVR. Among 126 individuals with post-SVR follow-up data, 27 reinfections were identified during 206 person-years of follow up (rate 13.1 per 100 person-years). ConclusionHomeless-experienced individuals initiating HCV treatment in a community-based program achieved high rates of treatment completion and SVR, but a large proportion did not initiate treatment. Individuals with OUD experienced lower but still substantial rates of cure. Treatment strategies targeting homeless-experienced people should focus on improving initial engagement and minimizing reinfection risk following treatment.

Agreement between self-reported psychoactive substance use and urine toxicology results for adults with opioid use disorder admitted to hospital

Hospitals often perform urine drug screens (UDS) upon inpatient admission to confirm self-reported psychoactive substance use for patients with opioid use disorder (OUD). We sought to evaluate the agreement between UDS and patient self-report for psychoactive substances detected with UDS for adults with OUD admitted to hospital. For 11 substance categories, we evaluated agreement between the UDS and the documented history over a 5-year period for consecutive adults admitted to one academic center with a history of OUD. Among the 153 patients, overall agreement across the 1683 different history/UDS pairs (i.e. either history+/UDS + or history-/UDS-) was high (81.3%) but varied (from lowest to highest) by substance [opiates (56.9%), benzodiazepines (66.0%), 6-acetylmorphine (67.3%), cocaine (81.0%), cannabinoids (81.0%), methadone (83.7%), buprenorphine (85.0%), amphetamine (94.8%), barbiturates (95.4%), and phencyclidine (98.7%)]. History+/UDS- pair mismatches were most frequent for 6-acetylmorphine (32.7%), methadone (14.3%) and oxycodone (12.4%); history-/UDS + pair mismatches were most frequent for opiates (43.1%), benzodiazepines (24.8%) and cannabinoids (18.3%). The change in agreement over time of self-reported heroin use may reflect an increasing number of patients unknowingly using illicit fentanyl products. Among hospitalized patients with OUD, agreement between reported psychoactive substance use history and UDS results is strong with the exception of opiates, heroin, and benzodiazepines.

Comorbid opioid use is undertreated among forensic patients with schizophrenia

BackgroundSubstance use disorders are associated with poorer clinical outcomes in patients with schizophrenia. There is no specific treatment for amphetamine or cannabis use disorder, but methadone and buprenorphine are used as replacement therapy in the treatment of opioid dependence. Our aim was to study whether patients with schizophrenia have received opioid replacement therapy for their opioid use disorder.MethodsThe study sample consisted of 148 individuals diagnosed with schizophrenia who were in involuntary psychiatric treatment as forensic patients in Finland in 2012. The proportion of the study sample with comorbid opioid use disorder having received opioid replacement therapy prior to their forensic psychiatric treatment was compared to the available information of opioid dependent patients in general. The data were collected from forensic examination statements, patient files and other medical registers retrospectively.ResultsOf the study sample, 15.6% (23/148) had a history of opioid use disorder, of whom 8.7% (2/23) had received opioid replacement treatment (95% confidence interval (Cl): 1.1–28.0), even though opioid use disorder had been diagnosed in the treatment system. According the available information the corresponding proportion among patients with opioid use disorder and using substance use disorder services was 30.4% (565/1860, 95% Cl: 28.3–32.5). The fraction of patients receiving opioid replacement therapy was significantly lower among patients with schizophrenia (p = 0.022).ConclusionsOpioid replacement therapy was seldom used among schizophrenia patients who were later ordered to involuntary forensic psychiatric treatment. More attention should be paid to the possible use of opioids when planning treatment for patients with schizophrenia.Trial registrationOur study is not a randomized controlled trial (but a register-based study); thus the trial registration is not applicable.

Are we ready to treat hepatitis C virus in individuals with opioid use disorder: assessment of readiness in European countries on the basis of an expert-generated model.

Individuals with a history of injecting drugs have a high prevalence of chronic hepatitis C (HCV) infection. Many have a history of opioid use disorder (OUD). Despite novel treatments with improved efficacy and tolerability, treatment is limited in the group. A faculty of experts shared insights from clinical practice to develop an HCV care-readiness model. Evidence and expert knowledge was collected. Ten experts developed a model of three factors (with measures): 'healthcare engagement', 'guidance' and 'place'. Overall, 40-90% of individuals with OUD engage with drug treatment services. Ten of 12 HCV guidelines provided specific advice for the OUD population. Ten of 12 OUD care guidelines provided useful HCV care advice. In 11 of 12 cases, location of HCV/drug treatment care was in different places. This readiness assessment shows that there are important limitations to successful HCV care in OUD. Specific actions should be taken: maintain/increase access to OUD treatment services/opioid agonist therapy, updating HCV guidance, locate care in the same place and allow wider prescribing of anti HCV medicines.

Healthcare utilization in adults with opioid dependence receiving extended release naltrexone compared to treatment as usual

BackgroundOpioid use disorders have reached epidemic proportions, with overdose now the leading cause of accidental death in the United States. Extended release naltrexone (XR-NTX) has emerged as a medication treatment that reduces opioid use and craving. However, the effect of XR-NTX therapy on acute healthcare utilization, including emergency department visits and inpatient hospitalizations, remains uncertain. The objective of the current study is to evaluate hospital-based healthcare resource utilization in adults involved in the criminal justice system with a history of opioid use disorder randomized to XR-NTX therapy compared with treatment as usual (TAU) during a 6-month treatment phase and 12months post-treatment follow up. MethodsThis retrospective exploratory analysis uses data collected in a published randomized trial. Comparisons of the number of emergency department visits and hospital admissions (for drug detox, psychiatric care and other medical reasons) were performed using chi square tests for any admission and negative binomial models for number of admissions. ResultsOf the 308 participants randomized, 96% had utilization data (76% complete 6months, 67% complete follow up). No significant differences were seen in overall healthcare utilization (IRR=0.88, 95%CI 0.63–1.23, p=0.45), or substance use-related drug detox hospitalizations (IRR=0.83, 95%CI 0.32–2.16, p=0.71). Despite having more participants report chronic medical problems at baseline (43% vs. 32%, p=0.05), those receiving XR-NTX generally experienced equivalent or lower rates of healthcare utilization compared to TAU. The XR-NTX group had significantly lower medical/surgical related hospital admissions (IRR=0.55, 95%CI 0.30–1.00, p=0.05) during the course of the entire study. ConclusionsXR-NTX did not significantly increase rates of healthcare utilization compared to TAU. Provider concerns regarding healthcare utilization should not preclude the consideration of XR-NTX as therapy for opioid use disorders.

Cost-effectiveness of extended release naltrexone to prevent relapse among criminal justice-involved individuals with a history of opioid use disorder.

Criminal justice-involved individuals are highly susceptible to opioid relapse and overdose-related deaths. In a recent randomized trial, we demonstrated the effectiveness of extended-release naltrexone (XR-NTX; Vivitrol® ) in preventing opioid relapse among criminal justice-involved US adults with a history of opioid use disorder. The cost of XR-NTX may be a significant barrier to adoption. Thus, it is important to account for improved quality of life and downstream cost-offsets. Our aims were to (1) estimate the incremental cost per quality-adjusted life-year (QALY) gained for XR-NTX versus treatment as usual (TAU) and evaluate it relative to generally accepted value thresholds; and (2) estimate the incremental cost per additional year of opioid abstinence. Economic evaluation of the aforementioned trial from the taxpayer perspective. Participants were randomized to 25weeks of XR-NTX injections or TAU; follow-up occurred at 52 and 78weeks. Five study sites in the US Northeast corridor. A total of 308 participants were randomized to XR-NTX (n=153) or TAU (n=155). Incremental costs relative to incremental economic and clinical effectiveness measures, QALYs and abstinent years, respectively. The 25-week cost per QALY and abstinent-year figures were $162 150 and $46 329, respectively. The 78-week figures were $76 400/QALY and $16 371/abstinent year. At 25weeks, we can be 10% certain that XR-NTX is cost-effective at a value threshold of $100 000/QALY and 62% certain at $200 000/QALY. At 78weeks, the cost-effectiveness probabilities are 59% at $100 000/QALY and 76% at $200 000/QALY. We can be 95% confident that the intervention would be considered 'good value' at $90 000/abstinent year at 25weeks and $500/abstinent year at 78weeks. While extended-release naltrexone appears to be effective in increasing both quality-adjusted life-years (QALYs) and abstinence, it does not appear to be cost-effective using generally accepted value thresholds for QALYs, due to the high price of the injection.

Recurrent Foreign Body Ingestions Following Rapid Methadone Taper: Neurological Aspects of Self-Injury and Opioid Therapy

Recurrent Foreign Body Ingestions Following Rapid Methadone Taper: Neurological Aspects of Self-Injury and Opioid Therapy

Kratom (Mitragyna speciosa) Use in a Veteran With Chronic Pain

Kratom (<i>Mitragyna speciosa</i>) Use in a Veteran With Chronic Pain

The opioid epidemic

Opioid use disorder is a growing epidemic, with an alarming number of associated deaths. In 2014, in the United States, 18,893 lethal overdoses were related to prescription opioids and 10,574 due to heroin. Despite the growing number of treatment options for substance use disorders, which are chronic, relapsing-remitting conditions, relapse rates remain as high as 91%. In the United States, 7.5 million children reside with at least one patient who abuses drugs or alcohol. Mothers are twice as likely to lose custody of their children. They have higher rates of comorbid abuse and psychopathology and limited social supports. Child service agencies, commonly involved in these scenarios, are often pressured to find permanent placement for children, within an expedited timeframe, inconsistent with the need for sufficient time for recovery and goals of family inclusion and unity. We present the complicated case of a 25-year-old woman with a history of opioid use disorder and depression, who, after being in and out of treatment programs for years, had a lethal overdose. She had a significant family history of addiction and had lost custody of her children. This challenging, but common presentation draws attention to challenges in providing treatment during this opioid epidemic.