Management Of Opioid Use Disorder Research Articles

P-511. Missed Opportunities for Pre-Exposure Prophylaxis Initiation in Hospitalized Persons with Opioid Use Disorder and Infectious Diseases

Abstract Background Hospitalizations are increasing among persons with opioid use disorder (OUD) secondary to overdose as well as infections. Hospital settings are a reachable moment not only to offer treatment for OUD and co-occurring infections, but also to offer HIV testing and link to antiretroviral therapy to treat and prevent HIV. Pre-exposure prophylaxis (PrEP) prevents HIV acquisition through both sharing injection drug use equipment and condomless sexual intercourse. Unfortunately, few persons who use drugs including those with OUD are offered PrEP. This descriptive analysis sought to examine patients’ knowledge and attitude about PrEP to better understand if PrEP initiation at time of hospital contact could be used as a way to increase PrEP uptake in patients with OUD.Figure 1.Participants’ perceived risk of HIV on hospital discharge. Methods A retrospective data analysis was performed from the ongoing parent study, Project COMMIT (Coordinated Medical Treatment of Opioid Use Disorder and Infectious Disease). Adult patients (N = 144) hospitalized with bacterial, viral, or fungal infection with moderate to severe OUD were recruited upon admission to hospital and randomized 1:1 to either: 1) infectious disease management of OUD with long-acting injectable buprenorphine vs. 2) treatment as usual. Of the 144, 73 participants who did not report HIV infection, completed a supplemental questionnaire assessing beliefs in PrEP. Basic demographic information, sexual and HIV risk factors, and opioid use risk factors and beliefs about PrEP were reported as frequencies and percentages. Results When exploring HIV risk behavior in the past 30 days, 46 (63%) used injection drugs, 26 (35.6%) had condomless sex, 3 (4.1%) knew of their sexual partner being HIV positive or of unknown status, and 12 (16.4%) shared works. Of the 73 who completed the survey, 29 (39.7%) had never heard of PrEP, and none (n=0, 0.0%) had taken PrEP before. When asked about perceived risk of HIV, on a 4-point scale (high, medium, low or no risk), a majority of participants 64 (87.7%) thought they had no or low risk of HIV infection. Conclusion This study identified the need for increased education about risk for HIV and PrEP among people who use drugs and attention to acute hospitalization as a reachable moment for engaging them in HIV prevention care. Disclosures Sheela Shenoi, MD MPH, Merck Pharmaceuticals: Stocks/Bonds (Private Company) Frances Levin, MD, Aelis Pharmaceuticals: Grant/Research Support|Indivior: Medication for Research|Major League Baseball: Advisor/Consultant|NCATS: Grant/Research Support|NIDA: Grant/Research Support|NYSPI: Salary Support|SAMSHA: Grant/Research Support|US World Meds: Grant/Research Support Edward Nunes, MD, Alkermes: Advisor/Consultant|Alkermes: donated medication or digital therapeutics|Braeburn: donated medication or digital therapeutics|Camurus: Advisor/Consultant|Camurus: donated medication or digital therapeutics|Chess Health: donated medication or digital therapeutics|Indivior: Advisor/Consultant|Indivior: donated medication or digital therapeutics|Pear Therapeutics: Advisor/Consultant|Pear Therapeutics: donated medication or digital therapeutics Alain H. Litwin, MD, MPH, MS, Gilead Sciences: Advisor/Consultant|Gilead Sciences: Grant/Research Support|Merck Pharmaceuticals: Advisor/Consultant Sandra Ann Springer, MD, Alkermes Inc: Honoraria|Alkermes Inc: In kind study drug donation for NIH sponsored research|Indivior Pharmaceutical company: In kind study drug donation for NIH sponsored research

Precipitated Withdrawal Induced by Prehospital Naloxone Administration

Objectives Buprenorphine is becoming a key component of prehospital management of opioid use disorder. It is unclear how many prehospital patients might be eligible for buprenorphine induction, as traditional induction requires that patients first have some degree of opioid withdrawal. The primary aim of this study was to quantify how many patients developed precipitated withdrawal after receiving prehospital naloxone for suspected overdose, as they could be candidates for prehospital buprenorphine. The secondary objective was to identify associated factors contributing to precipitated withdrawal, including dose of naloxone administered, and identify rate of subsequent transport. Methods A retrospective cohort study reviewing electronic patient care reports (ePCRs) from March 2019 to April 2023 in a single Emergency Medical Services (EMS) system was performed. Cases were included if naloxone was administered during the prehospital interval and excluded if the patient was in cardiac arrest upon arrival and died on scene. Precipitated opioid withdrawal was defined using reliably available ePCR data points measured by the Clinical Opiate Withdrawal Scale: administration of an antiemetic or sedative, persistent tachycardia, or new tachycardia after naloxone. Descriptive statistics were calculated to quantify the incidence of precipitated withdrawal. Risk ratios were calculated to identify variables associated with outcomes of interest. A subgroup analysis was performed examining patients explicitly diagnosed with an overdose by EMS. Results During the study period, 4561 individuals were given naloxone, and 2124 (46.2%) met our proxy criteria for precipitated withdrawal. Patients who received multiple doses of naloxone were more likely to meet our precipitated withdrawal definition versus those who received a single dose (RR 1.2, 95% CI 1.12–1.28). Patients who experienced precipitated withdrawal were more likely to accept transportation than those who did not experience withdrawal (RR 1.08 95% CI 1.04–1.12). Persistent tachycardia (80.3%) was the most common criterion met for our definition of precipitated withdrawal. Conclusions Almost half of patients who received a dose of prehospital naloxone for suspected overdose met our proxy criteria for precipitated withdrawal. Patients who met our precipitated withdrawal definition were more likely to have received greater doses of naloxone and were more likely to accept transport to an emergency department.

Enhancing the Management of Opioid Use Disorder in the Emergency Department: A Holistic Curricular Intervention.

Introduction Amid the opioid crisis, emergency medicine (EM) physicians increasingly tackle opioid use disorder (OUD) in the emergency department. Although the "X waiver" is no more, OUD-specific education requirements persist for EM clinicians and trainees. Traditional EM education emphasizes pathophysiology but overlooks the role of stigma in OUD as well as the importance of a peer recovery support specialist (peer) and community referral partners. We aimed to create and deliver a holistic EM OUD curriculum to boost practical OUD-specific knowledge and address OUD perceptions. Methods A task force of EM clinician-educators with expertise in OUD developed a four-hour educational curriculum to implement during a single EM residency didactic day. The curriculum highlighted a panel of peers, a series of lectures detailing specific aspects of OUD management, and an OUD tabletop simulation that focused on stigma. Pre- and post-participant surveys were obtained. Surveys assessed participant content knowledge via self-assessment as well as attitudes regarding persons with OUD via the Medical Condition Regard Scale (MCRS). A descriptive analysis was performed. Results Participants included 21 EM residents at various levels of training and faculty members, with 23 participants completing the pre-survey and 21 completing the post-survey. Post-curriculum delivery, all self-assessed knowledge categories demonstrated improvement; as examples, post-intervention, 100% of respondents reported understanding of medications for OUD (buprenorphine) indications and comfort with prescribing, compared to 52.7% and 56.5% prior to the intervention, respectively. Pre-survey MCRS assessments were largely positive; however, post-curriculum MCRS responses trended toward additional improvements in reported participant attitudes toward persons with OUD. A majority (95.2%) of respondents felt the curriculum improved topic understanding, and 90.5% reported improved confidence in treating patients with OUD. The peer panel and lectures were rated the most meaningful, followed by the simulation. Conclusion This OUD curricular intervention demonstrates the feasibility and perceived participant value of a holistic OUD curriculum. This curriculum improved participant OUD-specific knowledge and attitudes toward persons with OUD.

Management of opioid use disorder: 2024 update to the national clinical practice guideline.

In an evolving landscape of practices and policies, reviewing and incorporating the latest scientific evidence is necessary to ensure optimal clinical management for people with opioid use disorder. We provide a synopsis of the 2024 update of the 2018 National Guideline for the Clinical Management of Opioid Use Disorder, from the Canadian Research Initiative in Substance Matters. For this update, we followed the United States Institute of Medicine's Standards for Developing Trustworthy Clinical Practice Guidelines and used the Appraisal of Guidelines Research and Evaluation-Recommendation Excellence tool to ensure guideline quality. We carried out a comprehensive systematic literature review, capturing the relevant literature from Jan. 1, 2017, to Sept. 14, 2023. We drafted and graded recommendations according to the Grading of Recommendations, Assessments, Development and Evaluation approach. A multidisciplinary external national committee, which included people with living or lived experience of opioid use disorder, provided input that was incorporated into the guideline. From the initial 11 recommendations in the 2018 guideline, 3 remained unchanged, and 8 were updated. Specifically, 4 recommendations were consolidated into a single revised recommendation; 1 recommendation was split into 2; another recommendation was moved to become a special consideration; and 2 recommendations were revised. Key changes have arisen from substantial evidence supporting that methadone and buprenorphine are similarly effective, particularly in reducing opioid use and adverse events, and both are now considered preferred first-line treatment options. Slow-release oral morphine is recommended as a second-line option. Psychosocial interventions can be offered as adjunctive treatment but should not be mandatory. The guideline reaffirms the importance of avoiding withdrawal management as a standalone intervention and of incorporating evidence-based harm reduction services along the continuum of care. This guideline update presents new recommendations based on the latest literature for standardized management of opioid use disorder. The aim is to establish a robust foundation upon which provincial and territorial bodies can develop guidance for optimal care.

Effectiveness of long-acting buprenorphine - A systematic review.

To analyse the evidence of the effectiveness of long-acting injection buprenorphine (LAI-B) in the management of opioid use disorder (OUD). Databases were searched for studies reporting on the effectiveness of LAI-B for the treatment of OUD. Risk of bias was assessed, and a narrative synthesis of data was presented. The study adhered to PRISMA guidelines and was registered with PROSPERO (CRD42023396033). Eighteen studies were included in the final review: two double-blind randomised control trials, two open-label randomised control trials, two retrospective cohort studies, one non-controlled pilot study, and eleven observational studies. In comparative trials, LAI-B was superior to placebo and superior or non-inferior to treatment as usual. LAI-B was positively associated with improvements in abstinence rates and patient-centred outcomes. There was limited data on the long-term effects of continuous LAI-B prescription. LAI-B is an effective treatment for OUD with advantages over existing forms of treatment. Patients reported high levels of medication satisfaction and there were no significant safety concerns. This review highlights the need for future research on long-term effectiveness outcomes, with participants of more varied demographics and psychiatric comorbidity, which is more reflective of the OUD population seen in community clinical settings.

Navigating Buprenorphine Therapy: A Closer Look at Microdosing vs. Macrodosing for Pain Management and Opioid Addiction – A Narrative Review

Background: Buprenorphine therapy has emerged as a primary therapy method for both opioid addiction and chronic pain; however, the «one size fits all» approach to buprenorphine administration is no longer tenable. This review analyzes the pharmacology of both dosing approaches and their clinical outcomes, safety profiles, and societal implications, providing valuable insights for healthcare professionals. Methods: Multiple databases were used in conjunction with a set of inclusion and exclusion criteria to source articles to assess the consensus of best methods for treating opioid use disorder (OUD). This comprehensive review discusses two distinct dosing strategies, microdosing and macrodosing, through a detailed literature search to assess the differences and similarities of each strategy. Findings: Microdosing entails administering minimal buprenorphine doses, with promise in pain alleviation and addiction management while mitigating the risks of dependence and side effects typically associated with traditional opioids. In contrast, macrodosing employs higher buprenorphine doses, which is well-established for OUD and chronic pain management but raises concerns concerning misuse and overdose. Conclusion: Tailoring buprenorphine therapy to patients’ individual needs is essential in the face of contemporary healthcare challenges related to pain management and opioid addiction.

Leveraging Trauma Informed Care for Digital Health Intervention Development in Opioid Use Disorder.

Digital health refers to the use of information and communication technologies in medicine (including smartphone apps, wearables, other non-invasive sensors, informatics and telehealth platforms) to prevent illness, deliver treatment, and promote wellness. This rapidly proliferating group of technologies has the potential to reduce harm for people with opioid use disorder (OUD) and facilitate the recovery process; however, development in this space for OUD has been slower compared to that for other medical conditions. Unique issues with OUD management surrounding patient provider relationships, interaction with the healthcare system, autonomy and trust sometimes hinder care approaches, including those in digital health. The trauma informed care framework (TIC), developed for use by organizations to support individuals who have experienced trauma, has particular applicability for digital health interventions in OUD care. This manuscript will serve as a review of TIC principles and how they can be applied to digital health interventions to increase access, equity, and empowerment for people with OUD. We will highlight representative current and pipeline digital technologies for OUD, challenges with these technologies, TIC models for OUD, and the integration of TIC principles into digital technology development to better serve people with OUD. Finally, we will posit strategies to incorporate the aforementioned principles into future research efforts. We ultimately aim to use TIC as a lens through which to develop digital technologies to help individuals with OUD while minimizing harm.

Navigating new norms: Addiction specialists' perspectives on opioid use disorder treatments and policy challenges in the fentanyl era.

Amidst increasing opioid-related overdoses in the USA, opioid use disorder (OUD) treatment has seen few novel treatments emerge. High-potency synthetic opioids (HPSOs) have altered clinical approaches, prompting evaluation of existing medications for opioid use disorder (MOUD) and interest in slow-release oral morphine (SROM) as another therapeutic option. Here we survey addiction specialists on the influence of HPSOs on clinical practice, views on current MOUD regulations, and openness to novel therapies such as SROM. Anonymous, online survey conducted at a national conference of addiction specialists (N = 91). Pearson χ2 tests and Fisher's exact tests to compare respondent characteristics. Approximately 89% of respondents (N = 91) acknowledge that HPSOs shifted addiction treatment in recent years, with 86% modifying their MOUD prescribing accordingly. Moreover, 84% report having patients who could benefit from other full opioid agonists beyond methadone for OUD management. Many report off-label prescribing of full agonist opioids other than methadone for withdrawal symptoms or initiating MOUD. Eighty percent reported being in favor of incorporating SROM as a third-line monotherapy for OUD. This sample of addiction specialists supports innovative alternatives for MOUD in the USA to combat the challenges posed by fentanyl and related HPSOs. Future work should further addiction specialists' opinions on barriers to OUD treatment and exploration of these international strategies in the USA. This appears to be the first study exploring addiction specialists' perspectives on regulatory barriers to OUD treatment and their willingness to uptake internationally adopted strategies such as SROM.

Impact of implementing primary care-based medication for opioid use disorder on provider and staff perceptions.

Medication for opioid use disorder (MOUD) is the management of opioid use disorder (OUD) on an outpatient basis with buprenorphine or buprenorphine/naloxone (or methadone, which is limited to federally certified opioid treatment programs). Primary care practices are well poised to provide comprehensive care for patients with OUD, including provision of MOUD. The aim of this study was to assess provider and staff OUD attitudes and role perceptions before and after implementation of a MOUD clinical service line. A survey was distributed to evaluate attitudes and perceptions of patients with OUD and provision of MOUD among providers and staff in an academic family medicine clinic. Surveys were distributed in December 2020 (73% response rate), prior to a substance use disorder educational training and MOUD service line implementation, which provided patients with OUD both primary care services and management with buprenorphine/naloxone. A follow-up survey was distributed in February 2022 (69% response rate).Training and implementation of the MOUD service line demonstrated improvements in the domains of motivation (+0.63), attitudes (+0.32), satisfaction (+0.38), role support (+0.48), role adequacy (+0.39), and safety (+0.79) among surveyed participants. The change in satisfaction and safety domains was statistically significant (P < .05). There was no change in the role legitimacy domain.Implementation of a primary care-based MOUD service line positively affected provider and staff motivation, attitudes, satisfaction, sense of safety, role support, and adequacy when working with patients with OUD. This highlights the benefits of MOUD-specific clinical support to optimize care delivery within primary care.

A novel Project ECHO curriculum on older adult pain management and opioid use disorder for outpatient clinicians

ABSTRACT Chronic pain, opioid use, and opioid use disorder (OUD) are increasingly common in older adults. Outpatient clinician education may improve outcomes. Our aim was to create and evaluate a novel curriculum for outpatient clinicians on older adult pain management, opioid prescribing, and OUD leveraging Project ECHO®, a model for delivering subspecialized medical knowledge to community outpatient clinicians via videoconferencing. The series is comprised of 8-hour-long sessions, each with an expert-led interactive lectures followed by participant-led case discussions. Topics include pain assessment & treatment, considerations in older adults (e.g. cognition, caregiver support), shared decision-making, behavioral health, and OUD diagnosis and treatment. Sixty-nine clinicians attended the series and completed the pre-series survey; 78% (n = 54) completed the post-series survey. Clinicians reported a significant increase in self-efficacy in 14/14 queried competencies and greater frequency of performing 7/10 practice behaviors regarding older adult pain management, opioid prescribing, and OUD management. The most liked curricular components were opportunities to learn with subspecialists and discussions with other community clinicians. Qualitative analysis suggests that clinicians may benefit from education on specific geriatrics-related content areas. This novel curriculum has potential to improve management of older adult chronic pain, opioid prescribing, and OUD in a virtual and scalable format.

Implementation of a rural emergency department-initiated buprenorphine program in the mountain west: a study protocol

BackgroundOpioid related overdose morbidity and mortality continue to significantly impact rural communities. Nationwide, emergency departments (EDs) have seen an increase in opioid use disorder (OUD)-related visits compared to other substance use disorders (SUD). ED-initiated buprenorphine is associated with increased treatment engagement at 30 days. However, few studies assess rural ED-initiated buprenorphine implementation, which has unique implementation barriers. This protocol outlines the rationale and methods of a rural ED-initiated buprenorphine program implementation study.MethodsThis is a two-year longitudinal implementation design with repeated qualitative and quantitative measures of an ED-initiated buprenorphine program in the rural Mountain West. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework outlines intervention assessments. The primary outcome is implementation measured by ED-initiated buprenorphine protocol core components. Reach, adoption, and maintenance are secondary outcomes. External facilitators from an academic institution with addiction medicine and prior program implementation expertise partnered with community hospital internal facilitators to form an implementation team. External facilitators provide ongoing support, recommendations, education, and academic detailing. The implementation team designed and implemented the rural ED-initiated buprenorphine program. The program includes OUD screening, low-threshold buprenorphine initiation, naloxone distribution and administration training, and patient navigator incorporation to provide warm hand off referrals for outpatient OUD management. To address rural based implementation barriers, we organized implementation strategies based on Expert Recommendations for Implementing Change (ERIC). Implementation strategies include ED workflow redesign, local needs assessments, ED staff education, hospital leadership and clinical champion involvement, as well as patient and community resources engagement.DiscussionMost ED-initiated buprenorphine implementation studies have been conducted in urban settings, with few involving rural areas and none have been done in the rural Mountain West. Rural EDs face unique barriers, but tailored implementation strategies with external facilitation support may help address these. This protocol could help identify effective rural ED-initiated buprenorphine implementation strategies to integrate more accessible OUD treatment within rural communities to prevent further morbidity and mortality.Trial RegistrationClinicalTrials.gov National Clinical Trials, NCT06087991. Registered 11 October 2023 – Retrospectively registered, https://clinicaltrials.gov/study/NCT06087991.

Emergency department management of opioid use disorder in pediatric patients.

Opioid use disorder (OUD) has emerged as a significant public health crisis affecting individuals across all age groups. However, there remains a critical gap in understanding the specific nuances and challenges associated with OUD in pediatric populations. This article provides a comprehensive review of the epidemiology, definition of OUD, screening recommendations for OUD, and evidence-based management strategies for OUD in pediatric patients.

Opioid Medical Detoxification Compared to Opioid Agonist Treatment during Pregnancy: A Scoping Review.

Opioid use disorder (OUD) is highly prevalent, affecting up to 1% of pregnancies. The current standard of care for the management of OUD during pregnancy has been maintained with opioid agonist treatment (OAT), using either methadone or buprenorphine. OAT use has been associated with a risk of neonatal abstinence syndrome (NAS), which requires a longer neonatal length of stay for monitoring and possible pharmacological treatment. As a result, opioid medical detoxification (OMD) was proposed as an alternative strategy to reduce the stigma associated with OAT and to eliminate the risk of NAS by detoxifying or tapering pregnant persons during their pregnancy before delivery; however, the safety and effectiveness of OMD during pregnancy have not been established. This scoping review aims to summarize recent evidence related to maternal, obstetrical, and neonatal outcomes of OMD in comparison to OAT maintenance. This review also provides recommendations for future research initiatives to fill gaps in managing this patient population.

Care Integration for Hepatitis C Virus Treatment Through Facilitated Telemedicine Within Opioid Treatment Programs: Qualitative Study.

Telemedicine has the potential to remove geographic and temporal obstacles to health care access. Whether and how telemedicine can increase health care access for underserved populations remains an open question. To address this issue, we integrated facilitated telemedicine encounters for the management of hepatitis C virus (HCV), a highly prevalent condition among people with opioid use disorder (OUD), into opioid treatment programs (OTPs). In New York State, OTPs are methadone-dispensing centers that provide patient-centered, evidence-based treatment for OUD. We investigated the integration and impact of facilitated telemedicine into OTP workflows in these settings. This study aims to understand OTP staff experiences with integrating facilitated telemedicine for HCV treatment into OTPs, including best practices and lessons learned. We conducted semistructured interviews with 45 OTP staff members (13 clinical, 12 administrative, 6 physicians, and 14 support staff members) at least one year after the implementation of facilitated telemedicine for HCV management. We used hermeneutic phenomenological analysis to understand OTP staff experiences. We identified 4 overarching themes illustrating the successful integration of facilitated telemedicine for HCV care into OTPs. First, integration requires an understanding of the challenges, goals, and values of the OTP. As OTP staff learned about new, highly effective HCV therapies, they valued an HCV cure as a "win" for their patients and were excited about the potential to eliminate a highly prevalent infectious disease. Second, the integration of facilitated telemedicine into OTPs fosters social support and reinforces relationships between patients and OTP staff. OTP staff appreciated the ability to have "eyes on" patients during telemedicine encounters to assess body language, a necessary component of OUD management. Third, participants described high levels of interprofessional collaboration as a care team that included the blurring of lines between disciplines working toward a common goal of improving patient care. Study case managers were integrated into OTP workflows and established communication channels to improve patient outcomes. Fourth, administrators endorsed the sustained and future expansion of facilitated telemedicine to address comorbidities. OTP staff were highly enthusiastic about facilitated telemedicine for an underserved population. They described high levels of collaboration and integration comparable to relevant integrative frameworks. When situated within OTPs, facilitated telemedicine is a high-value application of telemedicine that provides support for underserved populations necessary for high-quality health care. These experiences support sustaining and scaling facilitated telemedicine in comparable settings and evaluating its ability to address other comorbidities. ClinicalTrials.gov NCT02933970; https://clinicaltrials.gov/study/NCT02933970.

Improving Healthcare Professionals' Access to Addiction Medicine Education Through VHA Addiction Scholars Program.

The seemingly inexorable rise of opioid-related overdose deaths despite the reduced number of COVID-19 pandemic deaths demands novel responses and partnerships in our public health system's response. Addiction medicine is practiced in a broad range of siloed clinical environments that need to be included in addiction medicine training beyond the traditional fellowship programs. Our objective in this project was to implement a knowledge-based, live virtual training program that would provide clinicians and other healthcare professionals with an overview of addiction, substance use disorders (SUD), and clinical diagnosis and management of opioid use disorder (OUD). The Veterans Health Administration (VHA) Emergency Department Opioid Safety Initiative (ED OSI) offered a four-day course for healthcare professionals interested in gaining knowledge and practical skills to improve VHA-based SUD care. The course topics centered around the diagnosis and treatment of SUD, with a focus on OUD. Additionally, trainees received six months of support to develop addiction medicine treatment programs. Evaluations of the course were performed immediately after completion of the program and again at the six-month mark to assess its effectiveness. A total of 56 clinicians and other healthcare professionals participated in the Addiction Scholars Program (ASP). The participants represented nine Veteran Integrated Service Networks and 21 different VHA medical facilities. Nearly 70% of participants completed the initial post-survey. Thirty-eight respondents (97.4%) felt the ASP series contained practical examples and useful information that could be applied in their work. Thirty-eight respondents (97.4%) felt the workshop series provided new information or insights into the diagnosis and treatment of SUD. Eleven capstone projects based on the information acquired during the ASP were funded (a total of $407,178). Twenty participants (35.7%) completed the six-month follow-up survey. Notably, 90% of respondents reported increased naloxone prescribing and 50% reported increased prescribing of buprenorphine to treat patients with OUD since completing the course. The ASP provided healthcare professionals with insight into managing SUD and equipped them with practical clinical skills. The students translated the information from the course to develop medication for opioid use disorder (M-OUD) programs at their home institutions.

Opioid use and risks in candidates and recipients of liver transplant.

Opioid use is extremely prevalent among patients with cirrhosis and those who received liver transplant (LT), despite concerns regarding opioid-related risks in this population. While there are many theoretical risks of opioids in patients with hepatic dysfunction, there is limited evidence on the effect of opioid use on clinical outcomes in cirrhosis and patients before and after LT specifically. As a result, there is significant center-level variability in opioid-related practices and policies. The existing data-largely based on retrospective observational studies-do suggest that opioids are associated with increased health resource utilization pre-LT and post-LT and that they may precipitate HE in patients with cirrhosis and increase the risk of graft loss and death after LT. The strongest predictor of opioid use after LT is opioid use before transplant; thus, a focus on safe opioid use in the pretransplant and peritransplant periods is essential for minimizing opioid-related harms. We describe 3 strategies to guide LT providers including (1) improved characterization of pain, mental health symptoms, and opioid and polysubstance use; (2) minimization of opioid prescriptions for those at highest risk of adverse events; and (3) safe prescribing strategies for those who do use opioids and for the management of opioid use disorder. Ultimately, our goal is to improve the quality of life and transplant outcomes among patients with cirrhosis and those who received LT, particularly those living with concurrent pain, mental health, and substance use disorders.

Managing Opioid Withdrawal Symptoms During the Fentanyl Crisis: A Review.

Illicitly manufactured fentanyl (IMF) is a significant contributor to the increasing rates of overdose-related deaths. Its high potency and lipophilicity can complicate opioid withdrawal syndromes (OWS) and the subsequent management of opioid use disorder (OUD). This scoping review aimed to collate the current OWS management of study populations seeking treatment for OWS and/or OUD directly from an unregulated opioid supply, such as IMF. Therefore, the focus was on therapeutic interventions published between January 2010 and November 2023, overlapping with the period of increasing IMF exposure. A health science librarian conducted a systematic search on November 13, 2023. A total of 426 studies were screened, and 173 studies were reviewed at the full-text level. Forty-nine studies met the inclusion criteria. Buprenorphine and naltrexone were included in most studies with the goal of transitioning to a long-acting injectable version. Various augmenting agents were tested (buspirone, memantine, suvorexant, gabapentin, and pregabalin); however, the liberal use of adjunctive medication and shortened timelines to initiation had the most consistently positive results. Outside of FDA-approved medications for OUD, lofexidine, gabapentin, and suvorexant have limited evidence for augmenting opioid agonist initiation. Trials often have low retention rates, particularly when opioid agonist washout is required. Neurostimulation strategies were promising; however, they were developed and studied early. Precipitated withdrawal is a concern; however, the rates were low and adequately mitigated or managed with low- or high-dose buprenorphine induction. Maintenance treatment continues to be superior to detoxification without continued management. Shorter induction protocols allow patients to initiate evidence-based treatment more quickly, reducing the use of illicit or non-prescribed substances.

Using a collaborative team- based approach to enhance the inpatient management of Opioid Use Disorder (OUD)

Using a collaborative team- based approach to enhance the inpatient management of Opioid Use Disorder (OUD)

Correction to: Buprenorphine extended-release injection (Brixadi®) in the management of opioid use disorder: a profile of its use in the USA

Correction to: Buprenorphine extended-release injection (Brixadi®) in the management of opioid use disorder: a profile of its use in the USA

The current state of knowledge on care for co-occurring chronic pain and opioid use disorder: A scoping review.

Opioid use disorder often co-occurs with chronic pain but assessment and treatment of these co-occurring disorders is complex. This review aims to identify current treatments and delivery models for co-occurring chronic pain and opioid use disorder (OUD) documented in the scientific literature. Scoping review. The review was conducted in six databases in June 2022 (no time limit): CINAHL, PsycINFO, Web of Science, Cochrane, PubMed and Embase. The PRISMA-ScR checklist was used to guide reporting. Forty-seven publications addressing the issue of co-occurring chronic pain and OUD management were included. Randomized controlled trials provide evidence for the effectiveness of opioid agonist treatments (OAT) such as methadone or buprenorphine/naloxone, as well as for combining OAT with Mindfulness-Oriented Recovery Enhancement or cognitive behavioural therapy. A number of other pharmacological treatments (opioid and nonopioid), nonpharmacological treatments (e.g. physiotherapy) and service delivery models (e.g. simultaneous treatment of comorbidities, interdisciplinary and interprofessional collaboration) are also underlined. In most cases, authors recommend a combination of strategies to meet patient needs. The scoping review reveals gaps in evidence-based knowledge to effectively care for co-occurring chronic pain and OUD, but several experts recommend the uptake of known 'best' practices such as integrated treatment of the multiple biopsychosocial dimensions of the co-occurring disorders as well as collaborative interdisciplinary work. Improving services is dependent on alleviating barriers such as working in silos, the costs associated with nonpharmacological treatments, and the double stigma associated with pain in people with a substance use disorder.