Medication-assisted Therapy Research Articles

Bridging the Gap: Can Group Interventions Assist Addiction Consult Services in Providing Integrated, Comprehensive Healthcare for Patients Hospitalized for Opioid-Related Infections?

Few healthcare systems provide integrated, comprehensive addiction treatment for patients with opioid-related infections (e.g., endocarditis) requiring long-term intravenous antibiotic treatment. Accordingly, this study outlines preliminary findings from a psychosocial intervention provided to patients hospitalized for opioid-related infections. Twenty-seven (56.5% female) patients aged 23-64 [M(SD) = 40.43(11.72)] years inducted on medication-assisted therapy by an addiction consult service participated in a weekly group intervention while hospitalized. These patients demonstrated gains in relevant knowledge from admission to discharge, 100% identified a follow-up plan at discharge, and 81.5% followed up in outpatient the next day. Immediate, 1-month, 3-month, and 6-month retention rates are presented, as well as comparisons to historical patients who did not receive the group intervention in the year prior to the study. This preliminary research outlines a group intervention that may be implemented into existing addiction consult services to improve integrated, comprehensive addiction treatment for patients with opioid-related infections.

Safety of oral naltrexone in HIV-positive men who have sex with men and transgender women with alcohol use disorder and initiating antiretroviral therapy.

HIV disproportionately affects men who have sex with men (MSM) and transgender women (TW). These populations use alcohol more heavily than the general population, and alcohol use disorders (AUDs) are more prevalent among them. Naltrexone (NTX) has documented efficacy and safety as a medication-assisted therapy for AUD. Its use has not been well-examined in persons with HIV (PWH) newly initiating antiretroviral therapy (ART) where the possibility of hepatotoxicity may be increased when initating multiple new medications. This study assessed the safety of oral NTX treatment (50 mg daily) initiated concomitantly with antiretroviral therapy (ART) in a double-blind randomized placebo-controlled trial of NTX in MSM/TW in Lima, Peru among MSM and TW with AUD (AUDIT score ≥ 8). We analyzed adverse event data from ART-naïve participants (N = 155) who were randomized (2:1) to initiate ART plus NTX (N = 103) or ART plus placebo (N = 52). Participants were monitored for 24 weeks while taking ART plus NTX/placebo, followed by 24 weeks receiving ART alone. Over 48 weeks, 135 grade 2 or 3 adverse events were reported, resulting in 1.3 clinical adverse events per participant equally represented in both treatment and placebo arms. Two serious adverse events occurred among two participants receiving NTX; neither was attributed to the study medication. No significant differences were found in the proportion of subjects reporting any adverse events between treatment arms across all time-points. These results suggest NTX is safe in MSM/TW PWH with AUD newly initiating ART, as no excess of clinical adverse events or transaminase elevation was associated with NTX use.

In Pursuit of Slowness

In Pursuit of Slowness

Non-invasive brain stimulation modalities for the treatment and prevention of opioid use disorder: a systematic review of the literature

The U.S. is currently facing an unprecedented epidemic of opioid-related deaths. Despite the efficacy of the current treatments for opioid use disorder (OUD), including psychosocial interventions and medication-assisted therapy (MAT), many patients remain treatment-resistant and at high risk for overdose. A potential augmentation strategy includes the use of non-invasive brain stimulation (NIBS) techniques, such as transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and auricular vagus nerve stimulation (aVNS). These approaches may have therapeutic benefits by directly or indirectly modulating the neurocircuitry affected in OUD. In this review, we evaluate the available studies on NIBS in the context of OUD withdrawal and detoxification, maintenance, and cravings, while also considering analgesia and safety concerns. In the context of opioid withdrawal and detoxification, a percutaneous form of aVNS has positive results in open-label trials, but has not yet been tested against sham. No randomized studies have reported on the safety and efficacy of NIBS specifically for maintenance treatment in OUD. TMS and tDCS have demonstrated effects on cravings, although published studies were limited by small sample sizes. NIBS may play a role in reducing exposure to opioids and the risk of developing OUD, as demonstrated by studies using tDCS in an experimental pain condition and TMS in a post-operative setting. Overall, while the preliminary evidence and safety for NIBS in the prevention and treatment of OUD appears promising, further research is needed with larger sample sizes, placebo control, and objective biomarkers as outcome measures before strong conclusions can be drawn.

Changes in the elimination and resurgence of alcohol-maintained behavior in rats and the effects of naltrexone.

Resurgence may be a mechanism of relapse in alcohol use disorder patients upon discharge from treatment as part of an abuse-treatment-relapse cycle. Adjunctive pharmacotherapies may be a means to facilitate behavioral treatments and block resurgence. Experiments were conducted using a model of alcohol self-administration to assess the repeatability of the elimination and resurgence of alcohol-maintained behavior and the effects of naltrexone. Experiments had three phases. In Phase 1, behavior was maintained by oral alcohol under a fixed-ratio schedule. In Phase 2, behavior was extinguished via condensed milk delivery under a differential-reinforcement-of-other-behavior (DRO) schedule. In Phase 3, the DRO schedule was eliminated. In Experiment 1, this 3-phase cycle was replicated 4 times. Across replications, response rates and dose of alcohol consumed did not differ in Phase 1, alcohol-maintained behavior was eliminated more rapidly in Phase 2, and the resurgence effect was generally stable in Phase 3. In Experiment 2, naltrexone was administered in Phase 2, Phase 3, or both Phases 2 and 3, to separate groups of rats. Naltrexone facilitated the elimination of alcohol-maintained behavior in Phase 2 and, the resurgence of alcohol-maintained behavior was reduced only for those rats that received naltrexone in both phases. Together, these experiments demonstrate that the resurgence of alcohol-maintained behavior is replicable within-subjects and, further, resurgence of alcohol-maintained behavior may be a useful model to evaluate pharmacological interventions to facilitate behavioral treatments and reduce the likelihood of relapse. Results with naltrexone support the use of medication-assisted therapy approaches to reduce relapse risk in patients. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Racial/Ethnic and Gender Differences in Associations of Medication-Assisted Therapy and Reduced Opioid Use between Outpatient Treatment Admission and Discharge

ABSTRACT Medication-assisted therapy (MAT) for opioid use disorders is an effective treatment strategy. Racial/ethnic and gender disparities in MAT utilization have been documented, but less is known about disparities in MAT outcomes. We used the Treatment Episodes Dataset–Discharges (TEDS-D; 2015– 2017) to identify outpatient treatment episodes with heroin or illicit opioids indicated at admission (n = 232,547). We used multivariate logistic regression to model the association between MAT and a reduction in opioid use between treatment admission and discharge. We explored moderation by race/ethnicity and gender by including an interaction term. We identified a strong moderating effect of race/ethnicity and gender. American Indian/Alaska Native (AI/AN) women demonstrated the strongest association between MAT (versus no MAT) and a reduction in opioid use (aOR = 6.05, 95% CI = 4.81– 7.61), while White men demonstrated the weakest association (aOR = 2.78, CI = 2.70– 2.87). Our findings could inform changes in clinical MAT settings that are based on harm reduction and the incremental transition from illicit opioids to medication-assistance among a diverse opioid use disorder population.

Peripartum pain management of women on medication-assisted therapy: A systematic review

Rates of opioid prescribing are at historically high levels, and, as opioid exposure increases, the number of women of childbearing age with opioid use disorder is rising. Despite this growing population, the optimal management of pain for parturients maintained on medical-assisted therapy (MAT, i.e., methadone or buprenorphine) is unknown. This systematic review is intended to evaluate patient outcomes associated with pain management strategies for parturients on MAT. Literature databases EMBASE, MEDLINE, and the Cochrane Library were searched up to September 2017. Articles were included if they discussed peripartum analgesic options for pregnant women with opioid dependence. The search identified 1,814 articles, of which, nine matched all inclusion criteria and were selected for data extraction and analysis. Articles were a mix of case series, retrospective case reviews, retrospective cohorts, and randomized controlled trials. They showed various responses ranging from no difference in analgesic requirements between MAT and non-MAT patients to MAT patients requiring higher amounts of opioids after a cesarean section. Parturients on MAT present a number of challenges for obstetric anesthesiologists, but various approaches can be used to achieve satisfactory analgesia. It is important to practice an individualized yet multidisciplinary approach to ensure the delivery of optimal patient care.

Changes in fentanyl demand following naltrexone, morphine, and buprenorphine in male rats

BackgroundIndividuals with opioid use disorder (OUD) exhibit high levels of economic demand for opioids, with high levels of consumption and relative insensitivity to changes in price. Because the medications used to treat OUD in medication-assisted therapy (MAT) act as antagonists or agonists at μ opioid receptors, they may alter the relationship between price and opioid intake. MethodsThis study examined demand for a commonly abused synthetic prescription opioid, fentanyl, in male rats following s.c. pre-treatment with naltrexone (0.1–1.0 mg/kg), morphine (0.3–3.0 mg/kg) or buprenorphine (0.3–3.0 mg/kg). We normalized demand curves to intake at the lowest price and estimated effects on elasticity (sensitivity to changes in price). Rats were first trained to earn fentanyl (5 μg/kg/infusion) on a fixed ratio schedule, then they underwent daily training under a threshold procedure designed to produce within-session demand curve estimates. Rats received 14 threshold sessions before undergoing a series of tests encompassing each drug, at each dose. ResultsElasticity was increased by pretreatment with naltrexone, morphine or buprenorphine. Morphine also decreased initial intake, when the price for fentanyl was lowest. In contrast, initial intake was increased by naltrexone (according to an inverted-U shaped curve). The effects of naltrexone did not persist after the test session, but morphine and buprenorphine continued affecting demand elasticity 24 h or 48 h after the test, respectively. ConclusionsThese results indicate that fentanyl demand is sensitive to blockade or activation of opioid receptors by the drug classes used for MAT in humans.

Acute Pain Management for Patients Receiving Medication-Assisted Therapy.

Evidence-based approaches for the treatment of opioid use disorder include the use of opioid medications (methadone, buprenorphine, or naltrexone), collectively referred to as medication-assisted therapy. Patients receiving medication-assisted therapy may present in the acute care setting with pain, often related to planned surgical procedures to treat health issues that were not addressed before entering treatment. Because these medications act on the same receptors as do analgesic opioids-and, in the cases of methadone and buprenorphine, have analgesic properties - managing acute pain in these patients can be challenging. Principles of effective pain management for these patients include continuing the usual medication-assisted therapy dose; using nonpharmacological and nonopioid pain management strategies as possible and immediate-release opioids, titrating to effect and monitoring for toxicity; anticipating tolerance and hyperalgesia; and establishing a collaborative treatment relationship with the medication-assisted therapy provider. Providing effective pain treatment supports ongoing recovery in patients with opioid use disorder.

Advancing the implementation and sustainment of medication assisted treatment for opioid use disorders in prisons and jails

BackgroundOpioid use disorder (OUD) is among the most prevalent medical condition experienced by incarcerated persons, yet medication assisted therapy (MAT) is uncommon. Four jail and prison systems partnered with researchers to document their adoption of MAT for incarcerated individuals with opioid use disorders (OUD) using their established treatment protocols. Employing the EPIS (Exploration, Planning, Implementation, and Sustainment) framework, programs report on systematic efforts to expand screening, treatment and provide linkage to community-based care upon release.ResultsAll four systems were engaged with implementation of MAT at the outset of the study. Thus, findings focus more on uptake and penetration as part of implementation and sustainment of medication treatment. The prevalence of OUD during any given month ranged from 28 to 65% of the population in the participating facilities. All programs developed consistent approaches to screen individuals at intake and provided care coordination with community treatment providers at the time of release. The proportion of individuals with OUD who received MAT ranged considerably from 9 to 61%. Despite efforts at all four sites to increase utilization of MAT, only one site achieved sustained growth in the proportion of individuals treated over the course of the project. Government leadership, dedicated funding and collaboration with community treatment providers were deemed essential to adoption of MAT during implementation phases. Facilitators for MAT included increases in staffing and staff training; group education on medication assisted therapies; use of data to drive change processes; coordination with other elements of the criminal justice system to expand care; and ongoing contact with individuals post-release to encourage continued treatment. Barriers included lack of funding and space and institutional design; challenges in changing the cultural perception of all approved treatments; excluding or discontinuing treatment based on patient factors, movement or transfer of individuals; and inability to sustain care coordination at the time of release.ConclusionsAdoption of evidence-based medication assisted therapies for OUD in prisons and jails can be accomplished but requires persistent effort to identify and overcome challenges and dedicated funding to sustain programs.

Obstetrician-gynecologists' practice patterns related to opioid use during pregnancy and postpartum-United States, 2017.

Objective:To describe obstetrician-gynecologists’ practices and attitudes related to opioid use among pregnant and postpartum women.Study Design:A 2017 cross-sectional survey assessed U.S. obstetrician-gynecologists’ (n=462; response rate=34%) practices (management) and attitudes (knowledge, preparedness, confidence, barriers, and resources needed) related to opioid use among pregnant and postpartum women. Modified Poisson regression determined adjusted prevalence ratios (aPR) for advising medication assisted therapy (MAT) for pregnant women with opioid use disorder (OUD) by knowledge, confidence, and preparedness.Results:Of respondents, 33% usually or always advised MAT to pregnant women with OUD. Confidence in treating pregnant women who use opioids (aPR: 1.3, 95% CI: 1.0-1.8) and knowledge that substance use services were covered under the Affordable Care Act (aPR: 1.4, 95% CI: 1.1-1.8) were associated with advising MAT.Conclusion:Evidence suggests that efforts are needed to enhance physician confidence to manage pregnant and postpartum patients who use opioids, which may increase optimal care of this patient population.

Cost-effectiveness of Direct Antiviral Agents for Hepatitis C Virus Infection and a Combined Intervention of Syringe Access and Medication-assisted Therapy for Opioid Use Disorders in an Injection Drug Use Population.

There are too many plausible permutations and scale-up scenarios of combination hepatitis C virus (HCV) interventions for exhaustive testing in experimental trials. Therefore, we used a computer simulation to project the health and economic impacts of alternative combination intervention scenarios for people who inject drugs (PWID), focusing on direct antiviral agents (DAA) and medication-assisted treatment combined with syringe access programs (MAT+). We performed an allocative efficiency study, using a mathematical model to simulate the progression of HCV in PWID and its related consequences. We combined 2 previously validated simulations to estimate the cost-effectiveness of intervention strategies that included a range of coverage levels. Analyses were performed from a health-sector and societal perspective, with a 15-year time horizon and a discount rate of 3%. From a health-sector perspective (excluding criminal justice system-related costs), 4 potential strategies fell on the cost-efficiency frontier. At 20% coverage, DAAs had an incremental cost-effectiveness ratio (ICER) of $27 251/quality-adjusted life-year (QALY). Combinations of DAA at 20% with MAT+ at 20%, 40%, and 80% coverage had ICERs of $165 985/QALY, $325 860/QALY, and $399 189/QALY, respectively. When analyzed from a societal perspective (including criminal justice system-related costs), DAA at 20% with MAT+ at 80% was the most effective intervention and was cost saving. While DAA at 20% with MAT+ at 80% was more expensive (eg, less cost saving) than MAT+ at 80% alone without DAA, it offered a favorable value compared to MAT+ at 80% alone ($23 932/QALY). When considering health-sector costs alone, DAA alone was the most cost-effective intervention. However, with criminal justice system-related costs, DAA and MAT+ implemented together became the most cost-effective intervention.

Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program

BackgroundEmergency departments are struggling to manage the increasing number of patients seen for opioid use disorders and opioid overdose. With opioid overdose deaths rising at alarming rates, emergency physicians are beginning to induce patients with long-acting opioids such as buprenorphine and referring patients to outpatient medication-assisted treatment facilities. The objective of this study was to describe a pragmatic approach to buprenorphine induction, referral to treatment, and assess follow-up rates. MethodsSingle center, retrospective analysis of emergency department patients undergoing buprenorphine induction and referral to outpatient medication-assisted treatment. Patients were identified by an ongoing log of induced patients, between May 2017 and October 2018. The data is analyzed using descriptive statistics, with means and associated standard deviations, medians and interquartile ranges for continuous variables, and frequencies as percentages for categorical data. ResultsOverall, 219 patients were seen and induced with buprenorphine in the emergency department. Mean age was 35 years old (SD 10.3) and 56% were male. Intravenous opioids were most commonly abused at 75%. Our primary outcome of interest was the percentage of patients enrolled in MAT at 30 days, which occurred in 49.3% of our population. Patients were in moderate withdrawal based on initial COWS scores of 13.1(SD 5.8), and received mean total doses of 7.7 mg (SD 3.3). Median ED length of stay decreased by 40% between May 2017 and October 2018. ConclusionEmergency department initiated buprenorphine induction using a structured pragmatic approach is effective at maintaining patients in medication-assisted therapy.

Tools for Community-Based Pharmacist Patient Care Services to Support Optimal Opioid Use

Tools for Community-Based Pharmacist Patient Care Services to Support Optimal Opioid Use

5B When Addiction Hurts: Managing Acute Pain in Patients Receiving Medication Assisted Therapy (MAT)

5B When Addiction Hurts: Managing Acute Pain in Patients Receiving Medication Assisted Therapy (MAT)

Age-Related Differences in Past or Present Hepatitis C Virus Infection Among People Who Inject Drugs: National Human Immunodeficiency Virus Behavioral Surveillance, 8 US Cities, 2015.

Historically, older people who inject drugs (PWID) have had the highest hepatitis C virus (HCV) burden; however, young PWID now account for recent increases. We assessed factors associated with past or present HCV infection (HCV antibody [anti-HCV] positive) among young (≤35 years) and older (>35 years) PWID. We calculated adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to examine sociodemographic and past 12-month injection behaviors associated with HCV infection. Of 4094 PWID, 55.2% were anti-HCV positive. Among young PWID, anti-HCV prevalence was 42.1% and associated with ≤high school diploma/General Education Development diploma (GED) (aPR, 1.17 [95% CI, 1.03-1.33]), receptive syringe sharing (aPR, 1.37 [95% CI, 1.21-1.56]), sharing injection equipment (aPR, 1.16 [95% CI, 1.01-1.35]), arrest history (aPR, 1.14 [95% CI, 1.02-1.29]), and injecting speedball (aPR, 1.37 [95% CI, 1.16-1.61]). Among older PWID, anti-HCV prevalence was 62.2% and associated with ≤high school diploma/GED (aPR, 1.08 [95% CI, 1.02-1.15]), sharing injection equipment (aPR, 1.08 [95% CI, 1.02-1.15]), high injection frequency (aPR, 1.16 [95% CI, 1.01-1.34]), and injecting speedball (aPR, 1.09 [95% CI, 1.01-1.16]). Anti-HCV prevalence is high among PWID and varies with age. Scaling up direct-acting antiviral treatment, syringe service programs, and medication-assisted therapy is critical to mitigating transmission risk and infection burden.

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

(372) Suboxone Therapy for Cancer Survivors with Opioid Use Disorder: A Case Report

Research has identified cancer survivors as a growing demographic of patients with opioid use disorder. Providers of this group may continue opioid medications despite remission of cancer, as clinical findings may be complicated by difficulty identifying a clear pain generator. We present a 57-year-old man with history of retroperitoneal liposarcoma that presented to the emergency department at a Veterans Affairs Hospital fifteen times between March 2017 and October 2018 with abdominal pain, nausea, and vomiting. He had been in remission since 2016 after treatment with chemotherapy and radiation. Of the multiple hospital visits, he was admitted five times and seen by multiple specialists, including gastroenterology, hematology-oncology, palliative care, and pain management. Because of the severity of pain and recent cancer remission, he underwent multiple comprehensive evaluations, including multiple CT scans, esophagogastroduodenoscopy, and PET scan. No evidence of recurrence was found. The patient was provided intravenous opioid therapy with relief at each encounter. After review of his clinical course, Pain providers identified he was consistently presenting prior to the anticipated renewal date of his opioids. The patient's symptoms were felt to be consistent with opioid withdrawal. Given the severity of symptoms and lack of indication for continuing opioids, the patient was determined to be a candidate for medication assisted therapy. He was subsequently tapered off opioids and started on buprenorphine 4 mg BID. He was titrated to 8 mg TID by addiction psychiatry with significant improvement in abdominal pain, sleep, and appetite. Since starting MAT, the patient hasn't presented to the ED for care. This case report highlights the need for vigilance against the development of OUD in cancer survivors. It also demonstrates the healthcare costs and concerns of continuing opioid therapy without indication. Identifying opioid use disorder and utilizing MAT may be crucial to treating OUD in this population.

Development of a School-Based Substance Treatment Model

The objective of this study was to develop a school-based substance treatment model and evaluate the feasibility and preliminary outcomes of treatment in a school-based setting to improve access to treatment for adolescents with substance use disorders. This study provided care to 41 youths (12 to 18 years old) in three school-based health clinics. The intervention consisted of 12 weeks of individual motivational interviewing, acceptance and commitment therapy, contingency management with urine drug screens, medication-assisted therapy, family sessions, and case management. Feasibility outcomes included the number of sessions attended, the Session Rating Scale, and qualitative feedback from patients (N = 41), therapists (N = 3), and a school principal. Preliminary treatment outcomes included the Timeline Followback Interview, a modified Outcome Rating Scale, and a questionnaire of school engagement. The average number of sessions completed was 7.4 (SD = 3.6), and the average Session Rating Scale score was 38.2 (0 = minimum alliance, 40 = maximum alliance). Qualitative interviews provided feedback to adapt the treatment model further. Youths reported significant pre-post improvements in emotional wellness, school engagement, and substance use. This study produced a school-based substance treatment model that is well-received by patients, demonstrated feasibility, showed positive preliminary outcomes, and is ready for further clinical testing.

In With the New: Managing Acute Malignant Pain in Patients on Opioid Replacement Therapy with Buprenorphine (SA521)

•Compare and contrast the pharmacology of pure and partial opioid agonists.•Describe an approach to treating acute pain in hospice patients receiving buprenorphine and naloxone therapy.•Establish the role of buprenorphine in hospice and palliative care clinical practice. After Dole and Nyswander introduced the role of methadone in drug rehabilitation in 1965, methadone became the standard for medication assisted therapy of opioid use disorders. Similarly, hospice and palliative care professionals have recognized the role of methadone in treating cancer-related pain. Since its release in the early 2000s, buprenorphine has become the preferred medication assisted treatment option given its ability to be prescribed in a less restrictive setting, the relative ease of dosing, and reduction in stigma. Given the popularity of buprenorphine for medication assisted treatment, hospice and palliative care practitioners must be prepared to manage patients on buprenorphine who require pain management for serious illness. We will present the case of a young hospice patient with terminal cancer whose pain was being managed with combination buprenorphine and naloxone therapy for opioid use disorder. We will describe the pharmacology of buprenorphine, how it is used in medication assisted treatment and how to transition patients on buprenorphine to a more traditional opioid agonist for acute pain management. Finally, we will discuss the possible role of buprenorphine for management of pain in the setting of an opioid use disorder.