Severe Opioid Use Research Articles

Stigma associated with medication treatment for young adults with opioid use disorder: a case series

BackgroundOpioid-related overdose deaths have risen sharply among young adults. Despite this increase, access to evidence-based medication for opioid agonist treatment (OAT) for youth remains low. Among older adults, barriers to OAT include the paucity of buprenorphine-waivered prescribers and low rates of prescribing among waivered physicians. We have increasingly found in our clinical practice significant stigma related to using OAT to treat addiction for young adults. In this series, we describe three cases of young adults who faced significant stigma related to their treatment.Case presentationsThe first case is a young male with a history of significant trauma and a severe opioid use disorder. He started buprenorphine and has found a job, stayed abstinent, and began a healthy relationship. At each step in his recovery, he has faced resistance to taking medication from other treatment providers, directors of sober houses, and his parents. The second case is a young woman who presented to a substance use treatment program after a relapse. She was unable to restart buprenorphine despite our calling to ask that it be restarted. Ultimately, she left against medical advice and was stabilized as an outpatient on buprenorphine. The final case is a young woman who stopped buprenorphine after being told she was “not sober” while attending 12-step group but restarted after conversations with her clinical team. In each case, the patient has continued their medication treatment and are stable.ConclusionsOpioid-related deaths continue to rise among all age groups, including young adults. Stigma related to medication treatment can be a substantial barrier for many young adult patients but there are concrete steps that providers and communities can take to address this stigma.

Cost-effectiveness of hydromorphone for severe opioid use disorder: findings from the SALOME randomized clinical trial.

Previous research has found diacetylmorphine, delivered under supervision, to be cost-effective in the treatment of severe opioid use disorder, but diacetylmorphine is not available in many settings. The Study to Assess Long-term Opioid Maintenance Effectiveness (SALOME) randomized controlled trial provided evidence that injectable hydromorphone is non-inferior to diacetylmorphine. The current study aimed to compare the cost-effectiveness of hydromorphone directly with diacetylmorphine and indirectly with methadone maintenance treatment. A within-trial analysis was conducted using the patient level data from the 6-month, double-blind, non-inferiority SALOME trial. A life-time analysis extrapolated costs and outcomes using a decision analytical cohort model. The model incorporated data from a previous trial to include an indirect comparison to methadone maintenance. A supervised clinic in Vancouver, British Columbia, Canada. A total of 202 long-term street opioid injectors who had at least two attempts at treatment, including one with methadone (or other substitution), were randomized to hydromorphone (n=100) or diacetylmorphine (n=102). We measured the utilization of drugs, visits to health professionals, hospitalizations, criminal activity, mortality and quality of life. This enabled us to estimate incremental costs, quality-adjusted life years (QALYs) and cost-effectiveness ratios from a societal perspective. Sensitivity analyses considered different sources of evidence, assumptions and perspectives. The within-trial analysis found hydromorphone provided similar QALYs to diacetylmorphine [0.377, 95% confidence interval (CI)=0.361-0.393 versus 0.375, 95% CI=0.357-0.391], but accumulated marginally greater costs [$49 830 ($28 401-73 637) versus $34 320 ($21 780-55 998)]. The life-time analysis suggested that both diacetylmorphine and hydromorphone provide more benefits than methadone [8.4 (7.4-9.5) and 8.3 (7.2-9.5) versus 7.4 (6.5-8.3) QALYs] at lower cost [$1.01million ($0.6-1.59million) and $1.02million ($0.72-1.51million) versus $1.15million ($0.71-1.84million)]. In patients with severe opioid use disorder enrolled into the SALOME trial, injectable hydromorphone provided similar outcomes to injectable diacetylmorphine. Modelling outcomes during a patient's life-time suggested that injectable hydromorphone might provide greater benefit than methadone alone and may be cost-saving, with drug costs being offset by costs saved from reduced involvement in criminal activity.

Medicaid problem: Youth with severe opioid use disorder not treated appropriately

More than one out of four adults addicted to heroin in publicly funded treatment get medication‐assisted treatment (MAT), while fewer than three out of 100 adolescents and young adults get MAT, researchers have found. Recently, the American Academy of Pediatrics recommended that MAT be provided to young people.

Men\u2019s and women\u2019s response to treatment and perceptions of outcomes in a randomized controlled trial of injectable opioid assisted treatment for severe opioid use disorder

BackgroundTo test whether there are gender differences in treatment outcomes among patients receiving injectable opioids for the treatment of long-term opioid-dependence. The study additionally explores whether men and women have different perceptions of treatment effectiveness.MethodsThis study is a secondary analysis from SALOME, a double-blind, phase III, randomized controlled trial testing the non-inferiorirty of injectable hydromorphone to injectable diacetylmorphine among 202 long-term street opioid injectors in Vancouver (Canada). Given this was a secondary analysis, no a priori power calaculation was conducted. Differences in baseline characteristics and six-month treatment outcomes (illicit heroin use, opioid use, crack cocaine use, non-legal activities, physical and psychological health scores, urine positive for street heroin markers, and retention) were analysed by gender using fitted models. Responses to an open ended question on reasons for treatment effectiveness were explored with a thematic analysis.ResultsMen and women differed significantly on a number of characteristics at baseline. For example, women were significantly younger, presented to treatment with significantly higher rates of prior month sex work (31.5% vs. 0%), and used significantly more crack cocaine (14.71 vs. 8.38 days). After six-months of treatment there were no significant differences in treatment outcomes by gender, after adjusting for baseline values. For both men and women, improved health and quality of life were the most common reasons provided for treatment effectiveness, however women were more specific in the types of health improvements.ConclusionsDespite presenting to treatment with vulnerabilities not faced to the same extent by men, at six-months women did not differ significantly from men in tested trial efficacy outcomes. While the primary outcome in the trial was the reduction of illicit opioid use, in the open-ended responses both men and women focused their comments on improvement in health and quality of life as reasons for treatment effectiveness. The supervised model of care with injectable medications provides a particularly suitable framework for providing care to opioid-dependent men and women not attracted or retained by other treatments. The absence of statistical differences reported in this secondary analysis may be due to lack of adequate statistical power to detect meaningful effects.Trial registrationThis trial is registered with ClinicalTrials.gov (NCT01447212) Registered: October 4, 2011 at the following link: https://clinicaltrials.gov/ct2/show/NCT01447212.

Safety profile of injectable hydromorphone and diacetylmorphine for long-term severe opioid use disorder

AimsTo review the safety profile of injectable hydromorphone and diacetylmorphine and explore if adverse events (AEs) or serious adverse events (SAEs) were associated with dose and patterns of attendance. MethodsThis was a non-inferiority randomized double-blind controlled trial (Vancouver, Canada) testing hydromorphone (n=100) and diacetylmorphine (n=102) for the treatment of severe opioid use disorder. Medications were delivered under the supervision of trained Registered Nurses up to three times daily. AEs were described using MedDRA codes. ResultsMost common related AEs included immediate post-injection reaction or injection site pruritus reactions, somnolence and opioid overdoses. Adjusted analysis indicated that participants in the hydromorphone group were less likely to have any related AE or SAE compared to the diacetylmorphine group. Related somnolence and opioid overdose events were distributed throughout the six months treatment period. In the diacetylmorphine group, five of the eleven related SAE opioid overdoses (requiring naloxone) occurred in the first 30days since most recent treatment initiation. Analysis of somnolence and opioid overdose (AEs and SAEs) event rates by received dose suggested a non-linear relationship. However, in the diacetylmorphine group higher event rates per person days were recorded at lower doses. ConclusionsWhen injectable hydromorphone and diacetylmorphine are individually dosed and monitored, their opioid-related side effects, including potential fatal overdoses, are safely mitigated and treated by health care providers. In the midst of an opioid overdose epidemic, injectable options are timely to reach a very important minority of people who inject street opioids and are not attracted to other treatments.

Medication-Assisted Treatment for Adolescents in Specialty Treatment for Opioid Use Disorder

PurposeThe American Academy of Pediatrics recently recommended that pediatricians consider medication-assisted treatment (MAT) for adolescents with severe opioid use disorders. Little is known about adolescents' current use of MAT. MethodsWe use data on episodes of specialty treatment for heroin or opioid use (n = 139,092) from a database of publicly funded treatment programs in the U.S. We compare the proportions of adolescents and adults who received MAT, first using unadjusted comparison of proportions, then using logistic regression to adjust for potential confounders. ResultsOnly 2.4% (95% confidence interval [CI], 1.4%–3.7%) of adolescents in treatment for heroin received MAT, as compared to 26.3% (95% CI, 26.0%–26.6%) of adults. Only .4% (95% CI, .2%–.7%) of adolescents in treatment for prescription opioids received MAT, as compared to 12.0% (95% CI, 11.7%–12.2%) of adults. Regression-adjusted results were qualitatively similar. ConclusionsRegulatory changes and expansions of Medicaid/CHIP coverage for MAT may be needed to improve MAT access.

Predictors of treatment allocation guesses in a randomized controlled trial testing double-blind injectable hydromorphone and diacetylmorphine for severe opioid use disorder

Background: SALOME (Study to Assess Longer-term Opioid Medication Effectiveness) tested in a double-blind non-inferiority clinical trial if hydromorphone could be as effective as diacetylmorphine for severe opioid use disorder. Although participants did not guess treatment correctly beyond what is expected by chance, perceived treatment assignment could affect patients’ response to treatment. This study tested if treatment allocation guess is associated with treatment outcomes and identified predictors of guess.Methods: Data were obtained through questionnaires and clinical records. Participants were asked what medication they thought they were receiving (diacetylmorphine, hydromorphone or unsure) and their open-ended reasons. Multinomial logistic regression was used to assess the predictors of treatment guess. An inductive thematic analysis was used to code open-ended responses. This clinical trial was registered with U.S. National Institutes of Health (https://clinicaltrials.gov/ct2/show/NCT01447212).Findings: Participants referred to prior experiences with opioids and the presence or absence of specific drug effects as reasons for their guesses. There were no differences in illicit opioid use and retention by guess; however those who guessed diacetylmorphine had better physical and mental health scores. Participants with a treatment-related observed drowsiness event, and higher perceived drug-related high scores were more likely to guess diacetylmorphine compared to hydromorphone. Guessing hydromorphone was more likely among those who made negative comments as reasons for treatment guesses.Conclusions: Understanding the clues participants use for treatment allocation guesses and relating them to treatment expectations could be integrated with accurate information about the treatment, providing an opportunity for patient–physician shared decision-making in opioid maintenance treatment.Clinical trial registration: U.S. National Institutes of Health; ClinicalTrials.gov Identifier: NCT01447212; https://clinicaltrials.gov/ct2/show/NCT01447212

Hydromorphone Compared With Diacetylmorphine for Long-term Opioid Dependence

Diacetylmorphine hydrochloride (the active ingredient in heroin), delivered under supervision, is effective for the treatment of severe opioid use disorder. However, owing to political and regulatory barriers, it is not available in many settings around the world, which limits the options for many long-term street opioid injectors not attracted into or retained in available treatments. To test if injectable hydromorphone hydrochloride is noninferior to injectable diacetylmorphine in reducing illicit heroin use for chronic injection opioid users after 6 months of intervention. The Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) was a phase 3, double-blind, noninferiority trial. The study randomized 202 long-term street opioid injectors in Vancouver, British Columbia, Canada. Eligible participants were recruited between December 19, 2011, and December 18, 2013. Both intent-to-treat (ITT) and per-protocol (PP) analyses were conducted. Participants were randomly assigned to receive injectable diacetylmorphine or hydromorphone (up to 3 times daily) for 6 months under supervision. Primary and coprimary efficacy outcomes were self-reported days of street heroin use (primary), days of any street-acquired opioids in the prior 30 days (noninferiority margin, 4 days), and the proportion of urinalyses positive for street heroin markers (margin, 10% of the observed rate in the diacetylmorphine group). The mean differences between diacetylmorphine and hydromorphone for the ITT and PP analyses were reported. The study included 202 participants; 100 randomized to receive hydromorphone and 102 to diacetylmorphine. Their mean (SD) age was 44.33 (9.63) years, and 30.7% (62 of 202) were women. Noninferiority of hydromorphone was confirmed in the PP analysis (-1.44; 90% CI, -3.22 to 0.27) for street heroin use, although the margin of 4 days was not excluded in the ITT analysis (-2.34; 90% CI, -4.14 to -0.52). Noninferiority was confirmed for any street opioids in the ITT analysis (-0.85; 90% CI, -2.97 to 1.25) and the PP analysis (-0.15; 90% CI, -2.09 to 1.76), as well as for the urinalyses (0.09; 90% CI, -0.02 to 0.19 for the ITT analysis and 0.13; 90% CI, 0.02-0.24 for the PP analysis). There were 29 SAEs considered to have some relationship with the injection medication, 5 in the hydromorphone group and 24 in the diacetylmorphine group (rate ratio, 0.21; 95% CI, 0.06-0.69). Seizures and overdoses accounted for 25 of the 29 related SAEs. This study provides evidence to suggest noninferiority of injectable hydromorphone relative to diacetylmorphine for long-term opioid dependence. In jurisdictions where diacetylmorphine is currently not available or for patients in whom it is contraindicated or unsuccessful, hydromorphone could be offered as an alternative. clinicaltrials.gov Identifier: NCT01447212.

Long-Term Suboxone Maintenance Therapy for Opioid Use Disorder: 2 Case Reports

The medical profession is divided in its approach to treating patients with addiction issues, particularly in regards to the treatment of opioid use disorder with Suboxone (buprenorphine/naloxone). Here we present two cases of patients who have achieved over 11 years of sobriety with long-term Suboxone maintenance therapy. Their stories help to demonstrate that Suboxone is a viable long-term treatment option for severe opioid addiction. While life-long Suboxone use can lead to physical dependence on the drug, this is far from simply replacing one addiction with another. Some providers may feel that physical dependence on a medication does not represent appropriate or adequate treatment of opioid use disorder; however, when compared with the grave potential consequences of severe opioid use disorder, the potential benefits of achieving sobriety with Suboxone maintenance far outweigh the risks.

Patients With Chronic Pain Need Better Psychiatric Care

Patients With Chronic Pain Need Better Psychiatric Care

How do gender and race/ethnicity influence perceived barriers to help-seeking for substance use problems?

demand for medical certification (% participation) vs. yearly certification cost ($10–150), # physicians visited to get certified (1–15), and delay until getting card (0.5–26 wk). All results reported are significant (p 270 times) vs. moderate (90–270) or infrequent ( 50 yr (L= .55, .36, .29 oz/day). Certified patients have the lowest MJ demand intensity. Patients with slight or moderate pain severity have higher MJ demand intensity than patients with no pain or severe pain. Certification demand is higher for patients with severe pain (UP= card cost, delay until certification), opioid use (UP= card cost, #physicians), and frequentMJ use (UP=#physicians).MJ diversion ismost likely amongpatientswho report cocaineuse. Psychiatric andother medical factors are not related toMJ use, certification, or diversion. Conclusions: MJ use is price-elastic and modulated by MJ-use frequency, age and pain. Certified patients exhibit lower demand. Patients with severe pain, opioid use and frequent MJ use exhibit higher certification demand. MJ diversion potential is related to cocaine use. This knowledge may inform clinical and policy decisions. Financial support: NIH R01DA032678, Joe Young Sr./Helene Lycaki Funds (State of Michigan), Detroit Wayne Mental Health Authority.

OR15-3 * 50 SHADES OF GRAY: ETHICAL CHOICES IN ADDICTION MEDICINE

Objectives. Recognize the roles of addiction medicine professionals regarding supply reduction. Handle patients with prescriptions that seems dubious or fraudulent. Feel comfortable navigating a patient dynamic when the patient is lying. The oral presentation will be focused around a challenging clinical vignette that presents a variety of potential choices, each with specific ethical consequences for the patient and physician. After discussing the vignette, there will be a structured discussion among presentation attendees. The moderator, Dr. Brennan, will use a common discussion technique in ethical discourse called anchoring, whereby the discussion is begun from a rigid viewpoint, and through discourse a consensus is gradually reached. The vignette discussed will be an adult male with a history of severe opioid use disorder who presented to an ER in New York City requesting admission for opioid detoxification and rehabilitation. The patient was very well known to the physician, having completed a 4 week inpatient stay for opioid use disorder several weeks prior to seeking readmission. In the interval weeks since discharge the patient had relapsed on opioids by finding several physicians in New York City to write him prescriptions for his drug of choice. Upon readmission to the inpatient unit his belongings were searched and recorded, and one of his prescriptions for opioids was mistakenly placed in his chart, rather than in his locker with the rest of his supplies. The physician happened to find this prescription and suspects that it was written at a pill mill, or perhaps written by a physician who didn't know that the patient had an addiction to opioids. Should the prescription, which represented the very crux of this patient's problem, be returned to the patient since it is their legal property? Or should the physician throw it away? What role should addiction medicine physicians have in patrolling other physicians with dubious prescribing habits?

Characterizing the Emerging Population of Prescription Opioid Abusers

Despite an alarming recent increase in prescription opioid abuse, the characteristics of prescription opioid abusers remain largely unknown. In this study, the demographic and drug use characteristics of 75 methadone patients (36 prescription opioid and 39 heroin users) were compared using a retrospective chart review. Prescription opioid abusers exhibited a profile of characteristics that may predict favorable treatment response, including less severe opioid use and IV drug use, and greater social stability compared to primary heroin abusers. Despite the limitations inherent in this retrospective chart review, this study provides initial evidence that prescription opioid abusers may have a number of characteristics that predict favorable treatment response. This new information may inform and assist current efforts to develop efficacious treatments for prescription opioid abuse.

Further Clinical Observations on the Treatment of Pertussis with Gold Tribromide

Heroin-assisted treatment comprises the use of diacetylmorphine (pharmaceutical heroin) for individuals with severe opioid use disorder. In Switzerland, take-home doses in heroin-assisted treatment are more strictly regulated as compared to conventional opioid agonist treatment. In light of the COVID-19 pandemic, the Swiss Federal Council provisionally adapted its policy, allowing for longer prescriptions of take-home diacetylmorphine. Before the beginning of the pandemic, take-home doses only occurred in exceptional circumstances and under strict criteria for patient eligibility. Following the legislative adaptations, we critically revised our internal centre policies as well. We report our experiences with oral take-home diacetylmorphine from a Swiss outpatient university centre specialising in heroin-assisted treatment. An additional 45 patients received take-home doses following the first lockdown. While some patients wished to return to their previous treatment regimen, most patients managed their medication well and showed good adherence. We also noticed an increase of treatment admissions that are likely related to the relaxed regulations. Previously, the strict therapeutic framework of visiting a HAT centre twice a day for supervised dispensing seemed to have discouraged these individuals from seeking medical treatment. From a medical point of view, the politically driven restrictions on take-home doses in heroin-assisted treatment are questionable and do not support the goal of harm reduction.