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Opioid Abuse [keywords]
- Buprenorphine in treatment of opioid addiction: opportunities, challenges and strategies. [JOURNAL ARTICLE]
- Expert Opin Pharmacother 2014 Aug 29.:1-13.
Introduction: Buprenorphine follows the success of methadone as another milestone in the history of treatment for opioid addiction. Buprenorphine can be used in an office-based setting where it is clearly effective, highly accepted by patients and has a favorable safety profile and less abuse potential. However, the adoption of buprenorphine treatment has been slow in the USA. Areas covered: This article first reviews the history of medication-assisted opioid addiction treatment and the current epidemic opioid addiction, followed by a review of the efficacy, pharmacology and clinical prescription of buprenorphine in office-based care. We then explore the possible barriers in using buprenorphine and the ways to overcome these barriers, including new formulations, educational programs and policy regulations that strike a balance between accessibility and reducing diversion. Expert opinion: Buprenorphine can align addiction treatment with treatments for other chronic medical illnesses. However, preventing diversion will require graduate and continuing medical education and integrated care models for delivery of buprenorphine to those in need.
- Impulsivity and opioid drugs: differential effects of heroin, methadone and prescribed analgesic medication. [JOURNAL ARTICLE]
- Psychol Med 2014 Aug 29.:1-13.
Previous studies have provided inconsistent evidence that chronic exposure to opioid drugs, including heroin and methadone, may be associated with impairments in executive neuropsychological functioning, specifically cognitive impulsivity. Further, it remains unclear how such impairments may relate of the nature, level and extent of opioid exposure, the presence and severity of opioid dependence, and hazardous behaviours such as injecting.Participants with histories of illicit heroin use (n = 24), former heroin users stabilized on prescribed methadone (methadone maintenance treatment; MMT) (n = 29), licit opioid prescriptions for chronic pain without history of abuse or dependence (n = 28) and healthy controls (n = 28) were recruited and tested on a task battery that included measures of cognitive impulsivity (Cambridge Gambling Task, CGT), motor impulsivity (Affective Go/NoGo, AGN) and non-planning impulsivity (Stockings of Cambridge, SOC).Illicit heroin users showed increased motor impulsivity and impaired strategic planning. Additionally, they placed higher bets earlier and risked more on the CGT. Stable MMT participants deliberated longer and placed higher bets earlier on the CGT, but did not risk more. Chronic opioid exposed pain participants did not differ from healthy controls on any measures on any tasks. The identified impairments did not appear to be associated specifically with histories of intravenous drug use, nor with estimates of total opioid exposure.These data support the hypothesis that different aspects of neuropsychological measures of impulsivity appear to be associated with exposure to different opioids. This could reflect either a neurobehavioural consequence of opioid exposure, or may represent an underlying trait vulnerability to opioid dependence.
- A 'Missing Not at Random' (MNAR) and 'Missing at Random' (MAR) Growth Model Comparison with a Buprenorphine/Naloxone Clinical Trial. [JOURNAL ARTICLE]
- Addiction 2014 Aug 29.
To compare three missing data strategies: 1) Latent growth model that assumes the data are missing at random (MAR) model, 2) Diggle-Kenward missing not at random (MNAR) model where dropout is a function of previous/concurrent urinalysis (UA) submissions, and 3) Wu-Carroll MNAR model where dropout is a function of the growth factors.Secondary data analysis of a National Drug Abuse Treatment Clinical Trials Network trial that examined a 7-day versus 28-day taper (i.e., stepwise decrease in buprenorphine/naloxone) on the likelihood of submitting an opioid-positive UA during treatment.11 outpatient treatment settings in 10 US cities.516 opioid dependent participants.Opioid UAs provided across the 4-week treatment period.The MAR model showed a significant effect (B=-0.45, p <0.05) of trial arm on the opioid-positive UA slope (i.e., 28-day taper participants were less likely to submit a positive UA over time) with a small effect size (d=0.20). The MNAR Diggle-Kenward model demonstrated a significant (B=-0.64, p<0.01) effect of trial arm on the slope with a large effect size (d=0.82). The MNAR Wu-Carroll model evidenced a significant (B=-0.41, p<0.05) effect of trial arm on the UA slope that was relatively small (d=0.31).This performance comparison of three missing data strategies (latent growth model, Diggle-Kenward selection model, Wu-Carrol selection model) on sample data indicates a need for increased use of sensitivity analyses in clinical trial research. Given the potential sensitivity of the trial arm effect to missing data assumptions, it is critical for researchers to consider whether the assumptions associated with each model are defensible.
- Intranasal Ketorolac as Part of a Multimodal Approach to Postoperative Pain. [JOURNAL ARTICLE]
- Pain Pract 2014 Aug 28.
Despite recent advances in the knowledge of pain mechanisms and pain management, postoperative pain continues to be a problem. Inadequately managed postsurgical pain has both clinical and economic consequences such as longer recovery times, delayed ambulation, higher incidence of complications, increased length of hospital stay, and potential to develop into chronic pain. Generally, opioids are the mainstay option for pain management in patients with moderate-to-severe postsurgical pain; however, opioids have significant side effects and have abuse potential. To improve patient and economic outcomes after surgery, postoperative pain guidelines have suggested incorporating a multi-modal/multi-mechanistic approach to pain treatment. A multi-modal approach is the simultaneous use of a combination of two or more (usually opioid and non-opioid) analgesics that provide two different mechanisms of actions. Utilizing a multi-modal approach may result in a greater reduction in pain vs. single therapies in addition to minimizing opioid use, thus reducing opioid related side effects. However, not all approaches may be effective for all types of patients and not all analgesics may be a viable option for outpatient settings, ambulatory surgery, or the fast-track surgical procedures. In this report, we present a review of the literature with a focus on intranasal ketorolac in order to provide a timely update regarding past, present, and future multi-modal treatment options for postoperative pain.
- Oregon's strategy to confront prescription opioid misuse: a case study. [JOURNAL ARTICLE]
- J Subst Abuse Treat 2014 Aug 2.
Governor John Kitzhaber appointed a Prescription Drug Taskforce to address Oregon's opioid epidemic. This case study reviews the Taskforce's participation in the National Governors Association State Policy Academy on Reducing Prescription Drug Abuse. To address the challenge of the misuse and abuse of prescription opioids, the Taskforce developed a strategy for practice change, community education and enhanced access to safe opioid disposal using stakeholder meetings, consensus development, and five action steps: (1) fewer pills in circulation, (2) educate prescribers and the public on the risks of opioid use, (3) foster safe disposal of unused medication, (4) provide treatment for opioid dependence, and (5) continued leadership from the Governor, health plans and health professionals. Although the story is ongoing, there are lessons for leadership in other states and for public health and medical practitioners throughout the country.
- The Pros and Cons of Long-Term Opioid Therapy. [JOURNAL ARTICLE]
- J Pain Palliat Care Pharmacother 2014 Sep; 28(3):308-310.
ABSTRACT Evidence supporting the efficacy of long-term opioid therapy for chronic noncancer pain is scarce. However, weak evidence suggests that those who are able to continue opioids long-term experience clinically significant pain relief. Fear of opioid abuse or addiction should not impede the prescribing of opioids if the patients are carefully selected and monitored. In patients taking opioids who experience intolerable side effects or unsatisfactory pain relief, alternatives should be sought as soon as possible. This report is adapted from paineurope 2014; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to healthcare professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com , at which European health professionals can register online to receive copies of the quarterly publication.
- Tramadol treatment of combat-related posttraumatic stress disorder. [JOURNAL ARTICLE]
- Ann Clin Psychiatry 2014 Aug; 26(3):217-221.
Improved psychopharmacologic treatment of posttraumatic stress disorder (PTSD) is needed. Accruing evidence implicates pain-conducting signals in PTSD pathophysiology.Four combat-related PTSD patients from the wars in Iraq and Afghanistan were treated with open-label tramadol hydrochloride (HCL), an atypical analgesic with opioid and non-opioid mechanisms of antinociception. Tramadol also inhibits neuronal reuptake of norepinephrine and serotonin.The clinical outcomes show evidence of a positive effect of twice-daily immediate-release tramadol HCL in men with combat-related PTSD. Total daily doses were 200 to 300 mg/d, with individual doses ranging from 100 to 200 mg.Given its unique mechanism of action, relatively low abuse potential, and ability to double as an analgesic for minor to moderate pain, tramadol is a promising candidate for clinical use in PTSD.
- Extended-release hydrocodone: the devil in disguise or just misunderstood? [Journal Article]
- Ann Pharmacother 2014 Oct; 48(10):1362-5.
Opioid abuse in the United States increased significantly over the past decade, leading to opioid-related deaths. Approval of Zohydro ER, a product that lacks an abuse-deterrent formulation, has provoked media controversy and aggressive legislative action from multiple stakeholders. Only the American Academy of Pain Management has released a position statement on this medication, and individual opinion varies. Additional single-entity extended-release hydrocodone formulations are in the pipeline, and Zohydro ER's limited clinical utility may make the controversy associated with its approval a moot point. As with other opioids, providers will need to assess individual patient risk versus benefit when prescribing Zohydro ER.
- Effects of Regulation on Methadone and Buprenorphine Provision in the Wake of Hurricane Sandy. [JOURNAL ARTICLE]
- J Urban Health 2014 Aug 28.
Hurricane Sandy led to the closing of many major New York City public hospitals including their substance abuse clinics and methadone programs, and the displacement or relocation of thousands of opioid-dependent patients from treatment. The disaster provided a natural experiment that revealed the relative strengths and weaknesses of methadone treatment in comparison to physician office-based buprenorphine treatment for opioid dependence, two modalities of opioid maintenance with markedly different regulatory requirements and institutional procedures. To assess these two modalities of treatment under emergency conditions, semi-structured interviews about barriers to and facilitators of continuity of care for methadone and buprenorphine patients were conducted with 50 providers of opioid maintenance treatment. Major findings included that methadone programs presented more regulatory barriers for providers, difficulty with dose verification due to impaired communication, and an over reliance on emergency room dosing leading to unsafe or suboptimal dosing. Buprenorphine treatment presented fewer regulatory barriers, but buprenorphine providers had little to no cross-coverage options compared to methadone providers, who could refer to alternate methadone programs. The findings point to the need for well-defined emergency procedures with flexibility around regulations, the need for a central registry with patient dose information, as well as stronger professional networks and cross-coverage procedures. These interventions would improve day-to-day services for opioid-maintained patients as well as services under emergency conditions.
- Where do we stand in the field of anti-abuse drug discovery? [JOURNAL ARTICLE]
- Expert Opin Drug Discov 2014 Aug 27.:1-4.
Drug abuse and addiction to licit and illicit drugs constitute an almost worldwide health and socioeconomic problem. This problem can be addressed in a number of ways. As far as pharmaceutical development and drug therapy is concerned, abuse-deterrent formulations (ADF), substitution therapies, antagonist therapies, aversion therapies, and diverse novel approaches can be considered. ADF (or tamper-resistant formulations) are an important step towards preventing the abuse of medically used drugs, such as strong opioid analgesics, and some drug treatments are well established, such as substitution therapy in opioid dependence with methadone and buprenorphine. Nevertheless, a large medical need remains, and drugs that effectively curb opioid or psychostimulant addiction by promoting abstinence and preventing relapse have yet to be developed. Many different targets and mechanisms are currently being considered in preclinical research, but apart from repurposing or reformulating already known drugs, very little clinical development is currently ongoing. It is hoped that at least a few of the investigated approaches (e.g., various glutamate and GABA receptor modulators, nociceptin/orphanin FQ peptide receptor agonists, or histamine H3 receptor antagonists) reach the stage of clinical development and eventually reach regulatory approval.