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Opioid Abuse [keywords]
- Diagnosis and treatment of narcotic bowel syndrome. [JOURNAL ARTICLE]
- Nat Rev Gastroenterol Hepatol 2014 Apr 22.
With increased prescription of opioids has come increased recognition of adverse consequences, including narcotic bowel syndrome (NBS). Characterized by incompletely controlled abdominal pain despite continued or increasing doses of opioids, NBS is estimated to occur in 4.2-6.4% of patients chronically taking opioids. Patients with NBS have a high degree of comorbid psychiatric illness, catastrophizing and disability; comorbid substance abuse must also be considered among this population. NBS should be distinguished from opioid-induced bowel disorder, which results from the effects of opioids on gastrointestinal motility and secretion. By contrast, the mechanisms of NBS are probably centrally mediated and include glial cell activation, bimodal opioid modulation in the dorsal horn, descending facilitation of pain and the glutaminergic system. Few treatments have been rigorously studied. A trial of opioid detoxification resulted in complete detoxification for the vast majority of patients with reduction in pain symptoms; however, despite improvement in pain, approximately half of patients returned to opioid use within 3 months. Improved strategies are needed to identify patients who will respond to detoxification and remain off opioids. Comorbid psychiatric and substance abuse disorders are barriers to durable response after detoxification and should be actively sought out and treated accordingly. An effective patient-physician relationship is essential.
- How Do Physicians Adopt and Apply Opioid Prescription Guidelines in the Emergency Department? A Qualitative Study. [JOURNAL ARTICLE]
- Ann Emerg Med 2014 Apr 14.
An increase in prescriptions for opioid pain medications has coincided with increasing opioid overdose deaths. Guidelines designed to optimize opioid prescriptions written in the emergency department have been implemented, with substantial controversy. Little is known about how physicians perceive and apply these guidelines. We seek to identify key themes about emergency physicians' definition, awareness, use, and opinions of opioid-prescribing guidelines.We conducted semistructured qualitative interviews with a convenience sample of 61 emergency physicians attending the American College of Emergency Physicians Scientific Assembly (October 2012, Denver, CO). Participants varied with respect to age, sex, geographic region, practice setting, and years of practice experience. We analyzed the interview content with modified grounded theory, an iterative coding process to identify patterns of responses and derive key themes. The study team examined discrepancies in the coding process to ensure reliability and establish consensus.When aware of opioid-prescribing guidelines, emergency physicians often defined them as policies developed by individual hospitals that sometimes reflected guidelines at the state or national level. Guidelines were primarily used by physicians to communicate decisions to limit prescriptions to patients on discharge rather than as tools for decisionmaking. Attitudes toward guidelines varied with regard to general attitudes toward opioid medications, as well as the perceived effects of guidelines on physician autonomy, public health, liability, and patient diversion.These exploratory findings suggest that hospital-based opioid guidelines complement and occasionally supersede state and national guidelines and that emergency physicians apply guidelines primarily as communication tools. The perspectives of providers should inform future policy actions that seek to address the problem of opioid abuse and overdose through practice guidelines.
- Utilizing buprenorphine-naloxone to treat illicit and prescription-opioid dependence. [REVIEW]
- Neuropsychiatr Dis Treat 2014.:587-598.
To review current evidence on buprenorphine-naloxone (bup/nx) for the treatment of opioid-use disorders, with a focus on strategies for clinical management and office-based patient care.Medline and the Cochrane Database of Systematic Reviews were searched. Consensus reports, guidelines published, and other authoritative sources were also included in this review. Apart from expert guidelines, data included in this review constitute level 1 evidence.Bup/nx is a partial μ-opioid agonist combined with the opioid antagonist naloxone in a 4:1 ratio. It has a lower abuse potential, carries less stigma, and allows for more flexibility than methadone. Bup/nx is indicated for both inpatient and ambulatory medically assisted withdrawal (acute detoxification) and long-term substitution treatment (maintenance) of patients who have a mild-to-moderate physical dependence. A stepwise long-term substitution treatment with regular monitoring and follow-up assessment is usually preferred, as it has better outcomes in reducing illicit opioid use, minimizing concomitant risks such as human immunodeficiency virus and hepatitis C transmission, retaining patients in treatment and improving global functioning.Bup/nx is safe and effective for opioid detoxification and substitution treatment. Its unique pharmaceutical properties make it particularly suitable for office-based maintenance treatment of opioid-use disorder.
- Use of prescription opioids with abuse-deterrent technology to address opioid abuse. [JOURNAL ARTICLE]
- Curr Med Res Opin 2014 Apr 16.
Abstract Objective: The development of new formulations of extended-release (ER) opioids with abuse-deterrent technology attempts to deter prescription opioid abuse while maintaining appropriate access to care for pain patients. This study examined the degree to which some patients may avoid switching to reformulated ER opioids with abuse-deterrent technology and the extent to which those patients are more likely to be abusers. Research design and methods: We analyzed Truven MarketScan pharmacy and medical claims data following the introduction of two reformulated ER opioids with abuse-deterrent technology. Adults aged 18-64 who were continuous users of extended-release oxycodone HCl (ER oxycodone) or extended-release oxymorphone HCl (ER oxymorphone) in a six-month period prior to the introduction of the respective reformulations of those products were identified and categorized based on whether they switched to the reformulation, switched to other ER/long-acting (LA) opioids (without abuse-deterrent technology), or discontinued ER/LA opioid treatment in a six-month post-reformulation period. Abusers were identified using ICD-9-CM diagnosis codes for opioid abuse/dependence. Pearson's chi-squared tests and Fisher's exact tests were then used to compare rates of abuse between patients who avoided switching to a reformulated ER opioid. Sensitivity analyses examined several definitions used in this analysis. Main outcome measures: ER/LA opioid utilization; rates of diagnosed opioid abuse Results: 31%-50% of patients avoided switching to reformulated ER opioids. Rates of diagnosed opioid abuse were higher among these patients compared to patients who transitioned to the reformulated ER opioids. Limitations: Due to the observational research design, caution is warranted in causal interpretation of the findings. The study was conducted among commercially-insured continuous ER oxycodone or ER oxymorphone users; future research should consider additional patient populations, such as non-continuous users and those without commercial insurance (i.e., Medicare, Medicaid, uninsured). Conclusions: Some patients switched to other ER/LA opioids without abuse-deterrent technology or discontinued ER/LA opioid treatment when their existing ER treatment was reformulated. Rates of opioid abuse were higher among patients who switched to other ER/LA opioids or discontinued ER/LA opioid treatment, suggesting that abusers may seek more easily abuseable alternatives such as prescription opioids without abuse-deterrent technology.
- WITHDRAWN: Psychosocial treatment for opiate abuse and dependence. [JOURNAL ARTICLE]
- Cochrane Database Syst Rev 2014 Apr 15.:CD004330.
Substance dependence is a social and public health problem; therefore it is a priority to develop effective treatments. Previous Cochrane reviews have explored the efficacy of pharmacotherapy for opiate dependence. This current review focuses on the role of psychosocial interventions alone for the treatment of opiate dependence. There is some evidence for the effectiveness of psychosocial interventions, but no systematic review has even been carried out.To assess the efficacy and acceptability of psychosocial interventions alone for treating opiate use disorders.Electronic searches of databases: Cochrane drugs and Alcohol Group Register of Trials (21 January 2004); Cochrane Central Register of Controlled Trials (CENTRAL-The Cochrane Library, Issue 1, 2004); MEDLINE (1966-2003), LILACS (1982-2003), EMBASE (1980-2003), PsycINFO (1872-2003). In addition reference searching, personal communication, conference abstracts, unpublished trials, book chapters on treatment of opioid dependence.Randomised controlled trials comparing psychosocial interventions alone versus pharmacological interventions or placebo or non-intervention for treating opioid use disorders.Two reviewers independently assessed trial quality and extracted data.Five trials involving 389 participants were included. These analysed Contingency Management, Brief Reinforcement Based Intensive Outpatient Therapy coupled with Contingency Management, Cue Exposure therapy, Alternative Program for Methadone Maintenance Treatment Program Drop-outs (MMTP) and Enhanced Outreach-Counselling Program. All the treatments were studied against the control (standard) treatment; therefore it was not possible to identify which type of psychosocial therapy was most effective.The main findings were that both Enhanced Outreach Counselling and Brief Reinforcement Based Intensive Outpatient Therapy coupled with Contingency Management had significantly better outcomes than standard therapy regarding relapse to opioid use, re-enrolment in treatment and retention in treatment. At 1-month and 3- month follow up the effects of Reinforcement Based Intensive Outpatient Therapy were not sustained. There was no further follow up of the Enhanced Outreach Counselling group. The Alternative Program for MMTP Drop-outs and the behavioural therapies of Cue Exposure and Contingency Management alone were no better than the control. As the studies were heterogeneous, it was not possible to pool the results and perform a meta-analysis.The available evidence has low numbers and is heterogeneous. At present psychosocial treatments alone are not adequately proved treatment modalities or superior to any other type of treatment.It is important to develop a better evidence base for psychosocial interventions to assist in future rationale planning of opioid use drug treatment services.
- Nalbuphine-induced psychosis treated with naloxone. [Journal Article]
- Am J Health Syst Pharm 2014 May 1; 71(9):717-21.
A case of nalbuphine-induced psychosis, which resolved after the administration of naloxone, is described.A 25-year-old African-American woman with a history of systemic lupus erythematosus was admitted to the hospital for management of cholecystitis. A laparoscopic cholecystectomy was performed, and the patient received multiple doses of i.v. hydromorphone for postoperative pain management. Four days later, shortly after receiving a dose of i.v. nalbuphine for opioid-induced pruritus, she experienced an acute psychotic event, with symptoms including intense headache, akathisia, altered mental status, and formication (a hallucinatory sensation of insects crawling on the skin). The neuropsychiatric symptoms abated within 5 minutes of two consecutively administered doses of i.v. naloxone. During this event, which lasted 25-30 minutes, there was no evidence of metabolic abnormalities and were no signs of infection. The patient did not have a history of mental illness or substance abuse. The patient did not receive further doses of nalbuphine and did not experience similar events during her hospital stay; she was discharged home 10 days later without further complications. According to the algorithm of Naranjo et al., the case was assigned a score of 6, indicating a probable adverse reaction to nalbuphine.A patient developed an acute psychotic reaction that was probably secondary to administration of i.v. nalbuphine for opioid-induced pruritus. Evidence supporting this diagnosis included correlation between the timing of administration of nalbuphine and symptom onset and the marked improvement in mentation following the administration of naloxone.
- Transient receptor potential vanilloid type 1 channel may modulate opioid reward. [JOURNAL ARTICLE]
- Neuropsychopharmacology 2014 Apr 15.
Transient receptor potential vanilloid type 1 (TRPV1), a nonselective cation channel, is a well-known pain-related receptor. TRPV1 involvement in morphine-induced antinociception, tolerance, and withdrawal symptoms has been previously reported. Emerging evidence indicates that TRPV1 may be related to both the cellular and behavioral effects of addictive drugs. In the present study, we investigated the role of TRPV1 in morphine reward using the conditioned place preference (CPP) paradigm in mice. Repeated morphine treatments upregulated TRPV1 expression in the dorsal striatum (DSt). Treatment with a TRPV1 agonist potentiated morphine reward, and pretreatment with TRPV1 antagonists attenuated these effects. Microinjection of a selective TRPV1 antagonist into the DSt significantly inhibited morphine-CPP. In addition, treatment with a TRPV1 antagonist suppressed morphine-induced increases in μ-opioid receptor binding, adenylyl cyclase 1 (AC1), p38 mitogen-activated protein kinase (p38 MAPK), and nuclear factor-kappa B (NF-κB) expression in the DSt. Administering a p38 inhibitor not only prevented morphine-CPP, but also prevented morphine-induced NF-κB and TRPV1 activation in the DSt. Furthermore, injecting an NF-κB inhibitor significantly blocked morphine-CPP. Our findings suggest that TRPV1 in the DSt contribute to morphine reward via AC1, p38 MAPK, and NF-κB. Brain TRPV1 may serve as a novel therapeutic target to treat morphine addictive disorders.Neuropsychopharmacology accepted article peview online, 15 April 2014. doi:10.1038/npp.2014.90.
- Ibudilast (AV411), and its AV1013 analog, reduce HIV-1 replication and neuronal death induced by HIV-1 and morphine. [JOURNAL ARTICLE]
- AIDS 2014 Apr 10.
Ibudilast (AV411, MN-166), a nonselective cyclic AMP phosphodiesterase inhibitor that has been used clinically in Asia for bronchial asthma, poststroke dizziness, and ocular allergies, and its amino analog, AV1013, attenuate glial activation, pro-inflammatory cytokine activation and restrict macrophage migration inhibitory factor (MIF). We explored the antiviral therapeutic potential of ibudilast and AV1013 for attenuating HIV-1 replication and the synergistic interactions seen with opiate abuse-HIV-1 comorbidity in neuronal death and inflammation. AV411 and AV1013 inhibited replication by HIV-1 in microglia and significantly suppressed Tat ± morphine-induced tumor necrosis factor-α and MIF production, the activation of the nuclear factor-kappa B subunit p65, and neuronal death. AV411 and AV1013 prevented HIV-1 replication, and attenuated tumor necrosis factor-α and MIF release at concentrations of 100 nmol/l and 1 μmol/l, which are likely achievable at clinical doses. More importantly, co-exposure with morphine did not negate the inhibitory actions of AV411.Collectively, our data suggest that AV411 and its amino analog, AV1013, may be useful neuroprotective agents counteracting neurotoxicity caused by infected and activated glia, and implicate them as potential therapies for the management of HIV-associated neurocognitive disorders in an opioid-abusing population.
- Psychostimulant addiction treatment. [REVIEW]
- Neuropharmacology 2014 Apr 12.
Treatment of psychostimulant addiction has been a major, and not fully met, challenge. For opioid addiction, there is strong evidence for the effectiveness of several medications. For psychostimulants, there is no corresponding form of agonist maintenance that has met criteria for regulatory approval or generally accepted use. Stimulant-use disorders remain prevalent and can result in both short-term and long-term adverse consequences. The mainstay of treatment remains behavioral interventions. In this paper, we discuss those interventions and some promising candidates in the search for pharmacological interventions. This article is part of a Special Issue entitled 'CNS Stimulants'.
- Trends in medical use, diversion, and nonmedical use of prescription medications among college students from 2003 to 2013: Connecting the dots. [JOURNAL ARTICLE]
- Addict Behav 2014 Mar 12; 39(7):1176-1182.
To examine trends in the lifetime and past-year prevalence of medical use, diversion, and nonmedical use of four prescription medication classes (i.e., sedative/anxiety, opioid, sleeping, and stimulant) among college students between 2003 and 2013; and to identify demographic and background characteristics associated with trends in past-year nonmedical use of prescription medications.A self-administered, cross-sectional Web survey was conducted in 2003, 2005, 2007, 2009, 2011, and 2013 at a large public four-year university in the Midwest United States.Approximately one in every five individuals reported nonmedical use of at least one prescription medication class in their lifetime. The past-year prevalence of medical use, diversion and nonmedical use of prescription stimulants increased significantly between 2003 and 2013 while the past-year prevalence of medical use, diversion and nonmedical use of prescription opioids decreased significantly over this same time period. The odds of past-year nonmedical use of each prescription medication class were generally greater among males, Whites, members of social fraternities and sororities, and those with a lifetime history of medical use of prescription medications or a past-year history of being approached to divert their prescription medications.The present study represents the first investigation to demonstrate that trends in medical use of controlled medications parallel changes in diversion and nonmedical use of the same medication class among college students. The findings reinforce the importance of continued monitoring of prescription medication use at colleges to help guide prevention and intervention efforts.