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- Oral or transdermal opioids for osteoarthritis of the knee or hip. [JOURNAL ARTICLE]
- Cochrane Database Syst Rev 2014 Sep 17.:CD003115.
Osteoarthritis is the most common form of joint disease and the leading cause of pain and physical disability in older people. Opioids may be a viable treatment option if people have severe pain or if other analgesics are contraindicated. However, the evidence about their effectiveness and safety is contradictory. This is an update of a Cochrane review first published in 2009.To determine the effects on pain, function, safety, and addiction of oral or transdermal opioids compared with placebo or no intervention in people with knee or hip osteoarthritis.We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and CINAHL (up to 28 July 2008, with an update performed on 15 August 2012), checked conference proceedings, reference lists, and contacted authors.We included randomised or quasi-randomised controlled trials that compared oral or transdermal opioids with placebo or no treatment in people with knee or hip osteoarthritis. We excluded studies of tramadol. We applied no language restrictions.We extracted data in duplicate. We calculated standardised mean differences (SMDs) and 95% confidence intervals (CI) for pain and function, and risk ratios for safety outcomes. We combined trials using an inverse-variance random-effects meta-analysis.We identified 12 additional trials and included 22 trials with 8275 participants in this update. Oral oxycodone was studied in 10 trials, transdermal buprenorphine and oral tapentadol in four, oral codeine in three, oral morphine and oral oxymorphone in two, and transdermal fentanyl and oral hydromorphone in one trial each. All trials were described as double-blind, but the risk of bias for other domains was unclear in several trials due to incomplete reporting. Opioids were more beneficial in pain reduction than control interventions (SMD -0.28, 95% CI -0.35 to -0.20), which corresponds to a difference in pain scores of 0.7 cm on a 10-cm visual analogue scale (VAS) between opioids and placebo. This corresponds to a difference in improvement of 12% (95% CI 9% to 15%) between opioids (41% mean improvement from baseline) and placebo (29% mean improvement from baseline), which translates into a number needed to treat (NNTB) to cause one additional treatment response on pain of 10 (95% CI 8 to 14). Improvement of function was larger in opioid-treated participants compared with control groups (SMD -0.26, 95% CI -0.35 to -0.17), which corresponds to a difference in function scores of 0.6 units between opioids and placebo on a standardised Western Ontario and McMaster Universities Arthritis Index (WOMAC) disability scale ranging from 0 to 10. This corresponds to a difference in improvement of 11% (95% CI 7% to 14%) between opioids (32% mean improvement from baseline) and placebo (21% mean improvement from baseline), which translates into an NNTB to cause one additional treatment response on function of 11 (95% CI 7 to 14). We did not find substantial differences in effects according to type of opioid, analgesic potency, route of administration, daily dose, methodological quality of trials, and type of funding. Trials with treatment durations of four weeks or less showed larger pain relief than trials with longer treatment duration (P value for interaction = 0.001) and there was evidence for funnel plot asymmetry (P value = 0.054 for pain and P value = 0.011 for function). Adverse events were more frequent in participants receiving opioids compared with control. The pooled risk ratio was 1.49 (95% CI 1.35 to 1.63) for any adverse event (9 trials; 22% of participants in opioid and 15% of participants in control treatment experienced side effects), 3.76 (95% CI 2.93 to 4.82) for drop-outs due to adverse events (19 trials; 6.4% of participants in opioid and 1.7% of participants in control treatment dropped out due to adverse events), and 3.35 (95% CI 0.83 to 13.56) for serious adverse events (2 trials; 1.3% of participants in opioid and 0.4% of participants in control treatment experienced serious adverse events). Withdrawal symptoms occurred more often in opioid compared with control treatment (odds ratio (OR) 2.76, 95% CI 2.02 to 3.77; 3 trials; 2.4% of participants in opioid and 0.9% of participants control treatment experienced withdrawal symptoms).The small mean benefit of non-tramadol opioids are contrasted by significant increases in the risk of adverse events. For the pain outcome in particular, observed effects were of questionable clinical relevance since the 95% CI did not include the minimal clinically important difference of 0.37 SMDs, which corresponds to 0.9 cm on a 10-cm VAS.
- The current status of opioid maintenance treatment in France: a survey of physicians, patients, and out-of-treatment opioid users. [Journal Article]
- Int J Gen Med 2014.:449-57.
Project Access France was a national survey designed to provide real-world observations on the status of opioid dependence treatment in France.The views of physicians (n=100), patients (n=130), and out-of-treatment opioid users (n=33) were collected via interviews and questionnaires.Physicians reported being moderately satisfied with treatment programs in their area (rating 6.9 out of 10). Most physicians (82%) reported being concerned about misuse and diversion of medication-assisted treatment (MAT) medications and 50% identified psychosocial/behavioral counseling as the key change that would most improve patient care. Among patients, the mean number of previous MAT episodes was low (1.5); 78% reported that it was easy to access a doctor to undergo MAT; 14% reported regularly or sometimes using heroin; misuse and diversion were reported in 15% and 39% of patients, respectively; and 57% of patients were not receiving psychosocial help. Out-of-treatment opioid users reported using drugs on a regular basis (42% regularly used heroin) and cited 'not wanting to give up drugs completely' as the most frequent reason for staying out of MAT.This survey highlights a number of positive features of the open-access, GP-based treatment model for opioid dependence in France. Challenges remain with regard to continued misuse/diversion of MAT medications and limited patient access to psychosocial support.
- Emergency Hospitalizations for Unsupervised Prescription Medication Ingestions by Young Children. [JOURNAL ARTICLE]
- Pediatrics 2014 Sep 15.
Emergency department visits and subsequent hospitalizations of young children after unsupervised ingestions of prescription medications are increasing despite widespread use of child-resistant packaging and caregiver education efforts. Data on the medications implicated in ingestions are limited but could help identify prevention priorities and intervention strategies.We used nationally representative adverse drug event data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project and national retail pharmacy prescription data from IMS Health to estimate the frequency and rates of emergency hospitalizations for unsupervised prescription medication ingestions by young children (2007-2011).On the basis of 1513 surveillance cases, 9490 estimated emergency hospitalizations (95% confidence interval: 6420-12 560) occurred annually in the United States for unsupervised prescription medication ingestions among children aged <6 years from 2007 through 2011; 75.4% involved 1- or 2-year old children. Opioids (17.6%) and benzodiazepines (10.1%) were the most commonly implicated medication classes. The most commonly implicated active ingredients were buprenorphine (7.7%) and clonidine (7.4%). The top 12 active ingredients, alone or in combination with others, were implicated in nearly half (45.0%) of hospitalizations. Accounting for the number of unique patients who received dispensed prescriptions, the hospitalization rate for unsupervised ingestion of buprenorphine products was significantly higher than rates for all other commonly implicated medications and 97-fold higher than the rate for oxycodone products (200.1 vs 2.1 hospitalizations per 100 000 unique patients).Focusing unsupervised ingestion prevention efforts on medications with the highest hospitalization rates may efficiently achieve large public health impact.
- Buprenorphine Diversion and Misuse in Outpatient Practice. [JOURNAL ARTICLE]
- J Addict Med 2014 Sep 11.
This case is an amalgamation of several real patients in office-based treatment for prescription opioid dependence synthesized into a single theoretical case. The case illustrates the various ways in which medication diversion and misuse may be encountered in clinical practice and therapeutic responses designed to maximize positive treatment outcomes. It is followed by discussions from several expert addiction medicine providers from 3 different countries, giving their perspectives on the salient aspects of this case. This case conference should be of particular interest to clinicians working with opioid-dependent patients in an outpatient setting.
- A Review of Buprenorphine Diversion and Misuse: The Current Evidence Base and Experiences From Around the World. [JOURNAL ARTICLE]
- J Addict Med 2014 Sep 11.
Outpatient opioid addiction treatment with sublingual buprenorphine pharmacotherapy has rapidly expanded in the United States and abroad, and, with this increase in medication availability, there have been increasing concerns about its diversion, misuse, and related harms. This narrative review defines the behaviors of diversion and misuse, examines how the pharmacology of buprenorphine alone and in combination with naloxone influence its abuse liability, and describes the epidemiological data on buprenorphine diversion and intravenous misuse, risk factors for its intravenous misuse, and the unintended consequences of misuse and diversion. Physician practices to prevent, screen for, and therapeutically respond to these behaviors, which are a form of medication nonadherence, are discussed, and gaps in knowledge are identified. Outpatient opioid addiction treatment with sublingual buprenorphine pharmacotherapy experiences from other countries that have varied health care systems, public policies, and access to addiction treatment are shared to make clear that diversion and misuse occur across the world in various contexts, for many different reasons, and are not limited to buprenorphine. Comparisons are made with other opioids with known abuse liability and medications with no known abuse. The objective was to facilitate understanding of diversion and misuse so that all factors influencing their expression (patient and provider characteristics and public policy) can be appreciated within a framework that also recognizes the benefits of addiction treatment. With this comprehensive perspective, further careful work can help determine how to minimize these behaviors without eroding the current benefits realized through improved addiction treatment access and expansion.
- P-59in- prison outcomes of buprenorphine maintainence for prisoners: results from a pilot intervention in tihar prisons, India. [Journal Article]
- Alcohol Alcohol 2014 Sep.:i64-i65.
A pilot study was done to test the feasibility and effectiveness of buprenorphine as maintenance treatment for opioid dependent prisoners in Tihar prisons, India. This was the first such intervention in a South Asian prison.The study had a pre-post test design with quantitative, qualitative and biochemical assessments at baseline and at three, six, nine and twelve months after initiation of treatment with buprenorphine. Psychosocial intervention was provided in both, group and individual sessions. A total of 133 opioid dependent inmates fulfilling the eligibility criteria of the study were recruited in the study from November, 2008-March, 2012.The study sample mostly comprised pretrial remand prisoners (95.3%) and most(94.3%) were repeat offenders. For most patients(95.3%), heroin was the primary drug of abuse. 50.3% were currently Injecting Drug Users (IDUs). Among the IDUs, sharing of syringe/needle was reported by 70% and paraphernalia by 49% in their drug using careers. Treatment was initiated with buprenorphine and the mean dose (in mg) of buprenorphine was 4.3± 2.0, 4.6± 1.9, 4.3 ±1.4, 4.3 ±1.5 given on 3,6,9&12 months respectively. Retention in the prison arm was excellent (98%) and compliance among those retained in prison was 100%. In the prison, during the course of the study, 10, 3, 1 prisoners reported injecting drug use at 3, 6, 9 months respectively. No reporting of injecting drug use was obtained at 12 months and thereafter. No other illicit drug use was reported at follow up. This was corroborated by results of urine screening suggestive of minimal or no drug use at follow up during imprisonment. A statistically significant reduction was found in severity of dependence, craving for drugs and withdrawal symptoms at follow up. Recognition of co-morbid health problems and appropriate treatment of the same was provided to the prisoners on OST. In qualitative assessments, most prisoners expressed satisfaction with treatment and reported experiencing OST treatment as their first ray of hope in their lives.Buprenorphine maintenance for opioid dependent prisoners was found to be feasible and effective in Tihar prisons. An upscale of this intervention in prisons in the region both as a drug treatment and harm reduction strategy is advisable.United Nations Office of Drugs and crime(UNODC- ROSA) under Project RAS H/71 IMPLEMENTED IN: Tihar Prisons, Delhi, India ACNOWLEDGEMENT: Ms. Christina Albertin, Regional representative, UNODC- ROSA; Prof. Rajat Ray(retd): ex HOD Psychiatry and Chief NDDTC.
- P-56efficacy of buprenorphine/naloxone combination in reducing intravenous misuse in opioid-dependent patients (rime study). [Journal Article]
- Alcohol Alcohol 2014 Sep.:i64.
this study assesses the effectiveness of buprenorphine/naloxone combination in reducing intravenous (IV) misuse of buprenorphine in opioid-dependent patients.158 patients >= 18 years, who misused buprenorphine intravenously >= 4 times/week and treated for opioid dependency with buprenorphine ( >= 2 mg/day dose) for >= 3 months were included in a multicenter, open-label, randomized controlled trial. They were required to report IV misuse in a daily diary. Randomization was 1:1 (buprenorphine/naloxone, n = 79: buprenorphine, n = 79). The trial was including a 3-month randomized treatment period with a follow-up optional 9-month treatment period for those who chose to continue receiving buprenorphine/naloxone.the primary outcome was the percentage of patients achieving >= 30% reduction in the mean number of weekly study drug injections throughout the randomized treatment period compared with baseline: 89.6% (n = 67) and 45.8% (n = 59) (p <0.0001) of patients in the buprenorphine/naloxone and buprenorphine groups, respectively. In the buprenorphine/naloxone group, 74.2% of patients stopped injecting the study drug compared to 15.9% in the buprenorphine group (p < 0.0001). Of those patients injecting the study drug, patients misusing buprenorphine/naloxone (n = 44) reported significantly less disagreeable side effects than the buprenorphine group (n = 71) (p < 0.0001). Buprenorphine/naloxone combination is significantly effective in reducing IV misuse of buprenorphine in opioid-dependent patients.
- P-52slow-release oral morphine (srom) as further medication in opioid subtitution treatment (ost): results from a registration study. [Journal Article]
- Alcohol Alcohol 2014 Sep.:i63.
Since 50 years oral methadone is the gold standard in OST. However, some of the heroin dependent patients refrain from this kind of treatment due to different reasons (e.g. no injections, limited well-being, excessive sweating). Additionally the prolongation of the QTc poses a clinical problem in double diagnosed patients as many medications that are necessary in the treatment of these patients, add to the QTc prolongation. Unconfirmed reports from different countries suggested that SROM could be a useful addition to the in Switzerland already registered substitution medications methadone, diamorphine, and buprenorphine. In order to test this assumption we conducted a prospective, multi-dose, open label, non-inferiority, cross-over study in a bi-national, multicentre setting over 11 weeks, in which methadone and SROM were compared (ITT population n = 276). Beyond this time-point, the participants were observed another 25 weeks. Main results were: The proportion of heroin-positive urine samples and retention rates under SROM was equal to the ones under methadone. The mean QTc-interval under methadone was significantly longer than that under SROM. Higher treatment satisfaction, fewer cravings for heroin, and lower mental stress were reported by patients under SROM. More Details will be presented. SROM is now registered in Switzerland as an OST medication.
- Sy03-2-4who-isam fellowship barriers of tobacco cessation among Indian buprenorphine-naloxone maintained patients. [Journal Article]
- Alcohol Alcohol 2014 Sep.:i6.
Prevalence of smoking in opioid agonist treatment programme, leading to significant health hazards and high mortality. This study aims to examine the readiness to quit, perceived personal health and risk susceptibility associated with tobacco use and importance of intervention, among patients on opioid agonist treatment with buprenorphine-naloxone.Fifty-five males on buprenorphine-naloxone treatment at National Drug Dependence Treatment Centre, India, were assessed using Tobacco Use Characteristics, Fagerstrom test for nicotine dependence (smoker and smokeless tobacco user), Readiness to Change questionnaire (RCQ), Smoker's Perceived Health Risk Evaluation (SPHERE), Importance of Intervention scale and a semi-structured questionnaire.65.4% of the subjects were smokers, 9% were using smokeless tobacco only whereas 25.6% were using both. Mean FTND score of 5 ± 1.70 among smokers, denotes medium dependence. Only one-fifth of them reported prior quit attempts for tobacco. None of the attempts involved any assistance. 38.8% did not plan to quit in next 6 month. Perceived personal health and risk were poor. Only 61.62% considered intervention for smoking cessation important. Most common choice of intervention was advice and guidance only (49%).Higher severity of nicotine dependence, Poor willingness to quit highlights the need for on-site motivational treatment.
- Or14-5medical board policies in the United States on buprenorphine maintenance therapy for the recovering opioid dependent physician seeking a return to clinical practice. [Journal Article]
- Alcohol Alcohol 2014 Sep.:i52.
Buprenorphine maintenance therapy for recovering opioid dependent physicians returning to practice is controversial, with concerns regarding neurocognition, despite treatment efficacy. This study's objective was to survey state medical board policies regarding physicians on buprenorphine maintenance therapy seeking a return to clinical practice.Fifty state medical boards were surveyed by phone and email to determine their policies regarding buprenorphine maintenance therapy for recovering physicians returning to practice.Sixteen state boards would not allow a physician on buprenorphine maintenance therapy to practice. Eight state boards have policies allowing the treatment. Still fifteen other state boards consider the issue on a case by case basis, but have no specific policy. Ten state boards have not responded to multiple requests for information, and state law precludes one board from interpreting statutes without formal rulemaking process.Many state medical boards have a defined policy addressing buprenorphine maintenance therapy for physicians in recovery from opioid dependence. A number of boards allow physicians on buprenorphine maintenance therapy to practice, but a greater number preclude it. Many consider the issue on an individual basis. Further research on the safety and efficacy of buprenorphine maintenance therapy may broaden treatment policies for physicians with opioid dependence.