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- Buprenorphine Prescription Compliance: An Original Observational and Longitudinal Study. [JOURNAL ARTICLE]
- J Psychoactive Drugs 2014 April-June; 46(2):162-167.
Abstract Introduction: Buprenorphine is one of the main opioid dependence treatments, especially in France, where it has been widely prescribed since 1996. But it can easily be misused and its prescription has to be followed up. In the literature, we found several studies on buprenorphine, but we did not find long-term ecological follow-up studies on buprenorphine prescription and compliance. Material and Method: The main purpose of this study was to define stability or instability of the prescription of buprenorphine to opiate-addicted patients. We carried out a forecast study on prescription of buprenorphine over a 10-year period, using software collecting prescription data. We performed statistical analysis of the conditions and transitions of opiate-addicted patients treated with buprenorphine along appointments. Discussion/Conclusion: We showed that 70% of buprenorphine prescriptions are stable; we assumed that our results correspond to buprenorphine compliance. The retention in treatment was associated with a positive evolution of prescription stability. Prior criminal records were the only factor linked to instability. We showed that collecting precise prescription data in face to face appointments using software, including legal prescription rules that guide practitioners in following buprenorphine prescription compliance, seemed to be a useful method to measure buprenorphine compliance.
- Intravenous sufentanil-midazolam versus sevoflurane anaesthesia in medetomidine pre-medicated Himalayan rabbits undergoing ovariohysterectomy. [JOURNAL ARTICLE]
- Vet Anaesth Analg 2014 Jul 21.
To compare physiological effects of sufentanil-midazolam with sevoflurane for surgical anaesthesia in medetomidine premedicated rabbits.Prospective, randomized controlled experimental study.Eighteen female Himalayan rabbits, weight 2.1 ± 0.1 kg.Premedication with 0.1 mg kg(-1) medetomidine and 5 mg kg(-1) carprofen subcutaneously, was followed by intravenous anaesthetic induction with sufentanil (2.3 μg mL(-1) ) and midazolam (0.45 mg mL(-1) ). After endotracheal intubation, anaesthesia was maintained with sufentanil-midazolam (n = 9) or sevoflurane (n = 9). Ovariohysterectomy was performed. Intermittent positive pressure ventilation was performed as required. Physiological variables were studied perioperatively. Group means of physiologic data were generated for different anaesthetic periods. Data were compared for changes from sedation, and between groups by anova. Post-operatively, 0.05 mg kg(-1) buprenorphine was administered once and 5 mg kg(-1) carprofen once daily for 2-3 days. Rabbits were examined and weighed daily until one week after surgery.Smooth induction of anaesthesia was achieved within 5 minutes. Sufentanil and midazolam doses were 0.5 μg kg(-1) and 0.1 mg kg(-1) , during induction and 3.9 μg kg(-1) hour(-1) and 0.8 mg kg(-1) hour(-1) during surgery, respectively. End-tidal sevoflurane concentration was 2.1% during surgery. Assisted ventilation was required in nine rabbits receiving sufentanil-midazolam and four receiving sevoflurane. There were no differences between groups in physiologic data other than arterial carbon dioxide. In rabbits receiving sevoflurane, mean arterial pressure decreased pre-surgical intervention, heart rate increased 25% during and after surgery and body weight decreased 4% post-operatively. Post-operative problems sometimes resulted from catheterization of the ear artery.Sevoflurane and sufentanil-midazolam provided surgical anaesthesia of similar quality. Arterial blood pressure was sustained during sufentanil-midazolam anaesthesia and rabbits receiving sevoflurane lost body weight following ovariohysterectomy. Mechanical ventilation was required with both anaesthetic regimens.Anaesthesia with sufentanil-midazolam in medetomidine premedicated healthy rabbits is useful in the clinical and the research setting, as an alternative to sevoflurane.
- Antinociceptive effect of buprenorphine and evaluation of the nociceptive withdrawal reflex in foals. [JOURNAL ARTICLE]
- Vet Anaesth Analg 2014 Jul 21.
To elicit and evaluate the NWR (nociceptive withdrawal reflex) in 2 and 11 day old foals, to investigate if buprenorphine causes antinociception and determine if the NWR response changes with increasing age. The effect of buprenorphine on behaviour was also evaluated.Prospective, experimental cross-over trial.Nine Norwegian Fjord research foals.Buprenorphine, 10 μg kg(-1) was administered intramuscularly (IM) to the same foal at 2 days and at 11 days of age. The NWR and the effect of buprenorphine were evaluated by electromyograms recorded from the left deltoid muscle following electrical stimulation of the left lateral palmar nerve at the level of the pastern. Mentation, locomotor activity and respiratory rate were recorded before and after buprenorphine administration.We were able to evoke the NWR and temporal summation in foals using this model. Buprenorphine decreased the root mean square amplitude following single electrical stimulation (p < 0.001) in both age groups, and increased the NWR threshold following single electrical stimulation in 2 day old foals (p = 0.0012). Repeated electrical stimulation at 2 Hz was more effective to elicit temporal summation compared to 5 Hz (p < 0.001). No effect of age upon the NWR threshold was found (p = 0.34). Sedation when left undisturbed (11 occasions), increased locomotor activity when handled (9 occasions) and tachypnea (13 occasions) were common side-effects of buprenorphine.These findings indicate that buprenorphine has antinociceptive effect in foals. Opioid side effects often recognized in adult horses also occur in foals.
- The Impact of Prior Authorization on Buprenorphine Dose, Relapse Rates, and Cost for Massachusetts Medicaid Beneficiaries with Opioid Dependence. [JOURNAL ARTICLE]
- Health Serv Res 2014 Jul 9.
To assess the impact of a 2008 dose-based prior authorization policy for Massachusetts Medicaid beneficiaries using buprenorphine + naloxone for opioid addiction treatment. Doses higher than 16 mg required progressively more frequent authorizations.Mediciaid claims for 2007 and 2008 linked with Department of Public Health (DPH) service records.We conducted time series for all buprenorphine users and a longitudinal cohort analysis of 2,049 individuals who began buprenorphine treatment in 2007. Outcome measures included use of relapse-related services, health care expenditures per person, and buprenorphine expenditures.We used ICD-9 codes and National Drug Codes to identify individuals with opioid dependence who filled prescriptions for buprenorphine. Medicaid and DPH data were linked with individual identifiers.Individuals using doses >24 mg decreased from 16.5 to 4.1 percent. Relapses increased temporarily for some users but returned to previous levels within 3 months. Buprenorphine expenditures decreased but total expenditures did not change significantly.Prior authorization policies strategically targeted by dose level appear to successfully reduce use of higher than recommended buprenorphine doses. Savings from these policies are modest and may be accompanied by brief increases in relapse rates. Lower doses may decrease diversion of buprenorphine.
- Opiate withdrawal complicated by tetany and cardiac arrest. [Journal Article]
- Case Rep Crit Care 2014.:295401.
Patients with symptoms of opiate withdrawal, after the administration of opiate antagonist by paramedics, are a common presentation in the emergency department of hospitals. Though most of opiate withdrawal symptoms are benign, rarely they can become life threatening. This case highlights how a benign opiate withdrawal symptom of hyperventilation led to severe respiratory alkalosis that degenerated into tetany and cardiac arrest. Though this patient was successfully resuscitated, it is imperative that severe withdrawal symptoms are timely identified and immediate steps are taken to prevent catastrophes. An easier way to reverse the severe opiate withdrawal symptom would be with either low dose methadone or partial opiate agonists like buprenorphine. However, if severe acid-base disorder is identified, it would be safer to electively intubate these patients for better control of their respiratory and acid-base status.
- Characteristics and quality of life of opioid-dependent pregnant women in Austria. [JOURNAL ARTICLE]
- Arch Womens Ment Health 2014 Jul 15.
This study investigated pregnant opioid-dependent women undergoing maintenance therapy, applying a multidisciplinary, case-management approach at the Addiction Clinic of the Medical University of Vienna, Austria. It aimed at characterizing the patients' basic demographic and clinical parameters and evaluating their overall quality of life (QoL) prepartum and postpartum. Three hundred ninety women were treated between 1994 and 2009 with buprenorphine (n = 77), methadone (n = 184), or slow-release oral morphine (SROM) (n = 129) on an outpatient basis throughout their pregnancy and postpartum period. All patients were subject to standardized prepartum and postpartum medical and psychiatric assessments, including QoL assessments using a German adaptation of the Lancashire QoL Profile (Berliner Lebensqualitaetsprofil), and regular supervised urine toxicologies. No medication group differences were revealed regarding basic demographic or clinical data. Mean maintenance doses (SD) at time of delivery were as follows: 64 mg (36 mg) methadone, 10 mg (6 mg) buprenorphine, 455 mg (207 mg) SROM. However, buprenorphine-medicated women showed significantly less concomitant benzodiazepine consumption than methadone- or SROM-maintained women (p = 0.005), and significantly less concomitant opioid consumption than methadone-maintained women (p = 0.033) during the last trimester. Overall QoL was good prepartum and postpartum in all measured domains except "finances" and "prospect of staying in the same housing situation," and no differences were observed in QoL among the three medication groups (p = 0.177). QoL improved significantly after delivery in most of the domains (p < 0.001). Although opioid-dependent pregnant women face high-risk pregnancies and show variability in addiction severity, they report good QoL independent of the medication administered. These results show that individually tailored treatment interventions are effective for this patient population and suggest a QoL improvement after delivery.
- [Sécurité de la plus récente classe d'antagonistes des opioïdes durant la grossesse.] [JOURNAL ARTICLE]
- Can Fam Physician 2014 Jul; 60(7):e348-e349.
J'ai une patiente dont 6 semaines de grossesse viennent d'être confirmées. Depuis 6 mois, elle suit une thérapie pour une dépendance aux opioïdes à l'aide d'une combinaison de buprénorphine et de naloxone. Devrais-je m'inquiéter qu'elle ait été exposée à cette combinaison de médicaments jusqu'à ce stade de sa grossesse? Faudrait-il que je change sa médication pour de la méthadone maintenant qu'elle est enceinte? RÉPONSE: Les données limitées sur l'exposition à la buprénorphine durant la grossesse ne révèlent pas d'augmentation du risque de résultats indésirables chez le nouveau-né. Il y a peu de données sur la naloxone durant la grossesse; par ailleurs, on ne s'attendrait pas à ce que l'administration par voie orale soit associée avec un risque accru de résultats de grossesse défavorables. On conseille aux médecins qui traitent des femmes enceintes ou qui deviennent enceintes et dont l'état est stable en prenant une thérapie à la buprénorphine et naloxone de continuer ce traitement mais d'envisager une transition à une monothérapie à la buprénorphine.
- Safety of the newer class of opioid antagonists in pregnancy. [Journal Article]
- Can Fam Physician 2014 Jul; 60(7):631-2.
I have a patient recently confirmed to be 6 weeks pregnant. For the past 6 months she has been treated for an opioid addiction with buprenorphine-naloxone combination. Should I be concerned about her exposure to this drug combination up to this point of the pregnancy? Should I switch her medication to methadone now that she is pregnant?The limited data on buprenorphine exposure during pregnancy show no increased risk of adverse outcomes in the newborn. There are limited data on naloxone exposure during pregnancy; however, oral use is not expected to be associated with an increased risk of adverse pregnancy outcomes. Physicians treating pregnant women or women who become pregnant while they are stable taking buprenorphine-naloxone treatment are advised to continue this treatment but to consider transition to buprenorphine monotherapy.
- PC.84 Withdrawal from "therapeutic" opiate during the neonatal period: an increasing problem? [Journal Article]
- Arch Dis Child Fetal Neonatal Ed 2014 Jun.:A65.
There are well developed services for pregnant substance users maintained on opiate replacement therapies (ORT) both nationally and locally. Recently the problem of addiction to prescription drugs has been highlighted by the Home Affairs Select Committee report(1) and has received national media attention. Locally an increase in pregnant women addicted to such prescription drugs, particularly opiates, has been observed. Whilst ORT are prescription medications, they are distinct in some ways from opiates prescribed for non replacement therapy. Such opiates are referred to in this report as "therapeutic" opiates.Cases of infants born to mothers using "therapeutic" opiates over the last 2 years were reviewed. A literature review was performed looking specifically at the common substances used during pregnancy in such situations.22 women delivered 23 infants over the 2 year period. The most commonly prescribed substances were codeine, oxycodone and buprenorphine patches, prescribed mainly for chronic pain. All infants were admitted to the neonatal service for observation/treatment of Neonatal Abstinence Syndrome Very few women had accessed the local multi disciplinary antenatal clinic for drug using women and antenatal communication and planning was poor.The use of "therapeutic" opiates during pregnancy is not uncommon Women using "therapeutic" opiates are not accessing specialist local services, probably as they do not see themselves/are not seen as "addicts" in the classic sense of the word. There is clearly a need for improved services for this group of pregnant women.House of Commons Home Affairs Committee. Drugs: new psychoactive substances and prescription drugs. Twelfth Report of Session 2013-14. 17/12/2013.
- A latent class analysis of self-reported clinical indicators of psychosocial stability and adherence among opioid substitution therapy patients: Do stable patients receive more unsupervised doses? [JOURNAL ARTICLE]
- Drug Alcohol Depend 2014 Jun 2.
To develop a stability typology among opioid substitution therapy patients using a range of adherence indicators derived from clinical guidelines, and determine whether stable patients receive more unsupervised doses.An interviewer-administered cross-sectional survey was used in opioid substitution therapy programmes in three Australian jurisdictions, totalling 768 patients in their current treatment episode for ≥4 weeks. A structured questionnaire collated data from patients about their demographics, treatment characteristics, past 6-month drug use and medication adherence, psychosocial stability, comorbidity, child welfare concerns and levels of supervised dosing. Latent class analysis (LCA) was used to derive a stability typology. Linear regression models examined predictors of unsupervised dosing in the past month.LCA identified two classes: (i) a higher-adherence group (67%) who had low-moderate probabilities of endorsing the opioid substitution therapy stability indicators and (ii) a lower-adherence group (33%) who had moderate-high probabilities of endorsing the stability indicators. There was no association between adherence profile and the number of unsupervised doses. Significant predictors of receiving larger numbers of unsupervised doses included being older, living in New South Wales or South Australia (vs. Victoria), receiving methadone (vs. mono-buprenorphine), being prescribed in private clinic or general practice (vs. public clinic), reporting a longer current treatment episode, not receiving a urine drug screen in the past month, being currently employed and not having a prison history.This study suggested that system-level factors and observable indicators of social functioning were more strongly associated with the receipt of less supervised treatment. Future research should examine this issue using prospectively collected data.