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Journal of General Internal Medicine Dec 2020Many clinicians are reevaluating the use of long-term opioid therapy (LTOT) for chronic pain in response to the opioid crisis and calls from organizations including the...
BACKGROUND
Many clinicians are reevaluating the use of long-term opioid therapy (LTOT) for chronic pain in response to the opioid crisis and calls from organizations including the Centers for Disease Control & Prevention to limit prescribing of high-dose opioids. However, this practice change is occurring largely in the absence of data regarding patient outcomes. A 2017 systematic review found inconclusive evidence on the impact of LTOT dose reduction and discontinuation on pain severity and function, quality of life, withdrawal symptoms, substance abuse, and adverse effects. This rapid systematic review provides an updated evidence synthesis of patient outcomes following LTOT dose reduction including serious harms such as overdose and suicide.
METHODS
We systematically searched numerous bibliographic databases from January 2017 (the end search date of the 2017 systematic review) through May 2020. One reviewer used prespecified criteria to assess articles for inclusion, evaluate study quality, abstract data, and grade strength of evidence, with a second reviewer checking.
RESULTS
We included 49 studies-1 systematic review, 34 studies included in that systematic review, and 14 new studies. We prioritized evidence synthesis of 19 studies with the most applicability to the Veteran population and outpatient settings. Among these studies, improvements in mean pain scores were common among patients tapering opioids while participating in intensive multimodal pain interventions and mostly unchanged with less intensive or nonspecific co-interventions. Our confidence in these findings is low due to methodological limitations of the studies. Observational data suggests that serious harms such as opioid overdose and suicidal ideation can occur following opioid dose reduction or discontinuation, but the incidence of these harms at the population level is unknown.
DISCUSSION
The net balance of benefits and harms of LTOT dose reduction for patients with chronic pain is unclear. Clinicians should closely monitor patients during the tapering process given the potential for harm.
Topics: Analgesics, Opioid; Chronic Pain; Drug Overdose; Drug Tapering; Humans; Quality of Life
PubMed: 33145689
DOI: 10.1007/s11606-020-06253-8 -
Drug and Alcohol Dependence Nov 2019Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in...
BACKGROUND
Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.
METHODS
We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.
RESULTS
The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.
CONCLUSIONS
Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.
Topics: Community Participation; Drug Overdose; Drug Storage; Education, Continuing; Evaluation Studies as Topic; Guideline Adherence; Health Education; Humans; Opioid Epidemic; Prescription Drug Monitoring Programs; Public Health; United States
PubMed: 31585357
DOI: 10.1016/j.drugalcdep.2019.107563 -
Journal of Hospital Medicine Sep 2022Hospital-based clinicians frequently care for patients with opioid withdrawal or opioid use disorder (OUD) and are well-positioned to identify and initiate treatment for...
Hospital-based clinicians frequently care for patients with opioid withdrawal or opioid use disorder (OUD) and are well-positioned to identify and initiate treatment for these patients. With rising numbers of hospitalizations related to opioid use and opioid-related overdose, the Society of Hospital Medicine convened a working group to develop a Consensus Statement on the management of OUD and associated conditions among hospitalized adults. The guidance statement is intended for clinicians practicing medicine in the inpatient setting (e.g., hospitalists, primary care physicians, family physicians, advanced practice nurses, and physician assistants) and is intended to apply to hospitalized adults at risk for, or diagnosed with, OUD. To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines and composed a draft statement based on extracted recommendations. Next, the working group obtained feedback on the draft statement from external experts in addiction medicine, SHM members, professional societies, harm reduction organizations and advocacy groups, and peer reviewers. The iterative development process resulted in a final Consensus Statement consisting of 18 recommendations covering the following topics: (1) identification and treatment of OUD and opioid withdrawal, (2) perioperative and acute pain management in patients with OUD, and (3) methods to optimize care transitions at hospital discharge for patients with OUD. Most recommendations in the Consensus Statement were derived from guidelines based on observational studies and expert consensus. Due to the lack of rigorous evidence supporting key aspects of OUD-related care, the working group identified important issues necessitating future research and exploration.
Topics: Adult; Analgesics, Opioid; Consensus; Hospital Medicine; Hospitalization; Humans; Opioid-Related Disorders
PubMed: 35880813
DOI: 10.1002/jhm.12893 -
The International Journal on Drug Policy Apr 2021Adult drug courts are growing in popularity within the Unites States, but the quality of substance use treatment within drug court programs and the impact of drug courts...
BACKGROUND
Adult drug courts are growing in popularity within the Unites States, but the quality of substance use treatment within drug court programs and the impact of drug courts on health and substance use treatment outcomes is largely unknown. We appraised the quality of United States adult drug court process evaluations and the inclusion of measures of substance use treatment quality.
METHODS
We systematically reviewed the adult drug court evaluations between 2008 and 2018 in accordance with recommended strategies for systematic gray literature search. We appraised evaluation quality using the Evidence for Policy and Practice Information and Coordination Center tool for process evaluations. We extracted recommended measures of substance use treatment quality, including measures related to screening and monitoring, diagnosis, service availability, service utilization, and outcomes.
RESULTS
Our search identified 112 evaluations. Process measures were included within 68 evaluations, 45% of which had poor data reliability. We found that less than 10% of evaluations reported substance use treatment quality measures related to service utilization, overdose, and mortality, while more than 75% contained criminal justice measures, including program graduation (completion of criminal justice proceedings) and participant recidivism.
CONCLUSIONS
We found low uptake of measures of substance use treatment quality. The absence of data call into question the ability of drug courts to stem harmful substance use related health outcomes.
Topics: Adult; Criminal Law; Humans; Pharmaceutical Preparations; Recidivism; Reproducibility of Results; Substance-Related Disorders; United States
PubMed: 33310636
DOI: 10.1016/j.drugpo.2020.103050 -
PloS One 2020Retention in opioid substitution (OST) treatment is associated with substantial reductions in all cause and overdose mortality. This systematic review aims to identify...
BACKGROUND
Retention in opioid substitution (OST) treatment is associated with substantial reductions in all cause and overdose mortality. This systematic review aims to identify both protective factors supporting retention in OST, and risk factors for treatment dropout.
METHODS
A systematic search was performed using MEDLINE, Embase, PsycInfo, CINAHL and Web of Science (January 2001 to October 2019). Randomised controlled trials (RCTs) and observational cohort studies reporting on retention rates and factors associated with retention in OST were included. Factors associated with treatment retention and dropout were explored according to the Maudsley Addiction Profile. A narrative synthesis is provided.
RESULTS
67 studies were included in this review (4 RCTs and 63 observational cohort studies; N = 294,592), all assessing factors associated with retention in OST or treatment dropout. The median retention rate across observational studies was approximately 57% at 12 months, which fell to 38.4% at three years. Studies included were heterogeneous in nature with respect to treatment setting, type of OST, risk factor assessment, ascertainment of outcome and duration of follow-up. While the presence of such methodological heterogeneity makes it difficult to synthesise results, there is limited evidence to support the influence of a number of factors on retention, including age, substance use, OST drug dose, legal issues, and attitudes to OST.
CONCLUSIONS
Younger age, substance use particularly cocaine and heroin use, lower doses of methadone, criminal activity/incarceration, and negative attitudes to MMT appear to be associated with reduced retention in OST. A consensus definition of retention is required to allow for comparability across future studies.
Topics: Databases, Factual; Humans; Opiate Substitution Treatment; Opioid-Related Disorders; Patient Dropouts; Retention in Care; Risk Factors
PubMed: 32407321
DOI: 10.1371/journal.pone.0232086 -
Frontiers in Public Health 2022The potential for digital initiatives for opioid harm reduction is boundless. Synthesized evidence on current interventions and their efficacy are emerging. This scoping...
BACKGROUND
The potential for digital initiatives for opioid harm reduction is boundless. Synthesized evidence on current interventions and their efficacy are emerging. This scoping review is an effort to aggregate Canadian and Australian digital health initiatives used to prevent opioid-related deaths and minimize harm, prior to and particularly during the pandemic of SARs-COVID-19, when the crisis escalated.
METHODS
The Joanna Briggs Institute's methodological framework for conducting scoping reviews was used. Peer reviewed and gray literature published between January 2016 to October 2021 were included. Search translation was performed across CINAHL, Cochrane, SCOPUS, MEDLINE Complete, and ProQuest Public Health with consistent use of key search terms. Citation checks were also conducted. Studies included were written in English and reported on digital technologies to prevent opioid-related harm and/or mortality in participants aged 18 years or older in Australia and Canada.
RESULTS
A total of 16 publications were included in the final analysis (Australia = 5; Canada = 11). The most frequently reported digital technologies were telehealth to support access to treatment ( = 3) and mobile applications for overdose monitoring and prevention ( = 3). Telehealth-delivered opioid replacement therapy demonstrated equal outcomes and treatment retention rates compared to in-person and mobile applications for overdose monitoring demonstrated lifesaving capability through direct linkages with emergency response services.
CONCLUSIONS
Digital interventions to minimize opioid crisis related harm and overdose prevention are fast emerging in Australia and Canada. During the pandemic, the crisis escalated in both countries as a public health emergency, and different initiatives were trialed. Digital harm reduction solutions via mobile apps (or SaaS solutions) were found to have the potential to prevent accidental overdose deaths and save lives, if rendered through privacy preserved, secure and trust enabled methods that empower users. Knowledge sharing between the two countries, relating to suitable interventions, may add significant value in combatting the escalating opioid crisis in the post pandemic era.
Topics: Analgesics, Opioid; Australia; COVID-19; Canada; Drug Overdose; Humans; Opioid Epidemic; Pandemics
PubMed: 35903371
DOI: 10.3389/fpubh.2022.900733 -
Audiology & Neuro-otology 2022The purpose of this review was to summarize the literature regarding the effects of opioids and illicit drugs on the auditory and vestibular systems.
BACKGROUND
The purpose of this review was to summarize the literature regarding the effects of opioids and illicit drugs on the auditory and vestibular systems.
METHODS
Data were sourced from published papers reporting hearing loss (HL) and/or vestibular loss (VL) following misuse or overdose of opioids or illicit drugs. Most papers consisted of retrospective single-case reports, with few retrospective reviews or prospective cohort studies. Search terms included variations of HL, VL, opioids, and illicit drugs. Search results yielded 51 articles published between 1976 and 2021. A total of 44 articles were reviewed after excluding studies that were not available in English (n = 3), only described acute effects in healthy cohorts (n = 3) or only described general health aspects in a group on methadone maintenance (n = 1).
RESULTS
Sixteen studies reported ototoxicity from illicit drugs, 27 from prescription opioids, and 1 was unspecified. This review shows that HL associated with amphetamines and cocaine was typically sudden, bilateral, and temporary. HL from cocaine/crack and heroin often presented with greatest losses in the mid-frequency range. HL associated with opioids was typically sudden, bilateral, moderately severe to profound, and in most cases permanent. The literature is sparse regarding VL from illicit drugs and opioids.
CONCLUSION
Practitioners who see patients for sudden or rapidly progressive HL or VL with no apparent cause should inquire about misuse of illicit drugs and opioids, particularly when the HL does not respond to steroid treatment.
Topics: Analgesics, Opioid; Cocaine; Hearing; Hearing Loss; Humans; Illicit Drugs; Prospective Studies; Retrospective Studies
PubMed: 35172308
DOI: 10.1159/000521965 -
Molecular Psychiatry Nov 2023In the past two decades, over-prescription of opioids for pain management has driven a steep increase in opioid use disorder (OUD) and death by overdose, exerting a...
In the past two decades, over-prescription of opioids for pain management has driven a steep increase in opioid use disorder (OUD) and death by overdose, exerting a dramatic toll on western countries. OUD is a chronic relapsing disease associated with a lifetime struggle to control drug consumption, suggesting that opioids trigger long-lasting brain adaptations, notably through functional genomic and epigenomic mechanisms. Current understanding of these processes, however, remain scarce, and have not been previously reviewed systematically. To do so, the goal of the present work was to synthesize current knowledge on genome-wide transcriptomic and epigenetic mechanisms of opioid action, in primate and rodent species. Using a prospectively registered methodology, comprehensive literature searches were completed in PubMed, Embase, and Web of Science. Of the 2709 articles identified, 73 met our inclusion criteria and were considered for qualitative analysis. Focusing on the 5 most studied nervous system structures (nucleus accumbens, frontal cortex, whole striatum, dorsal striatum, spinal cord; 44 articles), we also conducted a quantitative analysis of differentially expressed genes, in an effort to identify a putative core transcriptional signature of opioids. Only one gene, Cdkn1a, was consistently identified in eleven studies, and globally, our results unveil surprisingly low consistency across published work, even when considering most recent single-cell approaches. Analysis of sources of variability detected significant contributions from species, brain structure, duration of opioid exposure, strain, time-point of analysis, and batch effects, but not type of opioid. To go beyond those limitations, we leveraged threshold-free methods to illustrate how genome-wide comparisons may generate new findings and hypotheses. Finally, we discuss current methodological development in the field, and their implication for future research and, ultimately, better care.
Topics: Animals; Humans; Analgesics, Opioid; Opioid-Related Disorders; Drug Overdose; Chronic Disease; Genomics; Models, Animal
PubMed: 37723284
DOI: 10.1038/s41380-023-02238-1 -
Clinical Journal of the American... Apr 2022Methotrexate is used in the treatment of many malignancies, rheumatological diseases, and inflammatory bowel disease. Toxicity from use is associated with severe...
Methotrexate is used in the treatment of many malignancies, rheumatological diseases, and inflammatory bowel disease. Toxicity from use is associated with severe morbidity and mortality. Rescue treatments include intravenous hydration, folinic acid, and, in some centers, glucarpidase. We conducted systematic reviews of the literature following published EXtracorporeal TReatments In Poisoning (EXTRIP) methods to determine the utility of extracorporeal treatments in the management of methotrexate toxicity. The quality of the evidence and the strength of recommendations (either "strong" or "weak/conditional") were graded according to the GRADE approach. A formal voting process using a modified Delphi method assessed the level of agreement between panelists on the final recommendations. A total of 92 articles met inclusion criteria. Toxicokinetic data were available on 90 patients (89 with impaired kidney function). Methotrexate was considered to be moderately dialyzable by intermittent hemodialysis. Data were available for clinical analysis on 109 patients (high-dose methotrexate [>0.5 g/m]: 91 patients; low-dose [≤0.5 g/m]: 18). Overall mortality in these publications was 19.5% and 26.7% in those with high-dose and low-dose methotrexate-related toxicity, respectively. Although one observational study reported lower mortality in patients treated with glucarpidase compared with those treated with hemodialysis, there were important limitations in the study. For patients with severe methotrexate toxicity receiving standard care, the EXTRIP workgroup: () suggested against extracorporeal treatments when glucarpidase is not administered; () recommended against extracorporeal treatments when glucarpidase is administered; and () recommended against extracorporeal treatments instead of administering glucarpidase. The quality of evidence for these recommendations was very low. Rationales for these recommendations included: () extracorporeal treatments mainly remove drugs in the intravascular compartment, whereas methotrexate rapidly distributes into cells; () extracorporeal treatments remove folinic acid; () in rare cases where fast removal of methotrexate is required, glucarpidase will outperform any extracorporeal treatment; and () extracorporeal treatments do not appear to reduce the incidence and magnitude of methotrexate toxicity.
Topics: Drug Overdose; Drug-Related Side Effects and Adverse Reactions; Humans; Leucovorin; Methotrexate; Observational Studies as Topic; Poisoning; Renal Dialysis
PubMed: 35236714
DOI: 10.2215/CJN.08030621 -
Substance Abuse Treatment, Prevention,... Sep 2023The COVID-19 pandemic led to an unprecedented relaxation of restrictions on take-home doses in opioid agonist treatment (OAT). We conducted a mixed methods systematic... (Review)
Review
The impact of relaxing restrictions on take-home doses during the COVID-19 pandemic on program effectiveness and client experiences in opioid agonist treatment: a mixed methods systematic review.
BACKGROUND
The COVID-19 pandemic led to an unprecedented relaxation of restrictions on take-home doses in opioid agonist treatment (OAT). We conducted a mixed methods systematic review to explore the impact of these changes on program effectiveness and client experiences in OAT.
METHODS
The protocol for this review was registered in PROSPERO (CRD42022352310). From Aug.-Nov. 2022, we searched Medline, Embase, CINAHL, PsycInfo, Web of Science, Cochrane Register of Controlled Trials, and the grey literature. We included studies reporting quantitative measures of retention in treatment, illicit substance use, overdose, client health, quality of life, or treatment satisfaction or using qualitative methods to examine client experiences with take-home doses during the pandemic. We critically appraised studies using the Mixed Methods Appraisal Tool. We synthesized quantitative data using vote-counting by direction of effect and presented the results in harvest plots. Qualitative data were analyzed using thematic synthesis. We used a convergent segregated approach to integrate quantitative and qualitative findings.
RESULTS
Forty studies were included. Most were from North America (23/40) or the United Kingdom (9/40). The quantitative synthesis was limited by potential for confounding, but suggested an association between take-home doses and increased retention in treatment. There was no evidence of an association between take-home doses and illicit substance use or overdose. Qualitative findings indicated that take-home doses reduced clients' exposure to unregulated substances and stigma and minimized work/treatment conflicts. Though some clients reported challenges with managing their medication, the dominant narrative was one of appreciation, reduced anxiety, and a renewed sense of agency and identity. The integrated analysis suggested reduced treatment burden as an explanation for improved retention and revealed variation in individual relationships between take-home doses and illicit substance use. We identified a critical gap in quantitative measures of patient-important outcomes.
CONCLUSION
The relaxation of restrictions on take-home doses was associated with improved client experience and retention in OAT. We found no evidence of an association with illicit substance use or overdose, despite the expansion of take-home doses to previously ineligible groups. Including patient-important outcome measures in policy, program development, and treatment planning is essential to ensuring that decisions around take-home doses accurately reflect their value to clients.
Topics: Humans; COVID-19; Analgesics, Opioid; Pandemics; Quality of Life; Program Evaluation
PubMed: 37777766
DOI: 10.1186/s13011-023-00564-9