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Addiction Science & Clinical Practice Aug 2022Medications for opioid use disorder (MOUDs), including methadone, buprenorphine, and naltrexone, decrease mortality and morbidity for people with opioid use disorder...
BACKGROUND
Medications for opioid use disorder (MOUDs), including methadone, buprenorphine, and naltrexone, decrease mortality and morbidity for people with opioid use disorder (OUD). Buprenorphine and methadone have the strongest evidence base among MOUDs. Unlike methadone, buprenorphine may be prescribed in office-based settings in the U.S., including by nurse practitioners (NPs) and physician assistants (PAs) who have a federal waiver and adhere to federal patient limits. Buprenorphine is underutilized nationally, particularly in rural areas, and NPs/PAs could help address this gap. Therefore, we sought to identify perceptions of buprenorphine efficacy and perceptions of prescribing barriers among NPs/PAs. We also sought to compare perceived buprenorphine efficacy and perceived prescribing barriers between waivered and non-waivered NPs/PAs, as well as to compare perceived buprenorphine efficacy to perceived naltrexone and methadone efficacy.
METHODS
We disseminated an online survey to a random national sample of NPs/PAs. We used Mann-Whitney U tests to compare between waivered and non-waivered respondents. We used non-parametric Friedman tests and post-hoc Wilcoxon signed-rank tests to compare perceptions of medication types.
RESULTS
240 respondents participated (6.5% response rate). Most respondents agreed buprenorphine is efficacious and believed counseling and peer support should complement buprenorphine. Buprenorphine was generally perceived as more efficacious than both naltrexone and methadone. Perceived buprenorphine efficacy and prescribing barriers differed by waiver status. Non-waivered practitioners were more likely than waivered practitioners to have concerns about buprenorphine affecting patient mix. Among waivered NPs/PAs, key buprenorphine prescribing barriers were insurance prior authorization and detoxification access.
CONCLUSIONS
Our results suggest that different policies should target perceived barriers affecting waivered versus non-waivered NPs/PAs. Concerns about patient mix suggest stigmatization of patients with OUD. NP/PA education is needed about comparative medication efficaciousness, particularly regarding methadone. Even though many buprenorphine treatment patients benefits from counseling and/or peer support groups, NPs/PAs should be informed that such psychosocial treatment methods are not necessary for all buprenorphine patients.
Topics: Buprenorphine; Humans; Methadone; Naltrexone; Nurse Practitioners; Opiate Substitution Treatment; Opioid-Related Disorders; Physician Assistants
PubMed: 35945636
DOI: 10.1186/s13722-022-00321-6 -
Substance Abuse Treatment, Prevention,... May 2023Medications for opioid use disorder (MOUD; methadone, buprenorphine, naltrexone) are the most effective treatments for OUD, and MOUD is protective against fatal...
Drug use patterns and factors related to the use and discontinuation of medications for opioid use disorder in the age of fentanyl: findings from a mixed-methods study of people who use drugs.
BACKGROUND
Medications for opioid use disorder (MOUD; methadone, buprenorphine, naltrexone) are the most effective treatments for OUD, and MOUD is protective against fatal overdoses. However, continued illegal drug use can increase the risk of treatment discontinuation. Given the widespread presence of fentanyl in the drug supply, research is needed to understand who is at greatest risk for concurrent MOUD and drug use and the contexts shaping use and treatment discontinuation.
METHODS
From 2017 to 2020, Massachusetts residents with past-30-day illegal drug use completed surveys (N = 284) and interviews (N = 99) about MOUD and drug use. An age-adjusted multinomial logistic regression model tested associations between past-30-day drug use and MOUD use (current/past/never). Among those on methadone or buprenorphine (N = 108), multivariable logistic regression models examined the association between socio-demographics, MOUD type; and past-30-day use of heroin/fentanyl; crack; benzodiazepines; and pain medications. Qualitative interviews explored drivers of concurrent drug and MOUD use.
RESULTS
Most (79.9%) participants had used MOUD (38.7% currently; 41.2% past), and past 30-day drug use was high: 74.4% heroin/fentanyl; 51.4% crack cocaine; 31.3% benzodiazepines, and 18% pain medications. In exploring drug use by MOUD history, multinomial regression analyses found that crack use was positively associated with past and current MOUD use (outcome referent: never used MOUD); whereas benzodiazepine use was not associated with past MOUD use but was positively associated with current use. Conversely, pain medication use was associated with reduced odds of past and current MOUD use. Among those on methadone or buprenorphine, separate multivariable logistic regression models found that benzodiazepine and methadone use were positively associated with heroin/fentanyl use; living in a medium-sized city and sex work were positively associated with crack use; heroin/fentanyl use was positively associated with benzodiazepine use; and witnessing an overdose was inversely associated with pain medication use. Many participants qualitatively reported reducing illegal opioid use while on MOUD, yet inadequate dosage, trauma, psychological cravings, and environmental triggers drove their continued drug use, which increased their risk of treatment discontinuation and overdose.
CONCLUSIONS
Findings highlight variations in continued drug use by MOUD use history, reasons for concurrent use, and implications for MOUD treatment delivery and continuity.
Topics: Humans; Pharmaceutical Preparations; Fentanyl; Heroin; Opioid-Related Disorders; Benzodiazepines; Drug Overdose; Methadone; Pain; Buprenorphine; Crack Cocaine; Analgesics, Opioid; Opiate Substitution Treatment
PubMed: 37217975
DOI: 10.1186/s13011-023-00538-x -
Balkan Medical Journal Aug 2020The opioid epidemic has emerged as a major health and social problem over the last few decades. An increasing number of patients with opioid use disorder are presenting... (Review)
Review
The opioid epidemic has emerged as a major health and social problem over the last few decades. An increasing number of patients with opioid use disorder are presenting for perioperative management. These patients are either on buprenorphine or methadone for the maintenance and treatment of opioid addiction or chronic pain. In the settings of acute pain, the optimal management of patients with opioid use disorder is challenging, and recovery can be jeopardized secondary to the unique pharmacology of these agents. The purpose of this narrative review is to summarize the existing studies on the perioperative management of patients who are using buprenorphine and methadone and provide guidance for the management of patients with opioid use disorder during the perioperative period.
Topics: Buprenorphine; Humans; Methadone; Pain Management; Perioperative Care
PubMed: 32407063
DOI: 10.4274/balkanmedj.galenos.2020.2020.5.2 -
Journal of Addiction MedicineIn the context of the US overdose crisis, improving access to medications for opioid use disorder is urgently needed. The Canadian model of methadone treatment, whereby...
In the context of the US overdose crisis, improving access to medications for opioid use disorder is urgently needed. The Canadian model of methadone treatment, whereby clinicians can prescribe methadone for opioid use disorder in office-based settings and methadone can be dispensed through community pharmacies, offers a compelling model for adoption in the US. Office-based settings in which methadone is prescribed often adopt a rapid-access model, allowing walk-in appointments and same-day initiation of methadone. Prescribing authorization requirements have been relaxed over the past 25 years to improve access to methadone. This paper summarizes the model of office-based methadone prescribing in Canada, highlighting the regulatory structures, prescribing practices, and interprofessional collaborations that enable methadone treatment in office-based settings. Potential implementation strategies for adopting office-based prescribing in the US are discussed.
Topics: Analgesics, Opioid; Canada; Drug Overdose; Humans; Methadone; Opiate Substitution Treatment; Opioid-Related Disorders
PubMed: 35020695
DOI: 10.1097/ADM.0000000000000950 -
American Journal of Public Health Apr 2022
Topics: Heroin Dependence; Humans; Methadone; Opioid-Related Disorders
PubMed: 35349318
DOI: 10.2105/AJPH.2022.306806 -
Toxicology and Applied Pharmacology Nov 2023The use and/or misuse of opioids by pregnant women would expose the fetuses to these drugs during critical stages of development with serious effects for the newborn,...
The use and/or misuse of opioids by pregnant women would expose the fetuses to these drugs during critical stages of development with serious effects for the newborn, like the neonatal abstinence syndrome (NAS). We have revisited an established chicken model for NAS to describe the distribution of morphine and methadone to the brain and explore its validity as a valuable alternative to rodent models. For this purpose, chicken eggs were injected with a single dose of 10 mg/kg or 20 mg/kg morphine or 20 mg/kg methadone onto the chorioallantoic membrane (CAM) on embryonal day 13. Whole brains and lungs were harvested and the concentrations of morphine, methadone and their subsequent metabolites (morphine-3-glucuronide and EDDP, respectively) determined in the brain and lungs at different time points using LC-MS/MS. Morphine and methadone, as well as their metabolites, were detected both in the brain and lungs, with significantly higher concentrations in the lungs. Pharmacokinetic modelling showed that the distribution of morphine to the brain followed a first-order absorption with transit compartments and linear elimination, with concentrations linearly dependent on dose. Moreover, methadone, but not morphine, reduced μ receptor (the main morphine receptor) binding, which can be of relevance for opioid tolerance. The present study is the first to report the brain distribution of morphine, which can be described by standard pharmacokinetic processes, and methadone in the developing chicken embryo. The present findings supplement the already established model and support the use of this chicken model to study NAS.
Topics: Chick Embryo; Infant, Newborn; Animals; Female; Pregnancy; Humans; Methadone; Morphine; Analgesics, Opioid; Chickens; Chromatography, Liquid; Drug Tolerance; Tandem Mass Spectrometry; Neonatal Abstinence Syndrome; Brain; Receptors, Opioid, mu
PubMed: 37866706
DOI: 10.1016/j.taap.2023.116731 -
Drug and Alcohol Review May 2023Decentralising methadone maintenance treatment to primary care improves patients' access to care and their drug and HIV treatment outcomes. However, primary care...
INTRODUCTION
Decentralising methadone maintenance treatment to primary care improves patients' access to care and their drug and HIV treatment outcomes. However, primary care providers (PCP), especially those working in limited-resource settings, are facing great challenges to provide quality methadone treatment. This study explores the challenges perceived by PCP providing methadone treatment at commune health centres in a mountainous region in Vietnam.
METHOD
We conducted in-depth interviews with 26 PCP who worked as program managers, physicians, counsellors, pharmacists and medication dispensing staff at the methadone programs of eight commune health centres in Dien Bien, Vietnam, in November and December 2019. We used the health-care system framework in developing the interview guides and in summarising data themes.
RESULTS
Participants identified major challenges in providing methadone treatment in commune health centres at the individual, clinic and environmental levels. Individual-level challenges included a lack of confidence and motivation in providing methadone treatment. Clinic-level factors included inadequate human resources, lack of institutional support, insufficient technical support, lack of referral resources and additional support for patients. Environment-level factors comprised a lack of reasonable policies on financial support for providers at commune health centres for providing methadone treatment, lack of regulations and mechanisms to ensure providers' safety in case of potential violence by patients and to share responsibility for overdose during treatment.
DISCUSSION AND CONCLUSION
PCP in Vietnam faced multi-level challenges in providing quality methadone treatment. Supportive policies and additional resources are needed to ensure the effectiveness of the decentralisation program.
Topics: Humans; Methadone; Opiate Substitution Treatment; Politics; Primary Health Care; Vietnam
PubMed: 36851865
DOI: 10.1111/dar.13613 -
ELife Mar 2021Despite the rising prevalence of methadone treatment in pregnant women with opioid use disorder, the effects of methadone on neurobehavioral development remain unclear....
Despite the rising prevalence of methadone treatment in pregnant women with opioid use disorder, the effects of methadone on neurobehavioral development remain unclear. We developed a translational mouse model of prenatal methadone exposure (PME) that resembles the typical pattern of opioid use by pregnant women who first use oxycodone then switch to methadone maintenance pharmacotherapy, and subsequently become pregnant while maintained on methadone. We investigated the effects of PME on physical development, sensorimotor behavior, and motor neuron properties using a multidisciplinary approach of physical, biochemical, and behavioral assessments along with brain slice electrophysiology and in vivo magnetic resonance imaging. Methadone accumulated in the placenta and fetal brain, but methadone levels in offspring dropped rapidly at birth which was associated with symptoms and behaviors consistent with neonatal opioid withdrawal. PME produced substantial impairments in offspring physical growth, activity in an open field, and sensorimotor milestone acquisition. Furthermore, these behavioral alterations were associated with reduced neuronal density in the motor cortex and a disruption in motor neuron intrinsic properties and local circuit connectivity. The present study adds to the limited body of work examining PME by providing a comprehensive, translationally relevant characterization of how PME disrupts offspring physical and neurobehavioral development.
Topics: Analgesics, Opioid; Animals; Behavior, Animal; Brain; Female; Humans; Male; Maternal Exposure; Methadone; Mice; Mice, Inbred C57BL; Motor Neurons; Opiate Substitution Treatment; Opioid-Related Disorders; Pregnancy; Pregnancy Complications; Prenatal Exposure Delayed Effects
PubMed: 33724184
DOI: 10.7554/eLife.66230 -
Drug and Alcohol Dependence Jan 2021Alexithymia, difficulty identifying and describing one's emotions coupled with a tendency to externalize, is a potentially important yet understudied treatment target...
BACKGROUND
Alexithymia, difficulty identifying and describing one's emotions coupled with a tendency to externalize, is a potentially important yet understudied treatment target for patients with opioid use disorder. The aim of this study was to examine the role of alexithymia in pain experience among individuals with opioid use disorder.
METHODS
One-hundred-and-sixty-four patients receiving methadone maintenance treatment completed a battery of self-report measures related to alexithymia, drug use, and pain experiences. Comparisons were performed on the full sample between those with or without clinically significant levels of alexithymia. For a subsample reporting pain (n = 138), intercorrelations were performed to test whether drug use history, pain catastrophizing, pain acceptance, and alexithymia were related to pain severity and pain interference. Regression analyses were performed to test for serial mediation of pain catastrophizing and pain acceptance on the relationship between alexithymia and pain interference in this subsample.
RESULTS
Individuals with alexithymia showed increased pain catastrophizing and interference, and intercorrelations indicated that increased alexithymia was associated with increased pain interference, more pain catastrophizing, and reduced pain acceptance. A serial regression model among a subset of patients with pain indicated that pain catastrophizing and pain acceptance mediated the effect of alexithymia on pain interference.
CONCLUSIONS
These findings suggest that alexithymia, as well as both pain catastrophizing and pain acceptance, contribute to interference associated with pain and are potentially important intervention targets among methadone-treated patients with pain.
Topics: Adult; Affective Symptoms; Catastrophization; Emotions; Humans; Male; Methadone; Middle Aged; Opiate Substitution Treatment; Pain; Pain Measurement; Self Report
PubMed: 33168339
DOI: 10.1016/j.drugalcdep.2020.108387 -
Neuropsychopharmacology : Official... Nov 2022The high efficacy mu-opioid receptor (MOR) agonist methadone is an effective opioid use disorder (OUD) medication used exclusively in opioid-dependent patients. However,...
The high efficacy mu-opioid receptor (MOR) agonist methadone is an effective opioid use disorder (OUD) medication used exclusively in opioid-dependent patients. However, methadone has undesirable effects that limit its clinical efficacy. Intermediate efficacy MOR agonists may treat OUD with fewer undesirable effects. We compared the effects of methadone with the intermediate efficacy MOR agonist TRV130 (oliceridine) on fentanyl-vs.-food choice and somatic withdrawal signs in opioid-dependent and post-opioid-dependent rats. Male rats (n = 20) were trained under a fentanyl-vs.-food choice procedure. Rats were then provided extended fentanyl (3.2 µg/kg/infusion) access (6 p.m.-6 a.m.) for 10 days to produce opioid dependence/withdrawal. Rats were treated with vehicle (n = 7), TRV130 (3.2 mg/kg; n = 8), or methadone (3.2 mg/kg; n = 5) three times per day after each extended-access session (8:30 a.m., 11 a.m., 1:30 p.m.). Withdrawal sign scoring (1:55 p.m.) and choice tests (2-4 p.m.) were conducted daily. Vehicle, TRV130, and methadone effects on fentanyl choice were redetermined in post-opioid-dependent rats. Vehicle-, TRV130-, and methadone-treated rats had similar fentanyl intakes during extended access. Vehicle-treated rats exhibited increased withdrawal signs and decreased bodyweights. Both methadone and TRV130 decreased these withdrawal signs. TRV130 was less effective than methadone to decrease fentanyl choice and increase food choice in opioid-dependent rats. Neither methadone nor TRV130 decreased fentanyl choice in post-opioid-dependent rats. Results suggest that higher MOR activation is required to reduce fentanyl choice than withdrawal signs in fentanyl-dependent rats. Additionally, given that TRV130 did not precipitate withdrawal in opioid-dependent rats, intermediate efficacy MOR agonists like TRV130 may facilitate the transition of patients with OUD from methadone to lower efficacy treatments like buprenorphine.
Topics: Analgesics, Opioid; Animals; Buprenorphine; Fentanyl; Male; Methadone; Narcotics; Opioid-Related Disorders; Rats; Receptors, Opioid; Spiro Compounds; Substance Withdrawal Syndrome; Thiophenes
PubMed: 35906489
DOI: 10.1038/s41386-022-01393-3