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Clinical Toxicology (Philadelphia, Pa.) May 2024Pulmonary edema is a rare complication occurring after naloxone administration, but the causal relationship remains insufficiently investigated. We aimed to determine... (Review)
Review
INTRODUCTION
Pulmonary edema is a rare complication occurring after naloxone administration, but the causal relationship remains insufficiently investigated. We aimed to determine the likelihood of naloxone as the causative agent in published cases of pulmonary edema.
METHODS
A literature search was conducted across multiple databases, utilizing database-specific search terms such as "pulmonary edema/chemically induced" and "naloxone/adverse effects." Each case report was evaluated using the Naranjo scale, a standardized causality assessment algorithm.
RESULTS
We identified 49 published case reports of pulmonary edema following naloxone administration. The median total dose of naloxone was 0.2 mg for patients presenting following a surgical procedure and 4 mg for out-of-hospital opioid overdoses. Based on the Naranjo scale, the majority of cases were classified as "possible" ( = 38) or "probable" ( = 11) adverse reactions, while no "definite" cases of naloxone-induced pulmonary edema were identified. Many patients were classified as "possible" due to limited patient information or other potential risks, such as fluid administration or airway obstruction. Forty-six of 49 patients survived (94 percent).
DISCUSSION
Pulmonary edema may occur after both low and high doses of naloxone; however, low doses were primarily reported in the surgical population. Despite this complication, the majority of patients survived. Furthermore, no case report in our analysis was classified as a "definite" case of naloxone-induced pulmonary edema which limits the establishment of causality. Future studies should explore patient risk factors, including surgical versus outpatient setting and opioid-naïve versus opioid-tolerant for developing pulmonary edema and employ a causality assessment algorithm.
CONCLUSIONS
These case reports suggest pulmonary edema can occur following naloxone administration, irrespective of dose. According to the Naranjo scale, there were no definite cases of naloxone-induced pulmonary edema. Overall, we suggest the benefits of naloxone administration outweigh the risks. Naloxone should be administered to treat opioid overdoses while monitoring for the development of pulmonary edema.
Topics: Naloxone; Pulmonary Edema; Humans; Narcotic Antagonists; Analgesics, Opioid; Opiate Overdose; Drug Overdose
PubMed: 38865087
DOI: 10.1080/15563650.2024.2348108 -
Journal of Addictions NursingNursing professionals are vitally involved in the cascade of care for opioid use disorders (OUDs). The global spread of COVID-19 has had complex effects on public health...
BACKGROUND
Nursing professionals are vitally involved in the cascade of care for opioid use disorders (OUDs). The global spread of COVID-19 has had complex effects on public health aspects of major diseases, including OUDs. There are limited data on the major ways in which the COVID-19 pandemic has affected the functions of nursing professionals in the care of OUDs.
METHOD
This systematic review followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and examined published data for trends in OUD care during the first 2 years of the COVID-19 pandemic, focusing on nursing functions. The National Library of Medicine PubMed database and the EMBASE database were examined for peer-reviewed studies with primary data published between January 1, 2020, and December 31, 2021.
REVIEW FINDINGS AND CONCLUSIONS
Rapid changes were observed in numerous aspects of OUDs during the early pandemic stage, as well as its care by nursing and other health professionals. These changes include increased overdoses (primarily from synthetic opioids such as fentanyl) and emergency department visits. These trends varied considerably across U.S. jurisdictions, underscoring the importance of region-specific examinations for public health policy and intervention. Out of necessity, healthcare systems and nursing professionals adapted to the challenges of OUD care in the pandemic. These adaptations included increases in telehealth services, increases in take-home doses of methadone or buprenorphine/naloxone, and expansion of layperson training in the use of naloxone for overdose reversal. It is likely that some of these adaptations will result in long-term changes in standards of care practices for OUDs by nursing professionals.
Topics: Humans; COVID-19; Opioid-Related Disorders; Nurse's Role; Opiate Substitution Treatment; United States; Analgesics, Opioid; SARS-CoV-2
PubMed: 38830000
DOI: 10.1097/JAN.0000000000000573 -
Journal of Addiction MedicineThis systematic review summarizes the development, accuracy, quality, and clinical utility of predictive models to assess the risk of opioid use disorder (OUD),...
BACKGROUND
This systematic review summarizes the development, accuracy, quality, and clinical utility of predictive models to assess the risk of opioid use disorder (OUD), persistent opioid use, and opioid overdose.
METHODS
In accordance with Preferred Reporting Items for a Systematic Review and Meta-analysis guidelines, 8 electronic databases were searched for studies on predictive models and OUD, overdose, or persistent use in adults until June 25, 2023. Study selection and data extraction were completed independently by 2 reviewers. Risk of bias of included studies was assessed independently by 2 reviewers using the Prediction model Risk of Bias ASsessment Tool (PROBAST).
RESULTS
The literature search yielded 3130 reports; after removing 199 duplicates, excluding 2685 studies after abstract review, and excluding 204 studies after full-text review, the final sample consisted of 41 studies that developed more than 160 predictive models. Primary outcomes included opioid overdose (31.6% of studies), OUD (41.4%), and persistent opioid use (17%). The most common modeling approach was regression modeling, and the most common predictors included age, sex, mental health diagnosis history, and substance use disorder history. Most studies reported model performance via the c statistic, ranging from 0.507 to 0.959; gradient boosting tree models and neural network models performed well in the context of their own study. One study deployed a model in real time. Risk of bias was predominantly high; concerns regarding applicability were predominantly low.
CONCLUSIONS
Models to predict opioid-related risks are developed using diverse data sources and predictors, with a wide and heterogenous range of accuracy metrics. There is a need for further research to improve their accuracy and implementation.
Topics: Humans; Opioid-Related Disorders; Opiate Overdose; Risk Assessment; Models, Statistical; Analgesics, Opioid
PubMed: 38591783
DOI: 10.1097/ADM.0000000000001276 -
Value in Health : the Journal of the... May 2024Overdose prevention centers (OPCs) provide a safe place where people can consume preobtained drugs under supervision so that a life-saving medical response can be... (Review)
Review
OBJECTIVES
Overdose prevention centers (OPCs) provide a safe place where people can consume preobtained drugs under supervision so that a life-saving medical response can be provided quickly in the event of an overdose. OPCs are programs that are established in Canada and have recently become legally sanctioned in only a few United States jurisdictions.
METHODS
We conducted a systematic review that summarizes and identifies gaps of economic evidence on establishing OPCs in North America to guide future expansion of OPCs.
RESULTS
We included 16 final studies that were evaluated with the Consolidated Health Economic Evaluation Reporting Standards and Drummond checklists. Eight studies reported cost-effectiveness results (eg, cost per overdose avoided or cost per quality-adjusted life-year), with 6 also including cost-benefit; 5 reported only cost-benefit results, and 3 cost offsets. Health outcomes primarily included overdose mortality outcomes or HIV/hepatitis C virus infections averted. Most studies used mathematical modeling and projected OPC outcomes using the experience of a single facility in Vancouver, BC.
CONCLUSIONS
OPCs were found to be cost-saving or to have favorable cost-effectiveness or cost-benefit ratios across all studies. Future studies should incorporate the experience of OPCs established in various settings and use a greater diversity of modeling designs.
Topics: Humans; Cost-Benefit Analysis; Opiate Overdose; North America; Quality-Adjusted Life Years; Canada
PubMed: 38401795
DOI: 10.1016/j.jval.2024.02.004 -
Substance Use & Addiction Journal Apr 2024Buprenorphine is among the most effective treatments for opioid use disorder. Even though the federal government recently eliminated the waiver requirement and patient...
BACKGROUND
Buprenorphine is among the most effective treatments for opioid use disorder. Even though the federal government recently eliminated the waiver requirement and patient limits applicable to office-based buprenorphine treatment (OBBT), among other settings, some states may still have policies imposing requirements on OBBT providers not required by federal law.
METHODS
We collected statutes and regulations from 50 US states and the District of Columbia (ie, 51 jurisdictions) between August 11 and November 30, 2022 using the Nexis Uni legal database and search terms related to OBBT counseling, dosage, and/or frequency of visits. We then used template analysis, a mixed deductive-inductive qualitative method, to analyze legal content.
RESULTS
Ten jurisdictions (20%) in 2022 had an OBBT counseling, dosage, and/or visit frequency requirement. Four jurisdictions had at least one law in each OBBT policy category examined. One-fifth of jurisdictions have OBBT policies not required under federal law. Five of these jurisdictions are among those with the highest overdose death rates per capita, according to publicly available data from 2021. Some OBBT requirements could potentially limit clinician interest in offering buprenorphine treatment or result in inadequate care (eg, if dosage limitations are too low.).
CONCLUSIONS
Even though a federal waiver is no longer required for OBBT, our results suggests that at least some jurisdictions have other OBBT requirements, such as counseling, dosage, and/or frequency requirements. Given the severity of the ongoing opioid overdose crisis, policymakers should carefully consider the extent to which OBBT requirements are evidence based.
Topics: Humans; Buprenorphine; Opioid-Related Disorders; Opiate Substitution Treatment; Counseling; Drug Overdose
PubMed: 38288697
DOI: 10.1177/29767342231223721 -
CMAJ : Canadian Medical Association... Oct 2023Higher doses of opioids, mental health comorbidities, co-prescription of sedatives, lower socioeconomic status and a history of opioid overdose have been reported as... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Higher doses of opioids, mental health comorbidities, co-prescription of sedatives, lower socioeconomic status and a history of opioid overdose have been reported as risk factors for opioid overdose; however, the magnitude of these associations and their credibility are unclear. We sought to identify predictors of fatal and nonfatal overdose from prescription opioids.
METHODS
We systematically searched MEDLINE, Embase, CINAHL, PsycINFO and Web of Science up to Oct. 30, 2022, for observational studies that explored predictors of opioid overdose after their prescription for chronic pain. We performed random-effects meta-analyses for all predictors reported by 2 or more studies using odds ratios (ORs) and 95% confidence intervals (CIs).
RESULTS
Twenty-eight studies (23 963 716 patients) reported the association of 103 predictors with fatal or nonfatal opioid overdose. Moderate- to high-certainty evidence supported large relative associations with history of overdose (OR 5.85, 95% CI 3.78-9.04), higher opioid dose (OR 2.57, 95% CI 2.08-3.18 per 90-mg increment), 3 or more prescribers (OR 4.68, 95% CI 3.57-6.12), 4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35-5.57), prescription of fentanyl (OR 2.80, 95% CI 2.30-3.41), current substance use disorder (OR 2.62, 95% CI 2.09-3.27), any mental health diagnosis (OR 2.12, 95% CI 1.73-2.61), depression (OR 2.22, 95% CI 1.57-3.14), bipolar disorder (OR 2.07, 95% CI 1.77-2.41) or pancreatitis (OR 2.00, 95% CI 1.52-2.64), with absolute risks among patients with the predictor ranging from 2-6 per 1000 for fatal overdose and 4-12 per 1000 for nonfatal overdose.
INTERPRETATION
We identified 10 predictors that were strongly associated with opioid overdose. Awareness of these predictors may facilitate shared decision-making regarding prescribing opioids for chronic pain and inform harm-reduction strategies SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (https://osf.io/vznxj/).
Topics: Humans; Analgesics, Opioid; Chronic Pain; Drug Overdose; Opiate Overdose; Prescriptions; Observational Studies as Topic
PubMed: 37871953
DOI: 10.1503/cmaj.230459 -
Regional Anesthesia and Pain Medicine May 2024
Topics: Humans; Analgesics, Opioid; Canada; COVID-19; Drug Overdose; Opiate Overdose; Opioid-Related Disorders; Pandemics; United States
PubMed: 36427903
DOI: 10.1136/rapm-2022-104169 -
Journal of Addictions NursingIn individuals in the United States with opioid addiction, what is the effect of a medication-assisted treatment (MAT) in reducing the relapse and harm reduction when...
In individuals in the United States with opioid addiction, what is the effect of a medication-assisted treatment (MAT) in reducing the relapse and harm reduction when comparing the use of buprenorphine, methadone, and naltrexone? In 2017, it was estimated that 1.7 million individuals suffer from overuse of prescription opiates, 652,000 individuals suffer from heroin use disorder, and greater than 130 individuals die from opiate overdose daily (National Institutes of Health, 2019). Using a systematic literature review, the following results were found. Buprenorphine is currently the second most effective MAT in harm reduction and relapse prevention, can be initiated and maintained through primary care, has a low risk for overdose, but needs to be started only when moderate withdrawals have begun. Methadone is currently the gold standard in MAT and can be started in any stage of withdrawal; however, titrating to effective dose is a lengthy process, and it must be administered at a specialty clinic. Naltrexone in oral form has not been shown to be effective because of lack of adherence; however, the extended-release intramuscular injection form has been shown to reduce relapse and increase the quality of life before initiation individuals must be opioid free for 7-14 days. Choosing the proper MAT is highly individualized. It is recommended that more research be conducted in comparing all MAT options, looking at the quality of life on each MAT, researching motivations to stay on MAT and remain opioid free, and looking at the impact of external reward on adherence to the MAT program.
Topics: Humans; United States; Naltrexone; Opiate Substitution Treatment; Quality of Life; Opioid-Related Disorders; Methadone; Buprenorphine; Analgesics, Opioid; Recurrence
PubMed: 34224485
DOI: 10.1097/JAN.0000000000000392