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CNS Drugs Jun 2019Opioid use disorder affects over 26 million individuals worldwide. There are currently three World Health Organization-recommended and US Food and Drug... (Review)
Review
Opioid use disorder affects over 26 million individuals worldwide. There are currently three World Health Organization-recommended and US Food and Drug Administration-approved medication treatments for opioid use disorder: the full opioid agonist methadone, the opioid partial agonist buprenorphine, and the opioid receptor antagonist naltrexone. We provide a review of the use of buprenorphine for the treatment of opioid use disorder and discuss the barriers, challenges, risks, and efficacy of buprenorphine treatment vs. other treatments. Although evidence from numerous studies has shown buprenorphine to be effective for the treatment of opioid use disorder, a majority of patients with opioid use disorder do not receive buprenorphine, or any other medical treatment. We review the different formulations of buprenorphine, including newer long-acting injectable formulations that may decrease the risk of diversion and improve adherence.
Topics: Buprenorphine; Humans; Medication Adherence; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; Substance Withdrawal Syndrome
PubMed: 31062259
DOI: 10.1007/s40263-019-00637-z -
Pain Medicine (Malden, Mass.) Apr 2020An expert panel convened to reach a consensus on common misconceptions surrounding buprenorphine, a Schedule III partial µ-opioid receptor agonist indicated for chronic... (Review)
Review
OBJECTIVE
An expert panel convened to reach a consensus on common misconceptions surrounding buprenorphine, a Schedule III partial µ-opioid receptor agonist indicated for chronic pain. The panel also provided clinical recommendations on the appropriate use of buprenorphine and conversion strategies for switching to buprenorphine from a full µ-opioid receptor agonist for chronic pain management.
METHODS
The consensus panel met on March 25, 2019, to discuss relevant literature and provide recommendations on interpreting buprenorphine as a partial µ-opioid receptor agonist, prescribing buprenorphine before some Schedule II, III, or IV options, perioperative/trauma management of patients taking buprenorphine, and converting patients from a full µ-opioid receptor agonist to buprenorphine.
RESULTS
The panel recommended that buprenorphine's classification as a partial µ-opioid receptor agonist not be clinically translated to mean partial analgesic efficacy. The panel also recommended that buprenorphine be considered before some Schedule II, III, or IV opioids in patients with a favorable risk/benefit profile on the basis of metabolic factors, abuse potential, and tolerability and that buprenorphine be continued during the perioperative/trauma period. In addition, switching patients from a full µ-opioid receptor agonist to buprenorphine should be considered with no weaning period at starting doses that are based on the previous opioid dose.
CONCLUSIONS
These recommendations provide a framework for clinicians to address most clinical scenarios regarding buprenorphine use. The overall consensus of the panel was that buprenorphine is a unique Schedule III opioid with favorable pharmacologic properties and a safety profile that may be desirable for chronic pain management.
Topics: Analgesics, Opioid; Buprenorphine; Chronic Pain; Drug Substitution; Humans; Practice Guidelines as Topic; Receptors, Opioid, mu
PubMed: 31917418
DOI: 10.1093/pm/pnz356 -
Biomolecules May 2021Chronic pain, including neuropathic pain, represents an untreated disease with important repercussions on the quality of life and huge costs on the national health... (Review)
Review
Chronic pain, including neuropathic pain, represents an untreated disease with important repercussions on the quality of life and huge costs on the national health system. It is well known that opioids are the most powerful analgesic drugs, but they represent the second or third line in neuropathic pain, that remain difficult to manage. Moreover, these drugs show several side effects that limit their use. In addition, opioids possess addictive properties that are associated with misuse and drug abuse. Among available opioids compounds, buprenorphine has been suggested advantageous for a series of clinical reasons, including the effectiveness in neuropathic pain. Some properties are partly explained by its unique pharmacological characteristics. However, questions on the dynamic profile remain to be answered. Pharmacokinetics optimization strategies, and additional potentialities, are still to be explored. In this paper, we attempt to conceptualize the potential undiscovered dynamic profile of buprenorphine.
Topics: Analgesics; Buprenorphine; Chronic Pain; Humans; Neuralgia; Quality of Life
PubMed: 34072706
DOI: 10.3390/biom11060816 -
Journal of Addiction MedicineThis paper offers a review and recommendations for clinicians working with patients interested in discontinuing opioid agonist treatment. As buprenorphine/naloxone has... (Review)
Review
This paper offers a review and recommendations for clinicians working with patients interested in discontinuing opioid agonist treatment. As buprenorphine/naloxone has gained widespread acceptance for opioid addiction, many treatment providers and patients have a range of hopes and expectations about its optimal use. A surprising number assume buprenorphine/naloxone is primarily useful as a medication to transition off illicit opioid use, and success is partially defined by discontinuing the medication. Despite accumulating evidence that a majority of patients will need to remain on medication to preserve their gains, clinicians often have to address a patient's fervent desire to taper. Using the concept of "recovery capital," our review addresses (1) the appropriate duration of opioid agonist treatment, (2) risks associated with discontinuing, (3) a checklist that guides the patient through self-assessment of the wisdom of discontinuing opioid agonist treatment, and (4) shared decision making about how to proceed.
Topics: Analgesics, Opioid; Buprenorphine; Humans; Methadone; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders
PubMed: 33323695
DOI: 10.1097/ADM.0000000000000789 -
Canadian Family Physician Medecin de... Dec 2020
Topics: Analgesics, Opioid; Buprenorphine; Buprenorphine, Naloxone Drug Combination; Dose-Response Relationship, Drug; Humans; Naloxone; Opioid-Related Disorders; Substance Withdrawal Syndrome
PubMed: 33334955
DOI: 10.46747/cfp.6612891 -
CMAJ : Canadian Medical Association... Mar 2023
Topics: Humans; Delayed-Action Preparations; Buprenorphine
PubMed: 36972908
DOI: 10.1503/cmaj.220730-f -
Pain Management Jul 2020Buprenorphine is a Schedule III opioid with unique pharmacodynamic and pharmacokinetic properties that contribute to effective analgesia and fewer safety risks than... (Review)
Review
Buprenorphine is a Schedule III opioid with unique pharmacodynamic and pharmacokinetic properties that contribute to effective analgesia and fewer safety risks than other opioids. This review article focuses on the buccal film formulation, which is preferable to other buprenorphine formulations on the basis of bioavailability, safety and efficacy. The clinical studies reviewed here confirm that buprenorphine buccal film offers effective and continuous pain relief that is generally well tolerated, with no cases of respiratory depression reported in any of the studies. On the basis of these clinical data and individual patient risk/benefit assessments, clinicians should consider utilizing buprenorphine buccal film as a first-line opioid treatment for chronic pain over other buprenorphine formulations or other opioids.
Topics: Administration, Mucosal; Analgesics, Opioid; Buprenorphine; Cheek; Chronic Pain; Humans; Mouth Mucosa; Pain Management; Receptors, Opioid, mu
PubMed: 32394800
DOI: 10.2217/pmt-2020-0013 -
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 -
Health Services Research Apr 2022To examine the extent to which there was any therapeutic relationship between Veterans and their initial buprenorphine provider and whether the presence of this...
OBJECTIVE
To examine the extent to which there was any therapeutic relationship between Veterans and their initial buprenorphine provider and whether the presence of this relationship influenced treatment retention.
DATA SOURCES
National, secondary administrative data used from the Veterans Health Administration (VHA), 2008-2017.
STUDY DESIGN
Retrospective cohort study. The primary exposure was a therapeutic relationship between the Veteran and buprenorphine provider, defined as the presence of a previous visit or medication prescribed by the provider in the 2 years preceding buprenorphine treatment initiation. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year.
DATA COLLECTION/EXTRACTION METHODS
Adult Veterans (age ≥ 18 years) diagnosed with opioid use disorder and treated with buprenorphine or buprenorphine/naloxone within the VHA system were included in this study. We excluded those receiving buprenorphine patches, those with documentation of a metastatic tumor diagnosis within 2 years prior to buprenorphine initiation, and those without geographical information on rurality.
PRINCIPAL FINDINGS
A total of 28,791 Veterans were included in the study. Within the overall study sample, 56.3% (n = 16,206) of Veterans previously had at least one outpatient encounter with their initial buprenorphine provider, and 24.9% (n = 7174) of Veterans previously had at least one prescription from that provider in the 2 years preceding buprenorphine initiation. There was no significant or clinically meaningful association between therapeutic relationship history and treatment retention when defined as visit history (aHR: 0.99; 95% CI: 0.96, 1.02) or medication history (aHR: 1.03; 95% CI: 1.00, 1.07).
CONCLUSIONS
Veterans initiating buprenorphine frequently did not have a therapeutic history with their initial buprenorphine provider, but this relationship was not associated with treatment retention. Future work should investigate how the quality of Veteran-provider therapeutic relationships influences opioid use dependence management and whether eliminating training requirements for providers might affect access to buprenorphine, and subsequently, treatment initiation and retention.
Topics: Adolescent; Adult; Analgesics, Opioid; Buprenorphine; Humans; Opiate Substitution Treatment; Opioid-Related Disorders; Retrospective Studies; Veterans
PubMed: 34854083
DOI: 10.1111/1475-6773.13919 -
JAMA Network Open Jul 2022The opioid crisis has been exacerbated by the COVID-19 pandemic in the US, with concerns over major disruptions to medication treatment of opioid use disorder.
IMPORTANCE
The opioid crisis has been exacerbated by the COVID-19 pandemic in the US, with concerns over major disruptions to medication treatment of opioid use disorder.
OBJECTIVE
To investigate whether the COVID-19 pandemic was associated with disruption of buprenorphine and methadone supplies in the US.
DESIGN, SETTING, AND PARTICIPANTS
This repeated cross-sectional study used ARCOS (Automated Reports and Consolidated Ordering System) data, which monitor the flow of controlled substances in the US, from January 1, 2012, through June 30, 2021. Manufacturers and point of sale or distribution at the dispensing or retail level, including hospitals, retail pharmacies, clinicians, midlevel clinicians, and teaching institutions, were included in the analysis.
EXPOSURES
COVID-19 pandemic.
MAIN OUTCOMES AND MEASURES
Quarterly supplies of buprenorphine and methadone per capita in milligrams.
RESULTS
The per capita supply of methadone dropped from 13.2 mg in the first quarter of 2020 to 10.5 mg in the second quarter of 2020, whereas the per capita supply of buprenorphine increased from 3.6 mg to 3.7 mg in the same period. The per capita supply of methadone declined 20% (-2.7 mg) in the second quarter of 2020 compared with the first quarter of 2020, and the supply had not returned to 2019 levels as of June 2021, whereas the supply of buprenorphine per person increased consistently during the same period. There were considerable state disparities in the reduction of the methadone supply during the pandemic, with many states experiencing pronounced per capita supply decreases, including reductions as great as 50% in New Hampshire and Florida. These decreases in per capita methadone supply were not compensated by proportional increases in the per capita buprenorphine supply (linear fit, 0.17 [95% CI, -0.43 to 0.76]; P = .47).
CONCLUSIONS AND RELEVANCE
This cross-sectional study of buprenorphine and methadone supplies during the COVID-19 pandemic found a pronounced decline in the methadone supply but no disruption to the buprenorphine supply. Future research is needed to explain the pronounced state disparities in the methadone supply.
Topics: Buprenorphine; Cross-Sectional Studies; Humans; Methadone; Opiate Substitution Treatment; Pandemics; COVID-19 Drug Treatment
PubMed: 35881394
DOI: 10.1001/jamanetworkopen.2022.23708