Initiation and rapid titration of methadone and slow-release oral morphine (SROM) in an acute care, inpatient setting: a case series.

BACKGROUND: Methadone titration in an outpatient setting typically involves initiation with subtherapeutic doses with slow titration to mitigate the risks of respiratory depression and overdose. In pregnancy, and generally, subtherapeutic doses of methadone and slow titrations are associated with poorer outcomes in terms of treatment retention and ongoing illicit opioid use. We aim to describe rapid titration of OAT in an inpatient setting for pregnant injection opioid users with high opioid tolerance secondary to a fentanyl-based illicit drug supply. METHODS: Retrospective case series of patients admitted to a tertiary center with a primary indication of opioid withdrawal and treatment for severe opioid use disorder in pregnancy. RESULTS: Twelve women received rapid methadone titrations with or without slow-release oral morphine for opioid use disorder during a total of fifteen hospital admissions. All women included in the study were active fentanyl users (12/12). Methadone dosing was increased rapidly with no adverse events with a median dose at day 7 of 65 mg (IQR 60-70 mg) and median discharge dose of 85 mg (IQR 70-92.5 mg) during their admission for titration. Slow-release oral morphine was used in half of the titration admissions (8/15) with a median dose of 340 mg (IQR 187.5-425 mg) at discharge. The median length of admission was 12 days (IQR 9.5-15). CONCLUSIONS: A rapid titration of methadone was completed in an inpatient setting with or without slow-release oral morphine, without adverse events showing feasibility of this protocol for a pregnant population in an inpatient setting. Patients achieved therapeutic doses of methadone (and/or SROM) faster than outpatient counterparts with no known adverse events.

Initiation of Extended-release Depot Buprenorphine in a Patient Subject to a Community Treatment Order for Both Antipsychotic and Opioid Agonist Treatments.

ABSTRACT: Opioid use disorder (OUD) and schizophrenia are commonly comorbid, and patient outcomes are improved when these conditions are managed concurrently. Medication for OUD such as methadone and buprenorphine are treatments for OUD, yet psychosis introduces additional challenges in retaining patients in care. Extended-release depot buprenorphine is an emerging option for the treatment of moderate-to-severe OUD, and it may provide certain benefits in patients with concurrent OUD and psychosis. We present the case of a 32-year-old man with schizophrenia, traumatic brain injury, and OUD with a history of multiple opioid-related overdoses, followed by an assertive community treatment team, and subject to a community treatment order for both his primary psychotic disorder and OUD treatments. We discuss the role of extended-release depot buprenorphine in this unique patient population and the ethical considerations of involuntary treatment of OUD in patients lacking capacity to consent to treatment.

A contingency management approach for treatment of methamphetamine use disorder and human immunodeficiency virus antiretroviral treatment adherence in pregnancy to prevent mother-to-child transmission: a case report.

INTRODUCTION: This review highlights the rising prevalence of methamphetamine use in pregnancy in North American and the difficulty of managing active human immunodeficiency virus infection in a pregnant woman while actively using methamphetamines. Multidisciplinary medical teams with knowledge of addiction medicine, infectious disease management, and pregnancy are needed to provide combined expert care to reduce the harms associated with substance use and improve adherence to antiretroviral treatment. We report the case of a treatment-naïve pregnant patient with human immunodeficiency virus who was actively using methamphetamines. The patient was able to initiate and adhere to antiretroviral treatment while taking a prescription stimulant in a contingency management paradigm. To the best of our knowledge, this is the first documented case of prescription stimulants being used in pregnancy to improve adherence to antiretroviral medications. CASE PRESENTATION: A 32-year-old white woman with untreated human immunodeficiency virus, a newly diagnosed pregnancy, and actively using methamphetamines presented to a drop-in combined prenatal care and addiction medicine clinic. After initiating a prescription amphetamine in a contingency management paradigm, she was adherent to human immunodeficiency antiretroviral treatment and had a fully suppressed viral load throughout the remainder of her pregnancy. CONCLUSION: Active treatment of methamphetamine use disorders with prescription stimulants, coupled with contingency management, may represent a mechanism to engage patients in care and improve adherence to antiretroviral treatment (and prevent mother-to-child-transmission of human immunodeficiency virus).

Use of Injectable Opioid Agonist Therapy in a In-Patient Setting for a Pregnant Patient With Opioid Use Disorder: A Case Report.

BACKGROUND: In the era of highly potent illicit opioids, such as fentanyl and carfentanil, injectable opioid agonist treatment (iOAT) is an effective treatment for those with severe and treatment-refractory opioid use disorder. Untreated opioid use disorder in pregnancy can lead to maternal and neonatal morbidity and mortality. There are currently limited reports on the use of iOAT in pregnant women. The in-patient setting may provide an opportunity to pregnant women for stabilization with iOAT where first line therapies have been ineffective. CASE SUMMARY: We report a case of a pregnant individual who engaged in daily intravenous fentanyl who was admitted to the hospital at 29 weeks gestation for stabilization with iOAT, methadone, and slow-release oral morphine. Before admission, she endured 6 opioid overdoses in her pregnancy and continued to use illicit intravenous opioids in the community despite high dose methadone combined with slow-release oral morphine. Her withdrawal symptoms and cravings were ameliorated with hydromorphone 90 mg IM/IV BID, methadone 135 mg daily, and morphine sulfate sustained release 600 mg daily. With this regimen, she was able to reduce her intravenous fentanyl use to a single episode during her hospitalization. She completed her pregnancy in hospital, delivering a full-term live infant after receiving comprehensive prenatal care. DISCUSSION: This case report highlights iOAT as an option during pregnancy and describes the in-patient setting as appropriate to retain high-risk patients in care. This approach may benefit those who are refractory to standard opioid agonist treatment, the numbers of whom may be rising as tolerance to the illicit supply increases.

Aging and Sexual Health: A Cross-Sectional Survey of Patients in a Canadian Urban Academic Family Health Team.

Primary care physicians are in a position to recognize sexuality as a core component of health. Data examining the sexual behaviours of Canadians over the age of 50 and the role of primary care in this domain is lacking. A cross-sectional survey was administered to patients over the age of 50, which assessed the importance of sexual activity, problems, and preferences in discussing sexual health with their primary care providers. A total of 39 per cent of patients indicated ongoing sexual activity and 52% of male participants reported current sexual activity compared with 25 per cent of females (p < 0.01). More males reported sexual activity as important than did females (69% vs. 45%, p < 0.01). Participants identifying sexual health concerns discussed physical dysfunctions more than emotional, social, or global health concerns (p < 0.01). More male participants discussed sexual health concerns with their family physician than did females (p < 0.01). The results of our study indicate that many individuals over the age of 50 continue to be sexually active, and that physical and non-physical concerns directly impact participation in sexual activity.

Endothelial lipid phosphate phosphatase-3 deficiency that disrupts the endothelial barrier function is a modifier of cardiovascular development.

AIMS: Lipid phosphate phosphatase-3 (LPP3) is expressed at high levels in endothelial cells (ECs). Although LPP3 is known to hydrolyse the phosphate group from lysolipids such as spingosine-1-phosphate and its structural homologues, the function of Lpp3 in ECs is not completely understood. In this study, we investigated how tyrosine-protein kinase receptor (TEK or Tie2) promoter-dependent deletion of Lpp3 alters EC activities. METHODS AND RESULTS: Lpp3(fl/fl) mice were crossed with the tg.Tie2(Cre) transgenic line. Vasculogenesis occurred normally in embryos with Tie2(Cre)-mediated deletion of Lpp3 (called Lpp3(ECKO)), but embryonic lethality occurred in two waves, the first wave between E8.5 and E10.5, while the second between E11.5 and E13.5. Lethality in Lpp3(ECKO) embryos after E11.5 was accompanied by vascular leakage and haemorrhage, which likely resulted in insufficient cardiovascular development. Analyses of haematoxylin- and eosin-stained heart sections from E11.5 Lpp3(ECKO) embryos showed insufficient heart growth associated with decreased trabeculation, reduced growth of the compact wall, and absence of cardiac cushions. Staining followed by microscopic analyses of Lpp3(ECKO) embryos revealed the presence of apoptotic ECs. Furthermore, Lpp3-deficient ECs showed decreased gene expression and protein levels of Cyclin-D1, VE-cadherin, Fibronectin, Klf2, and Klf4. To determine the underlying mechanisms of vascular leakage and barrier disruption, we performed knockdown and rescue experiments in cultured ECs. LPP3 knockdown decreased transendothelial electrical resistance and increased permeability. Re-expression of ß-catenin cDNA in LPP3-knockdown ECs partially restored the effect of the LPP3 loss, whereas re-expression of p120ctn cDNA did not. CONCLUSION: These findings demonstrate the essential roles of LPP3 in the maturation of EC barrier integrity and normal cardiovascular development.