Methodological quality of guidelines for the management of opioid use disorder: A systematic review.

WHAT IS KNOWN AND OBJECTIVE: Opioid Use Disorder (OUD) has a high mortality rate and affects millions of people worldwide. Many organizations and societies develop Clinical Practice Guidelines (CPGs) to serve as a framework for healthcare providers to decide and support best practice to manage and treat OUD. However, not all CPGs sufficiently address all the important aspects of optimal care for managing OUD. This study aims to review current CPGs for management of OUD, evaluate their methodological quality and summarize their recommendations. METHODS: We conducted this systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Various databases were searched for CPGs and Appraisal of Guidelines for Research and Evaluation (AGREE-II) instrument was used to assess the methodological quality. We also summarized the treatments plans of CPGs across continuum of care (diagnosis and assessment, treatment initiation, pharmacotherapy and psychosocial). RESULTS: This review included 28 CPGs of varying qualities. CPGs from high-income countries and international organizations rated high for their methodological quality. Most CPGs scored high for the scope and purpose domain and scored low for applicability domain. Recommendations for the continuum of care for OUD varied across CPGs. Buprenorphine was recommended in most of the CPGs, followed by methadone. Recommendations for psychosocial interventions also varied, with cognitive behaviour therapies and counselling or education being the common recommendations in many CPGs WHAT IS NEW AND CONCLUSION: We found most CPGs have scope and purpose and clarity of presentation. However, the methodological rigour and applicability scored low. CPGs need to frame health questions in a comprehensible manner and provide an update as evidence grows. It is important for CPG developers to consider methodological quality as a factor when developing CPG recommendations.

Assessment of Chronic Pain Management in the Treatment of Opioid Use Disorder: Gaps in Care and Implications for Treatment Outcomes.

Chronic pain is a significant comorbid condition among individuals with opioid use disorder (OUD). However, due to conflicting perceptions of responsibility, structural barriers, and a lack of widely applied standards of care, it is unclear what the landscape of chronic pain management looks like in addiction medicine. Using a national opioid surveillance system, we analyzed survey data from new entrants (n = 14,449) to 225 OUD treatment centers from 2013 to 2018, as well as an online survey among a subset of respondents (n = 309). While chronic pain was reported by 33.4% of the sample, two-thirds of the chronic pain group (66.0%) reported their pain was not managed through their OUD treatment program, with 47% reporting worsening pain. Pain that was managed was primarily done so through pharmaceuticals (75.2%), notably as a secondary effect of medication-assisted treatment. In addition, 43.2% reported chronic pain as a primary factor in their opioid relapse. These data suggest that chronic pain is commonly reported, yet not managed by many OUD treatment programs, increasing the likelihood of opioid relapse. In order to improve poor outcomes among OUD patients, interdisciplinary collaboration/care, along with evidence-based policies or processes for quality pain management in addiction care need to be prioritized. PERSPECTIVE: This article suggests chronic pain is commonly reported, yet not managed by many OUD treatment programs, increasing the likelihood of opioid relapse. In order to improve low retention and success rates among OUD patients, interdisciplinary collaboration, evidence-based policies or processes (eg, referral) for quality pain management in addiction care need to be prioritized.

Treatment of Opioid Use Disorder in Pregnant Women via Telemedicine: A Nonrandomized Controlled Trial.

Importance: There are high rates of maternal and newborn morbidity and mortality associated with opioid use disorder (OUD). Integrating OUD treatment in obstetric practices for pregnant and postpartum women via telemedicine can increase access to care and reduce the consequences of OUD. Evaluation of this care delivery model, however, is needed before widespread adoption. Objective: To compare maternal and newborn outcomes among pregnant women with OUD receiving care via telemedicine vs in person. Design, Setting, and Participants: A nonrandomized controlled trial including 98 women receiving perinatal OUD treatment in 4 outpatient obstetric practices by telemedicine or in person and followed up until 6 to 8 weeks post partum was conducted from September 4, 2017, to December 31, 2018. Logistic regression with propensity score adjustment was applied to reduce group selection bias and control for potentially confounding variables. Interventions: Participants were seen weekly for 4 weeks, every 2 weeks for 4 weeks, and monthly thereafter and provided relapse prevention therapy and buprenorphine. Main Outcomes and Measures: The outcomes were retention in treatment, defined as uninterrupted addiction treatment during pregnancy through 6 to 8 weeks post partum; urine drug screen results at delivery and 6 to 8 weeks post partum; and a neonatal abstinence syndrome (NAS) diagnosis collected via electronic health records. Results: The mean (SD) age of the 98 pregnant women was 30.23 (5.12) years. Of these, 41 of 44 women (93.2%) in the telemedicine group and 48 of 54 women (88.9%) in the in-person group chose to continue treatment in the program after an initial evaluation. After propensity score weighting and doubly robust estimation, no significant differences were found between groups in retention in treatment at 6 to 8 weeks post partum (telemedicine: 80.4% vs in person: 92.7%; treatment effect, -12.2%; 95% CI, -32.3% to -4.4%). Similarly, after propensity score weighting and doubly robust estimation, there were no significant group differences in rates of NAS (telemedicine: 45.4% vs in person: 63.2%; treatment effect, -17.8%; 95% CI, -41.0% to 8.9%). Conclusions and Relevance: In this nonrandomized controlled trial, virtually integrated OUD care in obstetric practices produced similar maternal and newborn outcomes compared with in-person care. These findings may have important public health implications for combatting the opioid crisis and its consequences on pregnant women and their families. Future large randomized clinical trials are needed. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT04049032.

Job Satisfaction Among Methadone Maintenance Treatment Clinic Service Providers in Jiangsu, China: A Cross-sectional Survey.

OBJECTIVE: Service providers' job satisfaction is critical to the stability of the work force and thereby the effectiveness of methadone maintenance treatment (MMT) programs. This study aimed to explore MMT clinic service providers' job satisfaction and associated factors in Jiangsu, China. METHODS: This secondary study used baseline data of a randomized interventional trial implemented in Jiangsu, China. A survey was conducted among 76 MMT service providers using the computer-assisted self-interview (CASI) method. Job satisfaction responses were assessed via a 30-item scale, with a higher score indicating a higher level of job satisfaction. Perceived institutional support and perceived stigma due to working with drug users were measured using a 9-item scale. Correlation and multiple linear regression analyses were performed to identify factors associated with job satisfaction. RESULTS: Correlation analyses found a significant association between job satisfaction and having professional experience in the prevention and control of HIV, other sexually transmitted infections, or other infectious diseases (P = 0.046). Multiple regression analyses revealed that working at MMT clinics affiliated with Center for Disease Control and Prevention sites was associated with a lower level of job satisfaction (P = 0.014), and perception of greater institutional support (P = 0.001) was associated with a higher level of job satisfaction. CONCLUSION: Job satisfaction among MMT clinic service providers was moderate in our study. Our findings suggest that institutional support for providers should be improved, and that acquisition of additional expertise should be encouraged.

Buprenorphine compared with methadone in opioid-dependent pregnant women: How does it affect neonatal abstinence syndrome?

BACKGROUND: The growing opioid epidemic in the United States has led to increasingly high rates of neonatal abstinence syndrome (NAS). Preliminary studies have shown that buprenorphine maintenance treatment (BMT) may lead to better outcomes for infants than methadone maintenance treatment (MMT). OBJECTIVES: The authors gathered recent evidence to answer the following PICO (population, intervention, comparison, and outcome) question: In opioid-dependent pregnant women, how does buprenorphine compared with methadone administration affect NAS? DATA SOURCES: A literature search was completed in PubMed, Scopus, Embase, and Web of Science databases and limited to the past 5 years. The following parameters were analyzed in the articles: NAS occurrence, length of hospital stay in days, NAS treatment length, and amount of pharmacotherapy administered to treat NAS. CONCLUSIONS: In comparison to methadone, buprenorphine exposure in utero is associated with significantly shorter hospital stays for the infant after delivery, shorter length of NAS treatment, and decreased frequency/duration of pharmacotherapy for NAS symptoms in the infant. IMPLICATIONS FOR PRACTICE: Based on the findings, a weak recommendation can be made for the use of BMT over MMT in opioid-dependent pregnant women. However, further research is necessary to definitively recommend buprenorphine over methadone use in this population, especially regarding the effect of maternal severity of addiction on adherence to BMT, and long-term effects of in utero buprenorphine exposure.

Opioid substitution therapy for people living in German prisons-inequality compared with civic sector.

BACKGROUND: The above-average proportion of people with opioid use disorder living in prisons is a worldwide reality, and the need to treat these people was recognized internationally more than 20 years ago. Studies have shown that substitution therapies are best suited to treat opioid use disorder and reduce the risk of HIV and hepatitis C transmission and overdose. However, huge health inequalities exist in and outside of prison due to the different implementation of opioid substitution therapy (OST). People living in prisons are entitled to the best possible health care. This is established by the Universal Declaration of Human Rights and by the International Convention on Economic, Social and Cultural Rights. Solely the imprisonment, and not the loss of fundamental human rights, constitutes the punishment. METHODS: A qualitative literature search using PubMed and Google Scholar was performed in order to identify relevant publications. RESULTS: This review shows the inequality in availability of opioid substitution therapy for people living in prison compared with people outside of prison in Germany. It also gives possible reasons and evidence for this inequality, showing that continuing or initiating OST in prison is more beneficial for the health of people living in prison than abstinence-oriented treatment only. CONCLUSION: It is important that drug use disorder is treated as a serious illness also in prison. Joint efforts are needed to provide people living in prison with the best possible treatment and to minimize the adverse effects of drug use. Therefore, with laws, policies, and programs that conform to international human rights standards, each state must ensure that people living in prison receive the same health care as people outside of prison.

Buprenorphine in the United States: Motives for abuse, misuse, and diversion.

Opioid use disorder (OUD) and its consequences are a major public health concern. The partial agonist buprenorphine is a safe and effective treatment for OUD, but concerns about abuse, misuse, and diversion of buprenorphine have been raised. This narrative review examined the rates and motives for use of illicit buprenorphine in the United States. Findings from the 17 included studies suggest the majority of study participants using illicit buprenorphine do so for reasons related to misuse (to manage opioid withdrawal symptoms or achieve or maintain abstinence from other opioids). A smaller percentage of study respondents reported using buprenorphine for reasons related to abuse (to get high). There appears to be a gap between need for buprenorphine and access to adequate treatment. Attenuation of policy-related barriers and adoption of appropriate buprenorphine use by the treatment community are critical tools in the continued effort to reduce the burdens associated with OUD.

Deploying science to change hearts and minds: Responding to the opioid crisis.

The U.S. opioid epidemic, now in its third decade, continues to claim tens of thousands of lives each year. Despite strong scientific evidence to support the deployment of effective interventions from prevention to treatment, implementation and access to quality care continue to lag, in part, due to continued opioid prescribing, siloing of treatment services for those with opioid use disorder (OUD), public support for non-evidence-based practices, stigma, and discrimination. Primary prevention efforts should focus on avoiding exposure to opioids for chronic non-cancer pain, as there is little evidence of efficacy but substantial evidence of harms. FDA-approved medications for OUD (MOUD) have incontrovertible evidence supporting their efficacy, and their use saves lives. However, fewer than 10% of those in need are able to receive MOUD. The barriers include an inadequate workforce, inadequate reimbursement, challenges navigating the treatment system, and profiteering bad actors (e.g., treatment brokers, programs delivering non-evidenced-based care). Perhaps the greatest challenge (and deterrent from receiving MOUD) is stigma and lack of public knowledge about their efficacy. Detoxification is probably the most common form of "treatment" for OUD, but the evidence shows that detoxification actually increases the risk for overdose. Expansion of MOUD delivery in the criminal justice system, health care systems and communities is essential to stemming the tide of this epidemic. This article is a call to action for the scientific community to ensure that scientific evidence is guiding patient care, funding for treatment, and policy decisions that address the opioid epidemic.

Managing opioid use disorder in primary care: PEER simplified guideline.

OBJECTIVE: To use the best available evidence and principles of shared, informed decision making to develop a clinical practice guideline for a simplified approach to managing opioid use disorder (OUD) in primary care. METHODS: Eleven health care and allied health professionals representing various practice settings, professions, and locations created a list of key questions relevant to the management of OUD in primary care. These questions related to the treatment setting, diagnosis, treatment, and management of comorbidities in OUD. The questions were researched by a team with expertise in evidence evaluation using a series of systematic reviews of randomized controlled trials. The Guideline Committee used the systematic reviews to create recommendations. RECOMMENDATIONS: Recommendations outline the role of primary care in treating patients with OUD, as well as pharmacologic and psychotherapy treatments and various prescribing practices (eg, urine drug testing and contracts). Specific recommendations could not be made for management of comorbidities in patients with OUD owing to limited evidence. CONCLUSION: The recommendations will help simplify the complex management of patients with OUD in primary care. They will aid clinicians and patients in making informed decisions regarding their care.

The optimization of methadone dosing whilst treating with rifampicin: A pharmacokinetic modeling study.

BACKGROUND: The use of oral methadone in opioid substitution treatment (OST) for the management of opioid use disorder is established clinical practice. Confounding treatment is the increased risks of contracting Mycobacterium tuberculosis, the mainstay treatment of which incorporates the potent CYP 2B6 inducer rifampicin. METHODS: This study applied pharmacokinetic modelling using virtual clinical trials, to pharmacokinetically quantify the extent and impact of rifampicin-mediated drug-drug interactions (DDI) on methadone plasma concentrations. An R-methadone model was developed and validated against 11 retrospective clinical studies prior to use in all subsequent studies. The aims were to investigate: (i) the impact of the DDI on daily methadone doses of 60 mg, 90 mg and 120 mg; (ii) dose escalation during rifampicin and (iii) dose reduction following rifampicin cessation. RESULTS: A dose increase to 160 mg daily during rifampicin treatment phases was required to maintain peak methadone plasma concentrations within a derived therapeutic window of 80-700 ng/mL. Dose escalation prior to rifampicin initiation was not required and resulted in an increase in subjects with supra-therapeutic concentrations. However, during rifampicin cessation, a dose reduction of 10 mg every 2 days commencing prior to rifampicin cessation, ensured that most patients possessed a peak methadone plasma concentration within an optimal therapeutic window. IMPLICATIONS: Rifampicin significantly alters methadone plasma concentrations and necessitates dose adjustments. Daily doses of almost double those used perhaps more commonly in clinical practice are required for optimal plasma concentration and careful consideration of dose reduction strategies would be required during the deinduction phase.

Retrospective Review of a Novel Approach to Buprenorphine Induction in the Emergency Department.

BACKGROUND: The Emergency Department (ED) frequently treats patients with drug overdoses and is an important resource for individuals with opioid use disorder who are seeking treatment. Initiating medication-assisted treatment (MAT) in the ED seems to be an effective way to link patients with opioid use disorder (OUD) to treatment programs. There is ongoing discussion on the best approach to MAT in the ED setting. OBJECTIVE: Describe a new model for managing OUD in the ED. METHOD: Information was obtained retrospectively from the electronic medical records of patients seen in a large county tertiary care center's Clinical Decision Unit (CDU) for OUD between September 1, 2017 and February 6, 2018. Data were summarized descriptively. RESULTS: There were 18 different patients placed in the CDU during the study period. Ninety-five percent were induced with buprenorphine-naloxone in the CDU. The median initial Clinical Opioid Withdrawal Scale score at the time of induction was 10. The median total dose of buprenorphine-naloxone that was administered was 8/2 mg. The median amount of time spent in the CDU and ED combined was 23 h. Approximately (12/19) 63% of subjects went to their initial follow-up appointment in clinic. Nine were still active in clinic at 30 days and 4 were active at 6 months. CONCLUSIONS: This retrospective chart review shows promising preliminary data for managing OUD in an ED CDU. Such strategies have the potential to increase access to care in a vulnerable patient population.

Methadone maintenance treatment as social control: Analyzing patient experiences.

Methadone maintenance treatment (MMT) is a harm reduction approach for persons who wish to stop using opioids and is rather effective if used for a minimum of 12 months. Notably, research demonstrates that many persons enrolled in MMT programs discontinue care before this time, limiting its effects. To better understand this process, we undertook an exploratory descriptive qualitative study and interviewed 12 men and women who were using MMT. Using the theoretical work of Foucault and Hardt and Negri, the interview data highlighted that MMT continues to be strongly stigmatized, and that it is a system of care that involves rewards and penalties, based on if patients behave according to prescribed norms. These results suggest that MMT is a disciplinary mechanism, albeit one that impedes its own access. We consequently recommend that healthcare providers work to facilitate access to MMT, which means altering care delivery.

Integrated Brief Intervention for PTSD and Substance Use in an Antepartum Unit.

Purpose To evaluate the efficacy of a brief education session affecting patient perspectives on follow up care of substance use and trauma treatment in pregnant women admitted to a medical hospital. Description Participants (N = 31) were recruited from the antepartum unit at Magee-Women's Hospital at the University of Pittsburgh who had current substance use and history of trauma. A voluntary individual educational session was offered that discussed the diagnosis and treatment of substance use and trauma, fundamental coping skills, and local resources. Utility of the session, knowledge of PTSD, and barriers of care were evaluated through a pre- and post- session questionnaire. Assessment All participants found the session improved their knowledge of PTSD, substance use, safe coping skills, and increased their likelihood of pursuing further follow up treatment. Conclusion Brief educational interventions that are integrated in the medical hospital are found to be useful by patients and reported to influence their decision to seek further treatment. Further studies are needed to analyze the long-term outcomes of brief interventions.

Acute Pain Management for Patients Receiving Medication-Assisted Therapy.

Evidence-based approaches for the treatment of opioid use disorder include the use of opioid medications (methadone, buprenorphine, or naltrexone), collectively referred to as medication-assisted therapy. Patients receiving medication-assisted therapy may present in the acute care setting with pain, often related to planned surgical procedures to treat health issues that were not addressed before entering treatment. Because these medications act on the same receptors as do analgesic opioids-and, in the cases of methadone and buprenorphine, have analgesic properties - managing acute pain in these patients can be challenging. Principles of effective pain management for these patients include continuing the usual medication-assisted therapy dose; using nonpharmacological and nonopioid pain management strategies as possible and immediate-release opioids, titrating to effect and monitoring for toxicity; anticipating tolerance and hyperalgesia; and establishing a collaborative treatment relationship with the medication-assisted therapy provider. Providing effective pain treatment supports ongoing recovery in patients with opioid use disorder.

Identifying patient-important outcomes in medication-assisted treatment for opioid use disorder patients: a systematic review protocol.

INTRODUCTION: Illicit opioid use has become a national crisis in Canada, with over 65 000 people seeking treatment for opioid use disorder (OUD) in Ontario and British Columbia alone. Medication-assisted treatment (MAT) is a common treatment for OUD. There is substantial variability in treatment outcomes used to evaluate effectiveness of MAT, making it difficult to establish clinically and scientifically relevant treatment effect. Furthermore, patients are often excluded from the process of determining these outcomes. The primary objective of this review is to examine outcomes currently used to measure MAT effectiveness and to identify patient-relevant outcomes to enhance effectiveness of treatment options. This review refers to patient-important outcomes as those outcomes patients consider important to or markers of treatment success. METHODS AND ANALYSIS: MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane Library, Cochrane Clinical Trials Registry, National Institutes for Health Clinical Trials Registry and WHO International Clinical Trials Registry Platform databases will be searched. We will search databases from inception to the date the search is ran. Studies of interest include those evaluating the effectiveness of MAT for patients with OUD, with or without consultation with patients regarding what they consider to be important as an indicator of treatment success. Results will be analysed using thematic analysis and qualitative analysis where possible. This will result in comprehensive synthesis of all outcomes and measures found related to OUD treatment effectiveness. ETHICS AND DISSEMINATION: We are collaborating with Canadian Addiction Treatment Centres which provide MAT to patients with OUD who will participate in disseminating study results. Dissemination strategies will involve sharing study results through workshops, presentations, peer-reviewed publications, study reports, community presentations and resources in primary care settings. PROSPERO REGISTRATION NUMBER: CRD42018095553.