Rotation from methadone to buprenorphine using a micro-dosing regime in patients with opioid use disorder and serious mental illness: A case series.

INTRODUCTION: Inducting buprenorphine from methadone has traditionally involved initial opioid withdrawal, with risk of mental state deterioration in patients with serious mental illness (SMI). Micro-dosing of buprenorphine, with small incremental doses, is a novel off-label approach to transitioning from methadone and does not require a period of methadone abstinence. Given the limited literature about buprenorphine microdosing, we aimed to evaluate the feasibility and safety of inducting buprenorphine in a series of patients on methadone with SMI. METHODS: For this retrospective case series, we reviewed the records of 16 patients with SMI at a Melbourne addiction treatment centre, from January 2021 to July 2022, who transitioned via micro-dosing, from high-dose methadone (>30 mg) to buprenorphine and depot-buprenorphine. Psychiatric diagnoses, mental state, other substance withdrawal, transfer success, transition time, opioid withdrawal symptoms and overall patient experience were collected via objective and subjective reporting. RESULTS: Methadone to buprenorphine transfer was completed by 88% of patients. Mental health measures remained stable with the exception of mildly increased anxiety. Median transfer time was 6.5 days for inpatients, 9 days for mixed setting and 10 days for outpatients. Most patients (93%) rated their experience 'manageable' reporting mild withdrawal symptoms. One patient met study criteria for precipitated withdrawal. DISCUSSION AND CONCLUSIONS: This retrospective case series provides evidence that the use of a micro-dosing buprenorphine induction for methadone to buprenorphine transitions, including to depot-buprenorphine, has negligible risk, is tolerated by patients with SMI and is unlikely to precipitate an exacerbation of their mental illness.

The six Rs of managing high-risk opioid prescribing.

BACKGROUND: High-dose opioid prescribing is associated with an increased risk of harms, including death. OBJECTIVE: The aim of this article is to discuss the concept of high-risk opioid prescribing, as well as relevant management strategies for patients on >100 mg oral morphine equivalent daily dose (OMEDD). The six 'Rs' approach to managing high-risk opioid prescribing (Rotation of opioids; Reduction; Replacement pharmacotherapy; Reversal with naloxone; Referral; Restriction of supply) is discussed. DISCUSSION: The six Rs is an aide-memoire that summarises the management options available to mitigate the risk of high OMEDDs. However, an effective therapeutic alliance between clinician and patient remains the foundation of all risk mitigation strategies.

Residual cannabis levels in blood, urine and oral fluid following heavy cannabis use.

An understanding of tetrahydrocannabinol (THC) kinetics and residual levels after cannabis use is essential in interpreting toxicology tests in body fluids from live subjects, particularly when used in forensic settings for drug abuse, traffic and interpersonal violence cases. However the current literature is largely based on laboratory studies using controlled cannabis dosages in experienced users, with limited research investigating the kinetics of residual THC concentrations in regular high dose cannabis users. Twenty-one dependent cannabis users were recruited at admission to two residential detoxification units in Melbourne, Australia. After being provided with information about, and consenting to, the study, subjects volunteered to provide once-daily blood, urine and oral fluid (saliva) samples for seven consecutive days following admission, involving cessation and abstinence from all cannabis use. Blood and oral fluid specimens were analysed for THC and urine specimens for the metabolite THC-COOH. In some subjects THC was detectable in blood for at least 7 days and oral fluid specimens were positive for THC up to 78 h after admission to the unit. Urinary THC-COOH concentrations exceeded 1000 ng/mL for some subjects 129 h after last use. The presented blood THC levels are higher and persist longer in some individuals than previously described, our understanding and interpretation of THC levels in long term heavy cannabis users may need to be reconsidered.

Cannabis control. An approach to cannabis use and dependence.

BACKGROUND: Cannabis use is widespread in our community. Dependence on cannabis may be associated with significant mental and physical harms. OBJECTIVE: This article aims to give an overview of the adverse effects of cannabis use and guidelines for management of cannabis dependence. DISCUSSION: General practitioners can manage cannabis dependence from a harm minimisation framework using motivational interviewing and other counselling measures. Occasionally, pharmacologic approaches may be used with the caveat that they should be brief and carefully monitored.

Serious morbidity associated with misuse of over-the-counter codeine-ibuprofen analgesics: a series of 27 cases.

OBJECTIVE: To investigate morbidity related to misuse of over-the-counter (OTC) codeine-ibuprofen analgesics. DESIGN AND SETTING: Prospective case series collected from Victorian hospital-based addiction medicine specialists between May 2005 and December 2008. MAIN OUTCOME MEASURES: Morbidity associated with codeine-ibuprofen misuse. RESULTS: Twenty-seven patients with serious morbidity were included, mainly with gastrointestinal haemorrhage and opioid dependence. The patients were taking mean daily doses of 435-602 mg of codeine phosphate and 6800-9400 mg ibuprofen. Most patients had no previous history of substance use disorder. The main treatment was opioid substitution treatment with buprenorphine-naloxone or methadone. CONCLUSIONS: Although codeine can be considered a relatively weak opioid analgesic, it is nevertheless addictive, and the significant morbidity and specific patient characteristics associated with overuse of codeine-ibuprofen analgesics support further awareness, investigation and monitoring of OTC codeine-ibuprofen analgesic use.