RESUMO
Mainstays of opioid overdose prevention include medications for opioid use disorder (e.g., methadone or buprenorphine) and naloxone distribution. Inadequate access to buprenorphine limits its uptake, especially in communities of color, and people with opioid use disorders encounter multiple barriers to obtaining necessary medications including insurance, transportation, and consistent availability of telephones. UMass Memorial Medical Center and our community partners sought to alleviate these barriers to treatment through the deployment of a mobile addiction service, called the Road to Care. Using this approach, multidisciplinary and interprofessional providers deliver holistic addiction care by centering our patients' needs with respect to scheduling, location, and convenience. This program also extends access to buprenorphine and naloxone among people experiencing homelessness. Additional systemic and individualized barriers encountered are identified, as well as potential solutions for future mobile addiction service utilization. Over a two-year period, we have cared for 1,121 individuals who have accessed our mobile addiction service in over 4,567 encounters. We prescribed buprenorphine/naloxone (Suboxone®) to 330 individuals (29.4% of all patients). We have distributed nearly 250 naloxone kits directly on-site or and more than 300 kits via prescriptions to local pharmacies. To date, 74 naloxone rescue attempts have been reported back to us. We have demonstrated that a community-based mobile addiction service, anchored within a major medical center, can provide high-volume and high-quality overdose prevention services that facilitate engagement with additional treatment. Our experience is described as a case study below.
Assuntos
Buprenorfina , Overdose de Drogas , Transtornos Relacionados ao Uso de Opioides , Humanos , Serviços de Saúde Comunitária , Naloxona/uso terapêutico , Combinação Buprenorfina e Naloxona/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Buprenorfina/uso terapêutico , Overdose de Drogas/tratamento farmacológico , Overdose de Drogas/prevenção & controleRESUMO
INTRODUCTION: Conflictual evidence exists regarding the effects of cannabis use on the outcomes of opioid agonist therapy (OAT). In this exploratory analysis, we examined the effect of recent cannabis use on opioid use, craving, and withdrawal symptoms, in individuals participating in a trial comparing flexible buprenorphine/naloxone (BUP/NX) take-home dosing model to witnessed ingestion of methadone. METHODS: We analyzed data from a multi-centric, pragmatic, 24-week, open label, randomized controlled trial in individuals with prescription-type opioid use disorder (n = 272), randomly assigned to BUP/NX (n = 138) or methadone (n = 134). The study measured last week cannabis and opioid use via timeline-follow back, recorded at baseline and every two weeks during the study. Craving symptoms were measured using the Brief Substance Craving Scale at baseline, and weeks 2, 6, 10, 14, 18 and 22. The study measured opioid withdrawal symptoms via Clinical Opiate Withdrawal Scale at treatment initiation and weeks 2, 4, and 6. RESULTS: The mean maximum dose taken during the study was 17.3 mg/day (range = 0.5-32 mg/day) for BUP/NX group and 67.7 mg/day (range = 10-170 mg/day) in the methadone group. Repeated measures generalized linear mixed models demonstrated that cannabis use in the last week (mean of 2.3 days) was not significantly associated with last week opioid use (aß ± standard error (SE) = -0.06 ± 0.04; p = 0.15), craving (aß ± SE = -0.05 ± 0.08, p = 0.49), or withdrawal symptoms (aß ± SE = 0.09 ± 0.1, p = 0.36). Bayes factor (BF) for each of the tested models supported the null hypothesis (BF < 0.3). CONCLUSIONS: The current study did not demonstrate a statistically significant effect of cannabis use on outcomes of interest in the context of a pragmatic randomized-controlled trial. These findings replicated previous results reporting no effect of cannabis use on opioid-related outcomes.
Assuntos
Buprenorfina , Cannabis , Transtornos Relacionados ao Uso de Opioides , Síndrome de Abstinência a Substâncias , Humanos , Analgésicos Opioides/uso terapêutico , Cannabis/efeitos adversos , Antagonistas de Entorpecentes , Teorema de Bayes , Tratamento de Substituição de Opiáceos/métodos , Combinação Buprenorfina e Naloxona/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Metadona/uso terapêutico , Síndrome de Abstinência a Substâncias/tratamento farmacológicoRESUMO
BACKGROUND: Buprenorphine-naloxone is a medication shown to improve outcomes for individuals seeking treatment for opioid use disorder (OUD); however, outcomes are limited by low medication adherence rates. This is especially true during the early stages of treatment. METHODS: The present study proposes to utilize a sequential multiple assignment randomized trial design to compare two psychological interventions targeting buprenorphine-naloxone adherence: (1) contingency management (CM) and (2) brief motivational interviewing plus substance-free activities session plus mindfulness (BSM). Participants will be N = 280 adults who present to a university-based addictions clinic seeking treatment for OUD. Participants will be randomized to condition to receive 4 sessions of their assigned intervention (CM or BSM). Participants who are adherent, defined as attending physician appointments and having buprenorphine present in urine toxicology, will enter maintenance intervention for an additional 6 months. Those who are not adherent will be re-randomized to receive either the other intervention or both interventions. Follow-up will occur at 8 months post-randomization. CONCLUSIONS: This novel design will examine the benefit of sequential treatment decisions following non-adherence. The primary outcome of this study is buprenorphine-naloxone medication adherence, as assessed by physician visit attendance and presence of buprenorphine in urine. Results will elicit the relative efficacy of CM and BSM compared to one another and whether keeping the initial treatment approach when adding the alternative approach for initially non-adherent individuals is beneficial. TRIAL REGISTRATION: ClinicalTrials.gov NCT04080180.
Assuntos
Buprenorfina , Atenção Plena , Transtornos Relacionados ao Uso de Opioides , Adulto , Humanos , Combinação Buprenorfina e Naloxona/uso terapêutico , Antagonistas de Entorpecentes/efeitos adversos , Economia Comportamental , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/psicologia , Buprenorfina/uso terapêutico , Adesão à Medicação , Tratamento de Substituição de Opiáceos/métodosRESUMO
BACKGROUND: The State of New York, along with the whole nation, is struggling to combat the opioid epidemic. Major authoritative bodies on chronic pain and addiction have advocated against the use of opioids long term for chronic pain. In the spring of 2021, our pain management clinic made the decision to discontinue chronic opioid prescriptions, offering instead a three-part intervention to provide patients with support for chronic pain during the process of discontinuing chronic opioid therapy (COT). Our goal was to provide safer and more evidence-based care for our chronic pain population. OBJECTIVES: To safely wean patients in our pain management clinic off of COT and offer alternative pain interventions in order to help them reach their health goals. INTERVENTION: Our three-part intervention included a unified plan for weaning patients off COT while simultaneously offering (1) expansion of integrated pain modalities, (2) Suboxone therapy and (3) a community health worker (CHW) support programme. RESULTS: Over the course of 8 months, our clinic successfully transitioned 380 patients off of COT while simultaneously expanding access to alternative pain management modalities, Suboxone therapy and CHW support services. CONCLUSION: Alternative pain management modalities, Suboxone therapy and CHW support all help to aid patients weaning off of COT while still adequately addressing their chronic pain. Our model may be adaptable to other pain management practices hoping to decrease inappropriate use of COT.
Assuntos
Analgésicos Opioides , Dor Crônica , Analgésicos Opioides/uso terapêutico , Combinação Buprenorfina e Naloxona , Dor Crônica/induzido quimicamente , Dor Crônica/tratamento farmacológico , Dor Crônica/epidemiologia , Humanos , Manejo da Dor , Melhoria de QualidadeRESUMO
BACKGROUND: Opioid use disorder (OUD) is a major public health crisis for which buprenorphine-naloxone is an effective evidence-based treatment. Analysis of Reddit data yields detailed information about firsthand experiences with buprenorphine-naloxone that has the potential to inform treatment of OUD. METHODS: We conducted a thematic analysis of posts about buprenorphine-naloxone from a Reddit forum in which Reddit users anonymously discuss topics related to opioid use. We used an application programming interface to retrieve posts about buprenorphine-naloxone, then applied natural language processing to generate meta-information and curate samples of salient posts. We manually categorized posts according to their content and conducted natural language processing-aided analysis of posts about buprenorphine tapering strategies, withdrawal symptoms, and adjunctive substances/behaviors useful in the tapering process. RESULTS: A total of 16,146 posts from 1933 redditors were retrieved from the /r/suboxone subreddit. Thematic analysis of sample posts (N = 200) revealed descriptions of personal experiences (74%), nonpersonal accounts (24%), and other content (2%). Among redditors who reported tapering to termination (N = 40), 0.063 mg and 0.125 mg were the most common termination doses. Fatigue, gastrointestinal disturbance, and mood disturbance were the most frequent adverse effects, and loperamide and vitamins/dietary supplements the most frequently discussed adverse effects adjunctive substances/behaviors respectively. CONCLUSIONS: Discussions on Reddit are rich in information about buprenorphine-naloxone. Information derived from analysis of Reddit posts about buprenorphine-naloxone may not be available elsewhere and may help providers improve treatment of people with OUD through better understanding of the experiences of people who have used buprenorphine-naloxone.
Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Síndrome de Abstinência a Substâncias , Buprenorfina/uso terapêutico , Combinação Buprenorfina e Naloxona/uso terapêutico , Humanos , Antagonistas de Entorpecentes/uso terapêutico , Processamento de Linguagem Natural , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Síndrome de Abstinência a Substâncias/tratamento farmacológicoRESUMO
BACKGROUND: Medications for opioid use disorder such as opioid agonist treatment (OAT, including methadone, buprenorphine) are the gold standard intervention for opioid use disorder (OUD). Persons with OUD have high rates of neurocognitive impairment and psychiatric and substance use disorders, but few studies have examined these characteristics in diverse patients initiating OAT in opioid treatment programs (OTPs). Additionally, in these individuals, poor neurocognitive functioning and psychiatric/other substance use disorders are associated with poor OUD treatment outcomes. Given rapid changes in the opioid epidemic, we sought to replicate findings from our pilot study by examining these characteristics in a large diverse sample of persons with OUD starting OTP-based OAT. METHODS: Ninety-seven adults with OUD (M age = 42.2 years [SD = 10.3]; M education = 11.4 years [SD = 2.3]; 27% female; 22% non-Hispanic white) were enrolled in a randomized longitudinal trial evaluating methadone versus buprenorphine/naloxone on neurocognitive functioning. All participants completed a comprehensive neurocognitive, psychiatric, and substance use evaluation within one week of initiating OAT. RESULTS: Most of the sample met criteria for learning (79%) or memory (69%) impairment. Half exhibited symptoms of current depression, and comorbid substance use was highly prevalent. Lifetime cannabis and cocaine use disorders were associated with better neurocognitive functioning, while depression was associated with worse neurocognitive functioning. CONCLUSIONS: Learning and memory impairment are highly prevalent in persons with OUD starting treatment with either methadone or buprenorphine/naloxone in OTPs. Depression and comorbid substance use are prevalent among these individuals, but neither impact learning or memory. However, depression is associated with neurocognitive impairment in other domains. These findings might allow clinicians to help persons with OUD starting OAT to develop compensatory strategies for learning and memory, while providing adjunctive treatment for depression. Trial Registration NCT, NCT01733693. Registered November 4, 2012, https://clinicaltrials.gov/ct2/show/NCT01733693 .
Assuntos
Combinação Buprenorfina e Naloxona , Metadona , Transtornos Relacionados ao Uso de Opioides , Adulto , Analgésicos Opioides/uso terapêutico , Combinação Buprenorfina e Naloxona/uso terapêutico , Feminino , Humanos , Estudos Longitudinais , Masculino , Metadona/uso terapêutico , Pessoa de Meia-Idade , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Projetos PilotoRESUMO
INTRODUCTION: Urine drug screens (UDS) assist in clinical planning and assessment of adherence in opioid agonist treatment (OAT). Urine drug screens may also be used in criminal justice and child protection settings. Buprenorphine (BPN) UDS testing is complex. Immunoassay often does not detect BPN and gas chromatography-mass spectrometry (GC-MS) is needed. A limited understanding of testing can negatively influence UDS interpretation and clinical decision making. OBJECTIVES: The primary aim was to determine detection rates of BPN in UDS in participants on BPN or buprenorphine/naloxone (BNX) treatment. The secondary aim was to identify if comorbidities, sex, co-prescribed medications, or dosing site and observation were associated with BPN detection. SETTING: Public outpatient clinic in a specialist addiction treatment service. DESIGN/PARTICIPANTS: In this retrospective observational study, records of clients on supervised BPN/BNX treatment between September 2017 and 2018 were reviewed. MEASURES: Data extracted included UDS results, age, sex, indication for BPN, frequency of observed doses, dose of BPN, dosing site, comorbid medical conditions, and medications. RESULTS: One hundred and sixty-one medical records were reviewed. Ninety-seven (60 percent) underwent screening urine immunoassay. Of these 97, 51 (53 percent) had further GC-MS testing for BPN of which 22 (43 percent) did not detect BPN despite directly observed OAT. Co-prescription of medications known to interact with cytochrome P450 3A4 was associated with nondetection of BPN (p < 0.05). No significant association between median dose, dosing site, and observed dosing and BPN detection was identified. CONCLUSION: Urine drug testing for BPN is complex. Failure to detect BPN does not betoken nonadherence to treatment and is associated with co-prescription of drugs interacting with cytochrome P450 3A4.
Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/efeitos adversos , Buprenorfina/uso terapêutico , Combinação Buprenorfina e Naloxona/uso terapêutico , Criança , Avaliação Pré-Clínica de Medicamentos , Humanos , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologiaRESUMO
BACKGROUND: Untreated opioid use disorder (OUD) affects the care of HIV/HCV co-infected people who inject opioids. Despite active injection opioid use, there is evidence of increasing engagement in HIV care and adherence to HIV medications among HIV/HCV co-infected persons. However, less than one-half of this population is offered HCV treatment onsite. Treatment for OUD is also rare and largely occurs offsite. Integrating buprenorphine-naloxone (BUP-NX) into onsite care for HIV/HCV co-infected persons may improve outcomes, but the clinical impact and costs are unknown. We evaluated the clinical impact, costs, and cost-effectiveness of integrating (BUP-NX) into onsite HIV/HCV treatment compared with the status quo of offsite referral for medications for OUD. METHODS: We used a Monte Carlo microsimulation of HCV to compare two strategies for people who inject opioids: 1) standard HIV care with onsite HCV treatment and referral to offsite OUD care (status quo) and 2) standard HIV care with onsite HCV and BUP-NX treatment (integrated care). Both strategies assume that all individuals are already in HIV care. Data from national databases, clinical trials, and cohorts informed model inputs. Outcomes included mortality, HCV reinfection, quality-adjusted life years (QALYs), costs (2017 US dollars), and incremental cost-effectiveness ratios. RESULTS: Integrated care reduced HCV reinfections by 7%, cases of cirrhosis by 1%, and liver-related deaths by 3%. Compared to the status quo, this strategy also resulted in an estimated 11/1,000 fewer non-liver attributable deaths at one year and 28/1,000 fewer of these deaths at five years, at a cost-effectiveness ratio of $57,100/QALY. Integrated care remained cost-effective in sensitivity analyses that varied the proportion of the population actively injecting opioids, availability of BUP-NX, and quality of life weights. CONCLUSIONS: Integrating BUP-NX for OUD into treatment for HIV/HCV co-infected adults who inject opioids increases life expectancy and is cost-effective at a $100,000/QALY threshold.
Assuntos
Combinação Buprenorfina e Naloxona/administração & dosagem , Prestação Integrada de Cuidados de Saúde/organização & administração , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Abuso de Substâncias por Via Intravenosa/tratamento farmacológico , Adulto , Combinação Buprenorfina e Naloxona/economia , Coinfecção , Análise Custo-Benefício , Prestação Integrada de Cuidados de Saúde/economia , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Hepatite C/epidemiologia , Hepatite C/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Método de Monte Carlo , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/economia , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Abuso de Substâncias por Via Intravenosa/economiaRESUMO
The switch from methadone to buprenorphine-naloxone for individuals with heroin dependence is associated with several obstacles and challenges. Such patients may experience discomfort from discontinuing methadone, precipitated withdrawal symptoms induced by buprenorphine-naloxone, and poor psychosocial adjustments such as anticipatory anxiety regarding severe opioid withdrawal. We herein describe a 46-year-old man with a history of heroin dependence who underwent Traditional Chinese Medicine (TCM)-facilitated switching from methadone to buprenorphine-naloxone. No precipitated withdrawal was induced by buprenorphine-naloxone. The drug-switching process was successful and smooth. He maintained abstinence from heroin for the following year. In this case, we applied TCM for enhancement of methadone metabolism and detoxification, analgesic effects, and anxiolytic and hypnotic effects during the drug switch. We observed that TCM effectively facilitated the switch from methadone to buprenorphine-naloxone in our case. Further studies regarding TCM-facilitated treatment for heroin dependence should be conducted.
Assuntos
Combinação Buprenorfina e Naloxona/uso terapêutico , Dependência de Heroína/tratamento farmacológico , Medicina Tradicional Chinesa , Metadona/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
: In this article, we describe a middle-aged woman with a history of addiction to opioid medications who eventually became dependent on kratom. Her kratom-related withdrawal symptoms responded to a trial of buprenorphine-naloxone. Subsequently, she was maintained on this medication.
Assuntos
Analgésicos Opioides/administração & dosagem , Combinação Buprenorfina e Naloxona/administração & dosagem , Suplementos Nutricionais/efeitos adversos , Mitragyna/efeitos adversos , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Síndrome de Abstinência a Substâncias/tratamento farmacológico , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
BACKGROUND AND AIMS: Cannabis use is common among people on opioid agonist treatment (OAT), causing concern for some care providers. However, there is limited and conflicting evidence on the impact of cannabis use on OAT outcomes. Given the critical role of retention in OAT in reducing opioid-related morbidity and mortality, we aimed to estimate the association of at least daily cannabis use on the likelihood of retention in treatment among people initiating OAT. As a secondary aim we tested the impacts of less frequent cannabis use. DESIGN: Data were drawn from two community-recruited prospective cohorts of people who use illicit drugs (PWUD). Participants were followed for a median of 81 months (interquartile range = 37-130). SETTING: Vancouver, Canada. PARTICIPANTS: This study comprised a total of 820 PWUD (57.8% men, 59.4% of Caucasian ethnicity, 32.2% HIV-positive) initiating OAT between December 1996 and May 2016. The proportion of women was higher among HIV-negative participants, with no other significant differences. MEASUREMENTS: The primary outcome was retention in OAT, defined as remaining in OAT (methadone or buprenorphine/naloxone-based) for two consecutive 6-month follow-up periods. The primary explanatory variable was cannabis use (at least daily versus less than daily) during the same 6-month period. Confounders assessed included: socio-demographic characteristics, substance use patterns and social-structural exposures. FINDINGS: In adjusted analysis, at least daily cannabis use was positively associated with retention in OAT [adjusted odds ratio (aOR) = 1.21, 95% confidence interval (CI) = 1.04-1.41]. Our secondary analysis showed that compared with non-cannabis users, at least daily users had increased odds of retention in OAT (aOR = 1.20, 95% CI = 1.02-1.43), but not less than daily users (aOR = 1.00, 95% CI = 0.87-1.14). CONCLUSIONS: Among people who use illicit drugs initiating opioid agonist treatment in Vancouver, at least daily cannabis use was associated with approximately 21% greater odds of retention in treatment compared with less than daily consumption.
Assuntos
Uso da Maconha/epidemiologia , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Retenção nos Cuidados/estatística & dados numéricos , Adulto , Analgésicos Opioides/uso terapêutico , Colúmbia Britânica/epidemiologia , Combinação Buprenorfina e Naloxona/uso terapêutico , Feminino , Humanos , Estudos Longitudinais , Masculino , Metadona/uso terapêutico , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/epidemiologiaRESUMO
INTRODUCTION: Use of the unregulated herbal supplement kratom is on the rise in the United States. We present a case series of 2 patients who developed kratom dependence and withdrawal who were successfully transitioned to buprenorphine-naloxone maintenance. CASE SUMMARY: Two patients using kratom to self-treat chronic pain after prescription opioids were discontinued presenting to our clinic with evidence of kratom dependence and withdrawal. On examination, both patients showed signs of mild opioid withdrawal. Both patients were successfully transitioned to buprenorphine-naloxone maintenance via home initiation with control of both their opioid withdrawal and chronic pain. CONCLUSIONS: Kratom use is on the rise and with increasing evidence of developing opioid-type dependence due to chronic kratom use. This case series shows that buprenorphine can be used to treat kratom dependence and underlying chronic pain that drives it use.
Assuntos
Analgésicos Opioides/farmacologia , Combinação Buprenorfina e Naloxona/farmacologia , Dor Crônica/tratamento farmacológico , Suplementos Nutricionais/efeitos adversos , Mitragyna/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Síndrome de Abstinência a Substâncias/tratamento farmacológico , Analgésicos Opioides/administração & dosagem , Combinação Buprenorfina e Naloxona/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tratamento de Substituição de Opiáceos/métodosRESUMO
This study investigated a 51-year-old married man with a history of heroin dependence who underwent methadone maintenance treatment for 7 years. He received traditional Chinese medicine (TCM)-facilitated treatments and switched from methadone to buprenorphine/naloxone. Strong anxiety symptoms were observed during the initial stage; therefore, we prescribed a combination of Chaihu-Shugan-San, Zhi Bai Di Huang and Chin-Gin-Kuan-Ming decoction as the major herbal synergic regimen to relieve the symptoms of opioid withdrawal, anxiety and insomnia. During the treatment course, no precipitating withdrawal syndromes were noted, and the subject was gradually relieved of his anxiety symptoms through continual TCM treatments. In conclusion, TCM is effective in facilitating the switch from methadone to buprenorphine/naloxone and relieving anxiety symptoms. Therefore, focus on TCM-facilitated treatments for heroin dependence should be increased.
Assuntos
Ansiedade/prevenção & controle , Combinação Buprenorfina e Naloxona/administração & dosagem , Medicamentos de Ervas Chinesas/uso terapêutico , Metadona/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Substituição de Medicamentos , Humanos , Masculino , Pessoa de Meia-Idade , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/psicologiaRESUMO
BACKGROUND: North America is currently in the grips of a crisis rooted in the use of licit and illicit opioid-based analgesics. Drug overdose is the leading cause of accidental death in Canada and the US, and the growing toll of opioid-related morbidity and mortality requires a diversity of novel therapeutic and harm reduction-based interventions. Research suggests that increasing adult access to both medical and recreational cannabis has significant positive impacts on public health and safety as a result of substitution effect. Observational and epidemiological studies have found that medical cannabis programs are associated with a reduction in the use of opioids and associated morbidity and mortality. AIMS AND METHODS: This paper presents an evidence-based rationale for cannabis-based interventions in the opioid overdose crisis informed by research on substitution effect, proposing three important windows of opportunity for cannabis for therapeutic purposes (CTP) to play a role in reducing opioid use and interrupting the cycle towards opioid use disorder: 1) prior to opioid introduction in the treatment of chronic pain; 2) as an opioid reduction strategy for those patients already using opioids; and 3) as an adjunct therapy to methadone or suboxone treatment in order to increase treatment success rates. The commentary explores potential obstacles and limitations to these proposed interventions, and as well as strategies to monitor their impact on public health and safety. CONCLUSION: The growing body of research supporting the medical use of cannabis as an adjunct or substitute for opioids creates an evidence-based rationale for governments, health care providers, and academic researchers to consider the implementation and assessment of cannabis-based interventions in the opioid crisis.
Assuntos
Analgésicos Opioides/intoxicação , Overdose de Drogas/prevenção & controle , Maconha Medicinal/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Combinação Buprenorfina e Naloxona/uso terapêutico , Medicina Baseada em Evidências , Redução do Dano , Humanos , Metadona/uso terapêutico , Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/psicologia , Saúde Pública , Política PúblicaRESUMO
AIMS: To test if polysubstance use profiles and drug-related outcomes differ between those receiving and not receiving opioid substitution therapies (OST) among people who inject drugs (PWID). DESIGN: An annual cross-sectional, sentinel sample of PWID across Australia. SETTING: Data came from 3 years (2011-13) of the Illicit Drug Reporting System (IDRS). PARTICIPANTS: A total of 2673 participants who injected drugs from the combined national IDRS samples of 2011 (n = 868), 2012 (n = 922) and 2013 (n = 883). MEASUREMENTS: Latent class analysis (LCA) was used to summarize participants' self-reported use of 18 types of substances, with the resulting polysubstance use profiles then associated with participant experience of a number of drug-related outcomes. FINDINGS: Polysubstance use profiles exhibiting a broad range of substance use were generally at increased risk of negative drug-related outcomes, whether or not participants were receiving OST, including thrombosis among OST receivers [odds ratio (OR) = 2.13, 95% confidence intervals (CI) = 1.09-4.17], injecting with used needles among OST receivers and non-receivers, respectively (OR = 2.78, 95% CI = 1.50-5.13; OR = 2.15, 95% CI = 1.34-3.45) and violent criminal offences among OST receivers and non-receivers, respectively (OR =2.30, 95% CI = 1.16-4.58; OR = 1.87, 95% CI = 1.14-3.07). An important exception was non-fatal overdose which was related specifically to a class of PWID who were not receiving OST and used morphine frequently (OR = 1.83, 95% CI = 1.06-3.17) CONCLUSION: Regardless of opioid substitution therapies usage, people who inject drugs who use a broad-range of substances experience greater levels of injecting-related injuries and poorer health outcomes and are more likely to engage in criminal activity than other groups of people who inject drugs.
Assuntos
Abscesso/epidemiologia , Analgésicos Opioides/uso terapêutico , Overdose de Drogas/epidemiologia , Uso Comum de Agulhas e Seringas/estatística & dados numéricos , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Abuso de Substâncias por Via Intravenosa/tratamento farmacológico , Trombose/epidemiologia , Violência/estatística & dados numéricos , Adolescente , Adulto , Alcoolismo/epidemiologia , Transtornos Relacionados ao Uso de Anfetaminas/epidemiologia , Austrália/epidemiologia , Buprenorfina/uso terapêutico , Combinação Buprenorfina e Naloxona/uso terapêutico , Transtornos Relacionados ao Uso de Cocaína/epidemiologia , Estudos Transversais , Feminino , Dependência de Heroína/epidemiologia , Humanos , Masculino , Abuso de Maconha/epidemiologia , Metadona/uso terapêutico , Pessoa de Meia-Idade , Razão de Chances , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Interim methadone treatment (i.e., temporary medication-only treatment) has been tested in a few U.S. studies as a method for facilitated referral to and initiation of opioid maintenance treatment in heroin dependence. However, despite the favorable safety profile of buprenorphine compared with methadone, interim treatment with buprenorphine rarely has been tested and reported in the scientific literature. The present pilot effectiveness study aims to assess the feasibility of an interim buprenorphine treatment for initiation of individuals with opiate dependence into full-scale opioid maintenance treatment, and to study baseline predictors of successful transfer to full-scale treatment. METHODS: Interim treatment was introduced in a high-threshold setting with waiting lists to opioid maintenance treatment. Consecutive patients on the waiting list were offered the option to enter interim treatment. The interim program was a medication-only condition with supervised daily doses of buprenorphine-naloxone. The main outcome was successful transfer to full-scale opioid maintenance treatment, which required a drug-free urine sample. RESULTS: Forty-four patients entered interim buprenorphine treatment. Among them, 57% (n = 25) were successfully transferred to full-scale treatment after an average of 44 days. Remaining patients could not be transferred, generally because they did not manage to become drug-free. Successful transfer to full-scale treatment was associated with a lower baseline Alcohol Use Disorders Identification Test (AUDIT) score (4.4 vs. 12.6; P < .001) and tended to be associated with lower cannabis use (5.2 vs. 10.4 days during the past 30 days; P = .06) and lower heroin use (7.2 vs. 9.9 days; P = .09) prior to baseline. In a logistic regression analysis, only lower AUDIT score predicted successful treatment entry. CONCLUSIONS: According to these pilot data, supervised buprenorphine-naloxone in a medication-only interim treatment condition appears to be a feasible way to improve treatment initiation in a high-threshold setting. Polydrug use, including higher levels of alcohol consumption, may predict a more complicated course in interim treatment.
Assuntos
Combinação Buprenorfina e Naloxona/uso terapêutico , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/urina , Projetos Piloto , Adulto JovemRESUMO
AIMS: The aim of this study is to assess the prevalence of non-opioid drug use among opioid-addicted, buprenorphine injecting individuals in Georgia, during and after a 12-week course of buprenorphine-naloxone (Suboxone®) or methadone. METHODS: Randomized controlled trial with daily observed Suboxone® or methadone and weekly counseling, urine tests and timeline followback (TLFB) in weeks 0-12 and 20, and the Addiction Severity Index (ASI) at weeks 0, 4, 8, 12, 20. RESULTS: Of the 80 patients (40/group, 4 women), 68 (85%) completed the 12-weeks of study treatment and 66 (82.5%) completed the 20-week follow-up. At baseline, injecting more than one drug in the last 30 days was reported by 68.4% of patients in the methadone and 72.5% in the Suboxone® groups. Drug use was markedly reduced in both treatment conditions but there were significant differences in the prevalence of specific drugs with more opioid (1.5 vs. 0.2%; p=0.03), less amphetamine (0.2 vs. 2.8%; p<0.001) and less marijuana (1.7 vs. 10.2%; p<0.001) positive urine tests in the methadone vs. Suboxone® groups. At the 20-week follow-up, TLFB results on the 34 that continued methadone or the 3 on Suboxone® showed less opioid (5.6 vs. 27.6%; p<0.001), illicit buprenorphine (2.7 vs. 13.8%; p=0.005), benzodiazepine (13.5 vs. 34.5%; p<0.001), and marijuana (2.8 vs. 20.7%; p<0.001) use than the 29 who did not continue opioid substitution therapy. CONCLUSIONS: Despite small but significant differences in opioid and other drug use, both treatments were highly effective in reducing opioid and non-opioid drug use.
Assuntos
Buprenorfina/uso terapêutico , Usuários de Drogas/estatística & dados numéricos , Metadona/uso terapêutico , Naloxona/uso terapêutico , Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos/psicologia , Transtornos Relacionados ao Uso de Opioides/psicologia , Abuso de Substâncias por Via Intravenosa/psicologia , Adulto , Combinação Buprenorfina e Naloxona , Aconselhamento , Usuários de Drogas/psicologia , Feminino , República da Geórgia , Humanos , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/reabilitação , Abuso de Substâncias por Via Intravenosa/reabilitação , Resultado do TratamentoRESUMO
AIMS: conduct needs assessments and treatment compliance evaluations in MMT and Suboxone Substitution State Programs in Georgia (Republic of). 506 patients (2 females) were surveyed (92% on Methadone, 8% on Suboxone) from 6 Tbilisi and 4 regional State Programs in 2011 November. Mean age - 40±8,56 (22-65) year; 254 (51.4%) were in treatment for 1-3 year. Evaluation was carried out on the base of structured self-questionnaire that covers demographics, drug use history, general drug use trends, psychotherapeutic sessions' acceptance and open label question regarding treatment challenges and satisfaction. 305 (60.3%) attended individual and 57 (11.3%) group psychotherapy sessions with 50.79% attending once/month or rare. The main reason given for therapy non-attendance - no needs for it (29.48%); the main drugs before admission - heroin (80.04%), buprenorphine (53.49%); Main drugs used in Georgia nowadays - desomorphine ("crocodile"), alcohol and marihuana. Commonly used drugs by program patients (136 positive answers) - alcohol-13.62%, marihuana-10.39%, pregabalin - 8.17%, opioids- 6.62% (mostly-"crocodile"), home-made stimulants-6.23%, sedatives -5.45%. 55.4% are extremely satisfied with treatment, 82.4% - with program staff. Patients' main wishes- free of charge programs (46.4%) and provide take-home doses (22.07%). Methadone and Suboxone ST are being well accepted in Georgia and appear to be reducing illegal opioid use. However, the psychotherapeutic sessions' attendance is very low.
Assuntos
Tratamento de Substituição de Opiáceos/métodos , Cooperação do Paciente , Transtornos Relacionados ao Uso de Substâncias/tratamento farmacológico , Adulto , Idoso , Buprenorfina/uso terapêutico , Combinação Buprenorfina e Naloxona , Feminino , República da Geórgia/epidemiologia , Programas Governamentais , Dependência de Heroína/epidemiologia , Humanos , Hipnóticos e Sedativos , Masculino , Abuso de Maconha/epidemiologia , Metadona/uso terapêutico , Pessoa de Meia-Idade , Naloxona/uso terapêutico , Avaliação das Necessidades , Satisfação do Paciente , Psicoterapia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Inquéritos e Questionários , Adulto JovemRESUMO
UNLABELLED: Previous studies have not examined patterns of pain treatment use among patients seeking office-based buprenorphine-naloxone treatment (BNT) for opioid dependence. OBJECTIVES: To examine, among individuals with pain seeking BNT for opioid dependence, the use of pain treatment modalities, perceived efficacy of prior pain treatment, and interest in pursuing pain treatment while in BNT. METHODS: A total of 244 patients seeking office-based BNT for opioid dependence completed measures of demographics, pain status (ie, "chronic pain (CP)" [pain lasting at least 3 months] vs "some pain (SP)" [pain in the past week not meeting the duration criteria for chronic pain]), pain treatment use, perceived efficacy of prior pain treatment, and interest in receiving pain treatment while in BNT. RESULTS: In comparison with the SP group (N = 87), the CP group (N = 88) was more likely to report past-week medical use of opioid medication (adjusted odds ratio [AOR] = 3.2; 95% CI, 1.2-8.4), lifetime medical use of nonopioid prescribed medication (AOR = 2.2; 95% CI, 1.1-4.7), and lifetime use of prayer (AOR = 2.8; 95% CI, 1.2-6.5) and was less likely to report lifetime use of yoga (AOR = 0.2; 95% CI, 0.1-0.7) to treat pain. Although the 2 pain groups did not differ on levels of perceived efficacy of prior lifetime pain treatments, in comparison with the SP group, the CP group was more likely to report interest in receiving pain treatment while in BNT (P < 0.001). CONCLUSIONS: Individuals with pain seeking BNT for opioid dependence report a wide range of conventional, complementary, and alternative pain-related treatments and are interested (especially those with CP) in receiving pain management services along with BNT.
Assuntos
Analgésicos Opioides/uso terapêutico , Analgésicos/uso terapêutico , Buprenorfina/uso terapêutico , Dor Crônica/reabilitação , Terapias Complementares/estatística & dados numéricos , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/reabilitação , Atenção Primária à Saúde/estatística & dados numéricos , Adulto , Analgésicos/efeitos adversos , Analgésicos Opioides/efeitos adversos , Buprenorfina/efeitos adversos , Combinação Buprenorfina e Naloxona , Dor Crônica/epidemiologia , Terapia Combinada/estatística & dados numéricos , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Naloxona/efeitos adversos , Antagonistas de Entorpecentes/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Resultado do Tratamento , Revisão da Utilização de Recursos de SaúdeRESUMO
Untreated opioid dependence adversely affects HIV outcomes. Integrating buprenorphine/naloxone into HIV treatment settings is feasible; however, the optimal level of counseling has not been established. We conducted a 12-week randomized clinical trial of physician management (PM) versus PM plus enhanced medical management (EMM) in 47 subjects. At 12 weeks, there were no differences between the two groups in percentage of opioid negative urines (63.6% PM vs. 69.0% PM+EMM, p=.5), maximum duration of continuous abstinence (4.9 weeks PM vs. 5.2 weeks PM+EMM, p=.8) or retention (80% PM vs. 59% PM+EMM, p=.1). The percentage of subjects with detectable HIV viral loads decreased from 58% at baseline to 40% at 12 weeks across both groups (p=.02 for time) with no between group differences (p=.84 and p=.27 for the interaction). Providing more extensive counseling beyond PM is feasible in an HIV clinic, but we are unable to detect an improvement in outcomes associated with these services.