The Naloxone Component of Buprenorphine/Naloxone: Discouraging Misuse, but at What Cost?

Because opioid overdose deaths in the United States continue to rise, it is critical to increase patient access to buprenorphine, which treats opioid use disorder and reduces mortality. An underrecognized barrier to buprenorphine treatment (both for maintenance and treatment of acute withdrawal) is limited access to buprenorphine monoproduct. In the United States, buprenorphine is primarily prescribed as a combination product also containing naloxone, added to reduce the potential for misuse. Because naloxone has relatively low sublingual bioavailability compared with buprenorphine, adverse effects are generally considered mild and rare. The authors' clinical experience, however, suggests that adverse effects may be less benign than generally accepted and can have negative effects for the patient, the provider-patient relationship, and the health care system as a whole. The insistence on prescribing combination product can foster stigma and mistrust, creating barriers to care and increased risk of overdose and death.

Project Nurture Integrates Care And Services To Improve Outcomes For Opioid-Dependent Mothers And Their Children.

Children born to women with substance use disorders are at high risk for early foster care placement, which is associated with long-term adverse outcomes for children and places additional pressure on state budgets. Poor outcomes for drug-dependent mothers and their children may be further exacerbated by a lack of coordination between the health care and human services sectors. Project Nurture is an innovative model in Portland, Oregon, that integrates maternity care, substance use treatment, and social service coordination for Medicaid beneficiaries. This study assessed the impact of Project Nurture on a range of patient and child welfare outcomes. Among the "treatment" population of opioid-dependent women enrolled in Medicaid, Project Nurture was associated with reductions in child maltreatment, placement of children in foster care, and increases in both prenatal visits and maternal lengths-of-stay in the hospital, compared to opioid-dependent women enrolled in Medicaid in Oregon counties not served by the project. These results suggest that models based in a clinical setting that engage the human services sector may improve overall outcomes, even though the difficulty in sharing savings across sectors presents challenges to sustainability.

Current perspectives in the USA on the diagnosis and treatment of pelvic inflammatory disease in adolescents.

In this review, the epidemiology, diagnosis, and treatment of pelvic inflammatory disease (PID) are discussed from a USA perspective and the difficulties that USA adolescents face in recognizing and seeking care for PID and other sexually transmitted infections (STIs) are emphasized. Females aged 15-24 years have the highest incidence of cervical infection with Chlamydia trachomatis and Neisseria gonorrheae, the principal causes of PID. PID is common in this age group. However, the incidence of PID in the USA is not known, because it is not a reportable disease, and because clinicians vary in the criteria used for the diagnosis. The Centers for Disease Control and Prevention (CDC) recommended the following diagnostic criteria that include lower abdominal or pelvic pain and at least one of the following: adnexal tenderness or cervical motion tenderness or uterine tenderness. Because PID can have serious sequelae, the criteria emphasize sensitivity (few false-negatives) at the expense of specificity (some false-positives). Patients who have PID are usually treated in the outpatient setting, following the CDC's Guidelines for the Treatment of Sexually Transmitted Diseases 2015. They receive one dose of an intramuscular cephalosporin, together with 2 weeks of oral doxy cycline, and sometimes oral metronidazole. Improvement should usually be evident in 3 days. The USA does not offer comprehensive sex education for adolescents in public or private schools. Adolescents are unlikely to recognize the symptoms of PID and seek medical treatment. Confidentiality is important to adolescents, and low cost or free sources of confidential care are uncommon, making it unlikely that an adolescent would seek care even if she suspected an STI. The CDC has concluded that screening programs for chlamydia and gonorrhea infection help prevent PID; however, the lack of appropriate sources of care makes adolescents' participation in screening programs unlikely.

Treating Opioid Dependence with Buprenorphine in the Safety Net: Critical Learning from Clinical Data.

Research has examined the safety, efficacy, feasibility, and cost-effectiveness of buprenorphine for the treatment of opioid dependence, but few studies have examined patient and provider experiences, especially in community health centers. Using de-identified electronic health record system (EHRS) data from 70 OCHIN community health centers (n = 1825), this cross-sectional analysis compared the demographics, comorbidities, and service utilization of patients receiving buprenorphine to those not receiving medication-assisted treatment (MAT). Compared to non-MAT patients, buprenorphine patients were younger and less likely to be Hispanic or live in poverty. Buprenorphine patients were less likely to have Medicaid insurance coverage, more likely to self-pay, and have private insurance coverage. Buprenorphine patients were less likely to have problem medical comorbidities or be coprescribed high-risk medications. It is important for providers, clinic administrators, and patients to understand the clinical application of medications for opioid dependence to ensure safe and effective care within safety net clinics.

NSAID prescribing precautions.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used, but have risks associated with their use, including significant upper gastrointestinal tract bleeding. Older persons, persons taking anticoagulants, and persons with a history of upper gastrointestinal tract bleeding associated with NSAIDs are at especially high risk. Although aspirin is cardioprotective, other NSAIDs can worsen congestive heart failure, can increase blood pressure, and are related to adverse cardiovascular events, such as myocardial infarction and ischemia. Cyclooxygenase-2 inhibitors have been associated with increased risk of myocardial infarction; however, the only cyclooxygenase-2 inhibitor still available in the United States, celecoxib, seems to be safer in this regard. Hepatic damage from NSAIDs is rare, but these medications should not be used in persons with cirrhotic liver diseases because bleeding problems and renal failure are more likely. Care should be used when prescribing NSAIDs in persons taking anticoagulants and in those with platelet dysfunction, as well as immediately before surgery. Potential central nervous system effects include aseptic meningitis, psychosis, and tinnitus. Asthma may be induced or exacerbated by NSAIDs. Although most NSAIDs are likely safe in pregnancy, they should be avoided in the last six to eight weeks of pregnancy to prevent prolonged gestation from inhibition of prostaglandin synthesis, premature closure of the ductus arteriosus, and maternal and fetal complications from antiplatelet activity. Ibuprofen, indomethacin, and naproxen are safe in breastfeeding women. Care should be taken to prevent accidental NSAID overdose in children by educating parents about correct dosing and storage in childproof containers.

Epidemiology of infections in women.

This article describes the epidemiologic profiles of sexually transmitted infections seen in US women. We present a brief description of the infectious agent, describe the epidemiology of the infection among women in terms of race/ethnicity and age (if those data are available), and present what is known about the behavioral risk factors associated with acquisition.