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2.
J Am Board Fam Med ; 34(Suppl): S141-S146, 2021 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-33622829

RESUMEN

Prescription opioid dependence remains a major source of morbidity and mortality in the United States. Patients previously on high-dose opioids may poorly tolerate opioid tapers. Current guidelines support the use of buprenorphine therapy in opioid-tapering protocols, even among patients without a diagnosis of opioid use disorder. Buprenorphine microinduction protocols can be used to transition patients to buprenorphine therapy without opioid withdrawal. From November 2019 to April 2020, we transitioned 8 patients on high-dose prescribed opioids for pain to sublingual buprenorphine-naloxone using a microdose protocol without any evidence of precipitated withdrawal. Six of these patients remain on buprenorphine-naloxone and report improved analgesia. Because of its simplicity, the buprenorphine microinduction protocol can be easily adapted for telemedicine and may help to prevent unnecessary clinic visits and opioid-related admissions in the setting of social distancing regulations during the coronavirus 2019 pandemic.


Asunto(s)
Combinación Buprenorfina y Naloxona/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , Trastornos Relacionados con Opioides/tratamiento farmacológico , Administración Sublingual , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Síndrome de Abstinencia a Sustancias/prevención & control , Telemedicina/métodos
3.
J Subst Abuse Treat ; 123: 108263, 2021 04.
Artículo en Inglés | MEDLINE | ID: mdl-33612196

RESUMEN

The U.S. government declared the opioid epidemic as a national public health emergency in 2017, but regulatory frameworks that govern the treatment of opioid use disorder (OUD) through pharmaceutical interventions have remained inflexible. The emergence of the COVID-19 pandemic has effectively removed regulatory restrictions that experts in the field of medications for opioid use disorder (MOUD) have been proposing for decades and has expanded access to care. The regulatory flexibilities implemented to avoid unnecessary COVID-related death must be made permanent to ensure that improved access to evidence-based treatment remains available to vulnerable individuals with OUD who otherwise face formidable barriers to MOUD. We must seize this moment of COVOD-19 regulatory flexibilities to demonstrate the feasibility, acceptability, and safety of delivering treatment for OUD through a low-threshold approach.


Asunto(s)
Necesidades y Demandas de Servicios de Salud , Tratamiento de Sustitución de Opiáceos/tendencias , Trastornos Relacionados con Opioides/rehabilitación , Buprenorfina/administración & dosificación , Buprenorfina/uso terapéutico , Humanos , Metadona , Antagonistas de Narcóticos/administración & dosificación , Antagonistas de Narcóticos/uso terapéutico , Estados Unidos
4.
J Subst Abuse Treat ; 123: 108260, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-33612194

RESUMEN

The California Bridge Program supports expansion of medications for opioid use disorder (MOUD) in emergency departments (EDs) and hospital inpatient units across the state. Here, we describe the change in activity before and after the coronavirus disease 2019 (COVID-19) California statewide shutdown. Of the 70 participating hospitals regionally distributed across California, 52 report MOUD-related activity monthly. We analyzed data on outcomes of OUD care and treatment: identification of OUD, acceptance of referral, receipt of buprenorphine prescription, administration of buprenorphine, and follow-up linkage to outpatient OUD treatment, from May 2019 to April 2020. In estimating the expected number of patients who met each outcome in April 2020, we found decreases in the expected to observed number of patients across all outcomes (all p-values<0.002): 37% (from 1053 to 667) decrease in the number of patients identified with OUD, 34% (from 632 to 420) decrease in the number of patients who accepted a referral, 48% (from 521 to 272) decrease in the number of patients who were prescribed buprenorphine, 53% (from 501 to 234) decrease in the number of patients who were administered buprenorphine, and 33% (from 416 to 277) decrease in the number of patients who attended at least one follow-up visit for addiction treatment. The COVID-19 California statewide shutdown was associated with an abrupt and large decrease in the progress toward expanded access to OUD treatment.


Asunto(s)
Buprenorfina/uso terapéutico , Servicio de Urgencia en Hospital/estadística & datos numéricos , Antagonistas de Narcóticos/uso terapéutico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Evaluación de Resultado en la Atención de Salud , Pautas de la Práctica en Medicina , Buprenorfina/administración & dosificación , California , Humanos , Antagonistas de Narcóticos/administración & dosificación
5.
Value Health ; 24(2): 158-173, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33518022

RESUMEN

OBJECTIVES: The rapid increase in opioid overdose and opioid use disorder (OUD) over the past 20 years is a complex problem associated with significant economic costs for healthcare systems and society. Simulation models have been developed to capture and identify ways to manage this complexity and to evaluate the potential costs of different strategies to reduce overdoses and OUD. A review of simulation-based economic evaluations is warranted to fully characterize this set of literature. METHODS: A systematic review of simulation-based economic evaluation (SBEE) studies in opioid research was initiated by searches in PubMed, EMBASE, and EbscoHOST. Extraction of a predefined set of items and a quality assessment were performed for each study. RESULTS: The screening process resulted in 23 SBEE studies ranging by year of publication from 1999 to 2019. Methodological quality of the cost analyses was moderately high. The most frequently evaluated strategies were methadone and buprenorphine maintenance treatments; the only harm reduction strategy explored was naloxone distribution. These strategies were consistently found to be cost-effective, especially naloxone distribution and methadone maintenance. Prevention strategies were limited to abuse-deterrent opioid formulations. Less than half (39%) of analyses adopted a societal perspective in their estimation of costs and effects from an opioid-related intervention. Prevention strategies and studies' accounting for patient and physician preference, changing costs, or result stratification were largely ignored in these SBEEs. CONCLUSION: The review shows consistently favorable cost analysis findings for naloxone distribution strategies and opioid agonist treatments and identifies major gaps for future research.


Asunto(s)
Analgésicos Opioides/efectos adversos , Trastornos Relacionados con Opioides/economía , Costos y Análisis de Costo , Humanos , Metadona/economía , Metadona/uso terapéutico , Modelos Económicos , Naloxona/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , /prevención & control , Tratamiento de Sustitución de Opiáceos/economía , Tratamiento de Sustitución de Opiáceos/métodos , Epidemia de Opioides , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/terapia
6.
Value Health ; 24(2): 182-187, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33518024

RESUMEN

OBJECTIVE: Buprenorphine is an essential medication for the treatment of opioid use disorder (OUD), but studies show it has been underused over the last 2 decades. We sought to evaluate utilization of and spending on buprenorphine formulations in Medicaid and to evaluate the impact of key market and regulatory factors affecting availability of different formulations and generic versions. METHODS: We first identified all buprenorphine formulations approved by the Food and Drug Administration for OUD using Drugs@FDA. We then used National Drug Codes to identify each drug in the Medicaid State Drug Utilization Data and extracted annual utilization rates and spending between 2002 and 2018 by drug and according to whether a brand-name or generic version was dispensed. We compared these trends to market and regulatory factors that affected competition, which we identified through searching the Federal Register, Westlaw, PubMed, and Google News. RESULTS: Brand-name buprenorphine-naloxone sublingual tablet and film formulations (Suboxone) were dispensed 2.7 times more (n = 634 213 140) and reimbursed 4.4 times more (n = $4 440 556 473) than all other formulations combined (n = 237 769 689; $1 018 988 133). We identified numerous market and regulatory factors that contributed to an estimated 9-year delay in generic versions of the tablet formulation and 6-year delay for generic versions of the film formulation. CONCLUSIONS: Brand-name buprenorphine formulations have been widely used in Medicaid, leading to substantial costs, in part because generic versions were delayed by multiple years owing to market and regulatory factors. Timely availability of low-cost generics could have helped encourage OUD treatment with buprenorphine during the height of the opioid crisis.


Asunto(s)
Buprenorfina/economía , Buprenorfina/uso terapéutico , Medicaid/economía , Antagonistas de Narcóticos/economía , Antagonistas de Narcóticos/uso terapéutico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Buprenorfina/administración & dosificación , Combinación Buprenorfina y Naloxona/economía , Combinación Buprenorfina y Naloxona/uso terapéutico , Utilización de Medicamentos , Medicamentos Genéricos/economía , Medicamentos Genéricos/uso terapéutico , Competencia Económica , Humanos , Antagonistas de Narcóticos/administración & dosificación , Tratamiento de Sustitución de Opiáceos/economía , Tratamiento de Sustitución de Opiáceos/métodos , Patentes como Asunto , Estados Unidos
7.
Value Health ; 24(2): 188-195, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33518025

RESUMEN

OBJECTIVES: To measure access to opioid treatment programs (OTPs) and office-based buprenorphine treatment (OBBTs) at the smallest geographic unit for which the Census Bureau publishes demographic and socioeconomic data (ie, block group) and to explore disparities in access to treatment across the rural-urban and area deprivation continua across the United States. METHODS: Access to OTPs and OBBTs at the block group in 2019 was quantified using an innovative 2-step floating catchment area technique that accounts for the supply of treatment facilities relative to the population size, proximity of facilities relative to the location of population in block groups, and time as a barrier within catchments. Block groups were stratified into tertiles based on the rural-urban continuum codes (metropolitan, micropolitan, small town, or rural) and area deprivation index (least-deprived, middle-deprived, most-deprived). The Integrated Nested Laplace Approximation approach was used for statistical analysis. RESULTS: Across the United States, 3329 block groups corresponding to 2 915 949 adults lacked access to OTPs within a 2-hour drive of their community and 130 block groups corresponding to 86 605 adults did not have access to OBBTs. Disparities in access to treatment were observed across the urban-rural and area deprivation continua including (1) lowest mean access score to OBBTs were found among most-deprived small towns, and (2) lower mean access score to OTPs were found among micropolitan and small towns. CONCLUSIONS: The results of this study revealed disparities in access to medication-assisted treatment. The findings call for creative initiatives and local and regional policies to develop to mitigate access problems.


Asunto(s)
Buprenorfina/uso terapéutico , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Antagonistas de Narcóticos/uso terapéutico , Tratamiento de Sustitución de Opiáceos/estadística & datos numéricos , Trastornos Relacionados con Opioides/tratamiento farmacológico , Buprenorfina/administración & dosificación , Estudios Transversales , Accesibilidad a los Servicios de Salud/economía , Humanos , Antagonistas de Narcóticos/administración & dosificación , Trastornos Relacionados con Opioides/epidemiología , Características de la Residencia , Población Rural/estadística & datos numéricos , Análisis de Área Pequeña , Factores Socioeconómicos , Estados Unidos , Población Urbana/estadística & datos numéricos
8.
J Subst Abuse Treat ; 121: 108161, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33371945

RESUMEN

Correctional facilities are among the highest-risk settings for the spread of COVID-19. Prior to the COVID-19 pandemic, the Hennepin County Jail in Minneapolis, Minnesota, offered short-term methadone maintenance, buprenorphine initiation and maintenance, and naltrexone initiation and maintenance to all jail residents with moderate to severe opioid use disorder (OUD). In response to the pandemic, the jail reduced its population by 43%. The reduced jail census and relaxed federal telemedicine regulations in response to the COVID-19 public health emergency declaration allowed the jail to institute modifications that permitted individuals to start buprenorphine without an initial in-person visit with a clinician. The jail also instituted a buprenorphine taper to bridge individuals to maintenance or provide withdrawal management, depending on patient preference. With a decreased jail census, the use of remote visits, and modifications to the buprenorphine treatment program, clinicians are able to meet the OUD treatment demand. Some jails may need additional funding streams to offset pandemic-related health treatment costs.


Asunto(s)
Buprenorfina/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Opioides/rehabilitación , Prisiones , Telemedicina , Humanos , Minnesota
10.
JAMA Netw Open ; 3(12): e2029676, 2020 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-33320266

RESUMEN

Importance: Whereas outpatient treatment with medication for opioid use disorder (MOUD) is evidence based, there is a large network of inpatient facilities in the US that are reimbursed by commercial insurers and do not typically offer MOUD. Objective: To compare the rates of opioid-related overdose and all-cause hospitalization after outpatient MOUD treatment vs inpatient care. Design, Setting, and Participants: This comparative effectiveness research study used deidentified claims of commercially insured individuals in the US from the MarketScan Commercial Claims and Encounters Database from January 1, 2010, to December 31, 2017, to obtain a sample of 37 090 individuals with opioid use disorder who initiated treatment with inpatient care and/or MOUD. Data were analyzed from October 1, 2019, to May 1, 2020. To address nonrandom treatment assignment, individuals with opioid use disorder who initiated MOUD or who entered inpatient care were matched 1:1 based on propensity scores. Exposures: The independent variable of interest was the type of treatment initiated. Individuals could initiate 1 of 5 potential treatments: (1) outpatient MOUD, (2) short-term inpatient care, (3) short-term inpatient care followed by outpatient MOUD within 30 days, (4) long-term inpatient care, or (5) long-term inpatient care followed by outpatient MOUD within 30 days. Main Outcomes and Measures: Opioid-related overdose and all-cause hospitalization at any point within the 12 months after treatment of opioid use disorder. The hazard for each outcome was estimated using a time-to-event Cox proportional hazards regression model. Results: The cohort included 37 090 individuals matched 1:1 between inpatient and outpatient treatment (20 723 [56%] were younger than 30 years; 23 250 [63%] were male). After propensity score matching, compared with the inpatient treatments, initiation of outpatient MOUD alone was followed by the lowest 1-year overdose rate (2.2 [95% CI, 2.0-2.5] per 100 person-years vs 3.5 [95% CI, 2.7-4.4] to 7.0 [95% CI, 4.6-10.7] per 100 person-years) and hospitalization rate (39 [95% CI, 38-40] per 100 person-years vs 57 [95% CI, 54-61] to 74 [95% CI, 73-76] per 100 person-years). Outpatient MOUD was also associated with the lowest hazard of these events compared with inpatient care, which had hazard ratios ranging from 1.71 (95% CI, 1.35-2.17) to 2.67 (95% CI, 1.68-4.23) for overdose and 1.33 (95% CI, 1.23-1.44) to 1.90 (95% CI, 1.83-1.97) for hospitalizations. Conclusions and Relevance: The results of this comparative effectiveness research study suggest that lower rates of subsequent overdose and hospitalization are associated with outpatient MOUD compared with short- or long-term inpatient care. When patients and clinicians have a choice of treatment, outpatient MOUD treatment may be associated with lower overdose and hospitalization on balance. Future research should assess which patients benefit most from inpatient care and how best to leverage existing inpatient treatment infrastructure.


Asunto(s)
Buprenorfina , Sobredosis de Droga , Hospitalización/estadística & datos numéricos , Pacientes Internos/estadística & datos numéricos , Trastornos Relacionados con Opioides/tratamiento farmacológico , Pacientes Ambulatorios/estadística & datos numéricos , Adulto , Buprenorfina/administración & dosificación , Buprenorfina/efectos adversos , Investigación sobre la Eficacia Comparativa , Sobredosis de Droga/epidemiología , Sobredosis de Droga/etiología , Sobredosis de Droga/terapia , Femenino , Humanos , Masculino , Antagonistas de Narcóticos/administración & dosificación , Antagonistas de Narcóticos/efectos adversos , Evaluación de Procesos y Resultados en Atención de Salud
11.
J Addict Med ; 14(6): e369-e371, 2020 12.
Artículo en Inglés | MEDLINE | ID: mdl-33031212

RESUMEN

OBJECTIVES: The COVID-19 epidemic in the United States has hit in the midst of the opioid overdose crisis. Emergency medical services (EMS) clinicians may limit their use of intranasal naloxone due to concerns of novel coronavirus infection. We sought to determine changes in overdose events and naloxone administration practices by EMS clinicians. METHODS: Between April 29, 2020 and May 15, 2020, we surveyed directors of EMS fellowship programs across the US about how overdose events and naloxone administration practices had changed in their catchment areas since March 2020. RESULTS: Based on 60 respondents across all regions of the country, one fifth of surveyed communities have experienced an increase in opioid overdoses and events during which naloxone was administered, and 40% have experienced a decrease. The findings varied by region of the country. Eighteen percent of respondents have discouraged or prohibited the use of intranasal naloxone with 10% encouraging the use of intramuscular naloxone. CONCLUSIONS: These findings may provide insight into changes in opioid overdose mortality during this time and assist in future disaster planning.


Asunto(s)
Infecciones por Coronavirus/epidemiología , Servicios Médicos de Urgencia/estadística & datos numéricos , Naloxona/uso terapéutico , Antagonistas de Narcóticos/uso terapéutico , Neumonía Viral/epidemiología , Analgésicos Opioides/toxicidad , Infecciones por Coronavirus/prevención & control , Sobredosis de Droga/tratamiento farmacológico , Sobredosis de Droga/mortalidad , Humanos , Control de Infecciones , Naloxona/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , Rociadores Nasales , Pandemias/prevención & control , Neumonía Viral/prevención & control , Encuestas y Cuestionarios , Estados Unidos/epidemiología
12.
Am J Emerg Med ; 38(9): 1787-1791, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32739849

RESUMEN

BACKGROUND: Currently, ≤5% of bystanders witnessing an opioid overdose (OD) in the US administer antidote to the victim. A possible model to mitigate this crisis would be a system that enables 9-1-1 dispatchers to both rapidly deliver naloxone by drone to bystanders at a suspected opioid OD and direct them to administer it while awaiting EMS arrival. METHODS: A simulated 9-1-1 dispatcher directed thirty subjects via 2-way radio to retrieve naloxone nasal spray from atop a drone located outside the simulation building and then administer it using scripted instructions. The primary outcome measure was time from first contact with the dispatcher to administration of the medication. RESULTS: All subjects administered the medication successfully. The mean time interval from 9 -1-1 contact until antidote administration was 122 [95%CI 109-134] sec. There was a significant reduction in time interval if subjects had prior medical training (p = 0.045) or had prior experience with use of a nasal spray device (p = 0.030). Five subjects had difficulty using the nasal spray and four subjects had minor physical impairments, but these barriers did not result in a significant difference in time to administration (p = 0.467, p = 0.30). A significant number of subjects (29/30 [97%], p = 0.044) indicated that they felt confident they could administer intranasal naloxone to an opioid OD victim after participating in the simulation. CONCLUSIONS: Our results suggest that bystanders can carry out 9-1-1 dispatcher instructions to fetch drone-delivered naloxone and potentially decrease the time interval to intranasal administration which supports further development and testing of a such a system.


Asunto(s)
Aeronaves/instrumentación , Sobredosis de Droga/tratamiento farmacológico , Servicios Médicos de Urgencia , Naloxona/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , Trastornos Relacionados con Opioides/tratamiento farmacológico , Administración Intranasal , Adulto , Anciano , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estados Unidos
13.
Public Health Rep ; 135(1_suppl): 100S-127S, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32735190

RESUMEN

OBJECTIVES: In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies. METHODS: We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings. RESULTS: The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed. CONCLUSIONS: Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.


Asunto(s)
Política de Salud , Epidemia de Opioides/prevención & control , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/prevención & control , Canadá/epidemiología , Control de Medicamentos y Narcóticos/organización & administración , Educación en Salud/organización & administración , Humanos , Naloxona/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , Trastornos Relacionados con Opioides/mortalidad , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina , Características de la Residencia , Estados Unidos/epidemiología
15.
PLoS One ; 15(6): e0234683, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32544184

RESUMEN

Rapid resuscitation of an opioid overdose with naloxone, an opioid antagonist, is critical. We developed an opioid receptor quantitative systems pharmacology (QSP) model for evaluation of naloxone dosing. In this model we examined three opioid exposure levels that have been reported in the literature (25 ng/ml, 50 ng/ml, and 75 ng/ml of fentanyl). The model predicted naloxone-fentanyl interaction at the mu opioid receptor over a range of three naloxone doses. For a 2 mg intramuscular (IM) dose of naloxone at lower fentanyl exposure levels (25 ng/ml and 50 ng/ml), the time to decreasing mu receptor occupancy by fentanyl to 50% was 3 and 10 minutes, respectively. However, at a higher fentanyl exposure level (75 ng/ml), a dose of 2 mg IM of the naloxone failed to reduce mu receptor occupancy by fentanyl to 50%. In contrast, naloxone doses of 5 mg and 10 mg IM reduced mu receptor occupancy by fentanyl to 50% in 5.5 and 4 minutes respectively. These results suggest that the current doses of naloxone (2 mg IM or 4 mg intranasal (IN)) may be inadequate for rapid reversal of toxicity due to fentanyl exposure and that increasing the dose of naloxone is likely to improve outcomes.


Asunto(s)
Unión Competitiva , Fentanilo/metabolismo , Modelos Teóricos , Naloxona/administración & dosificación , Receptores Opioides mu/metabolismo , Analgésicos Opioides/metabolismo , Simulación por Computador , Relación Dosis-Respuesta a Droga , Sobredosis de Droga/tratamiento farmacológico , Fentanilo/toxicidad , Humanos , Naloxona/uso terapéutico , Antagonistas de Narcóticos/administración & dosificación , Resultado del Tratamiento
16.
Lancet ; 395(10241): 1938-1948, 2020 06 20.
Artículo en Inglés | MEDLINE | ID: mdl-32563380

RESUMEN

The treatment of opioid withdrawal is an important area of clinical concern when treating patients with chronic, non-cancer pain, patients with active opioid use disorder, and patients receiving medication for opioid use disorder. Current standards of care for medically supervised withdrawal include treatment with µ-opioid receptor agonists, (eg, methadone), partial agonists (eg, buprenorphine), and α2-adrenergic receptor agonists (eg, clonidine and lofexidine). Newer agents likewise exploit these pharmacological mechanisms, including tramadol (µ-opioid receptor agonism) and tizanidine (α2 agonism). Areas for future research include managing withdrawal in the context of stabilising patients with opioid use disorder to extended-release naltrexone, transitioning patients with opioid use disorder from methadone to buprenorphine, and tapering opioids in patients with chronic, non-cancer pain.


Asunto(s)
Tratamiento de Sustitución de Opiáceos/métodos , Trastornos Relacionados con Opioides/tratamiento farmacológico , Síndrome de Abstinencia a Sustancias/tratamiento farmacológico , Agonistas de Receptores Adrenérgicos alfa 2/administración & dosificación , Agonistas de Receptores Adrenérgicos alfa 2/efectos adversos , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Esquema de Medicación , Humanos , Antagonistas de Narcóticos/administración & dosificación , Antagonistas de Narcóticos/efectos adversos
17.
J Addict Med ; 14(4): e136-e138, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32433364

RESUMEN

BACKGROUND: To reduce the spread of coronavirus disease 2019 (COVID-19), many substance use disorder treatment programs have transitioned to telemedicine. Emergency regulatory changes allow buprenorphine initiation without an in-person visit. We describe the use of videoconferencing for buprenorphine initiation combined with street outreach to engage 2 patients experiencing homelessness with severe opioid use disorder (OUD). CASE PRESENTATION: Patient 1 was a 30-year-old man with severe OUD who had relapsed to injection heroin/fentanyl after incarceration. A community drop-in center outreach harm reduction specialist facilitated a videoconference with an addiction specialist at an OUD bridge clinic. The patient completed a community buprenorphine/naloxone initiation and self-titrated to his prior dose, 8/2 mg twice daily. One week later, he reconnected with the outreach team for a follow-up videoconference visit. Patient 2, a 36-year-old man with severe OUD, connected to the addiction specialist via a syringe service program harm reduction specialist. He had been trying to connect to a community buprenorphine/naloxone provider, but access was limited due to COVID-19, so he was using diverted buprenorphine/naloxone to reduce opioid use. He was restarted on his previous dose of 12/3 mg daily which was continued via phone follow-up 16 days later. CONCLUSIONS: COVID-19-related regulatory changes allow buprenorphine initiation via telemedicine. We describe 2 cases where telemedicine was combined with street outreach to connect patients experiencing homelessness with OUD to treatment. These cases highlight an important opportunity to provide access to life-saving OUD treatment for vulnerable patients in the setting of a pandemic that mandates reduced face-to-face clinical interactions.


Asunto(s)
Buprenorfina/administración & dosificación , Infecciones por Coronavirus/epidemiología , Tratamiento de Sustitución de Opiáceos/métodos , Trastornos Relacionados con Opioides/terapia , Neumonía Viral/epidemiología , Centros de Tratamiento de Abuso de Sustancias , Telecomunicaciones/organización & administración , Adulto , Betacoronavirus , Combinación Buprenorfina y Naloxona/uso terapéutico , Personas sin Hogar , Humanos , Masculino , Antagonistas de Narcóticos/administración & dosificación , Innovación Organizacional , Pandemias , Centros de Tratamiento de Abuso de Sustancias/métodos , Centros de Tratamiento de Abuso de Sustancias/organización & administración , Telemedicina/métodos , Telemedicina/organización & administración
18.
Value Health ; 23(4): 451-460, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32327162

RESUMEN

OBJECTIVES: To determine the cost-effectiveness of pharmacy-based intranasal naloxone distribution to high-risk prescription opioid (RxO) users. METHODS: We developed a Markov model with an attached tree for pharmacy-based naloxone distribution to high-risk RxO users using 2 approaches: one-time and biannual follow-up distribution. The Markov structure had 6 health states: high-risk RxO use, low-risk RxO use, no RxO use, illicit opioid use, no illicit opioid use, and death. The tree modeled the probability of an overdose happening, the overdose being witnessed, naloxone being available, and the overdose resulting in death. High-risk RxO users were defined as individuals with prescription opioid doses greater than or equal to 90 morphine milligram equivalents (MME) per day. We used a monthly cycle length, lifetime horizon, and US healthcare perspective. Costs (2018) and quality-adjusted life-years (QALYs) were discounted 3% annually. Microsimulation was performed with 100 000 individual trials. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS: One-time distribution of naloxone prevented 14 additional overdose deaths per 100 000 persons, with an incremental cost-effectiveness ratio (ICER) of $56 699 per QALY. Biannual follow-up distribution led to 107 additional lives being saved with an ICER of $84 799 per QALY compared with one-time distribution. Probabilistic sensitivity analyses showed that a biannual follow-up approach would be cost-effective 50% of the time at a willingness-to-pay (WTP) threshold of $100 000 per QALY. Naloxone effectiveness and proportion of overdoses witnessed were the 2 most influential parameters for biannual distribution. CONCLUSION: Both one-time and biannual follow-up naloxone distribution in community pharmacies would modestly reduce opioid overdose deaths and be cost-effective at a WTP of $100 000 per QALY.


Asunto(s)
Analgésicos Opioides/administración & dosificación , Sobredosis de Droga/prevención & control , Naloxona/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , Administración Intranasal , Analgésicos Opioides/economía , Analgésicos Opioides/envenenamiento , Servicios Comunitarios de Farmacia/economía , Servicios Comunitarios de Farmacia/organización & administración , Análisis Costo-Beneficio , Costos de los Medicamentos , Sobredosis de Droga/economía , Humanos , Cadenas de Markov , Naloxona/economía , Antagonistas de Narcóticos/economía , Trastornos Relacionados con Opioides/complicaciones , Trastornos Relacionados con Opioides/economía , Años de Vida Ajustados por Calidad de Vida , Riesgo
19.
Ann Emerg Med ; 76(3): 318-327, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32241746

RESUMEN

Despite consensus recommendations from the American College of Emergency Physicians (ACEP), the Centers for Disease Control and Prevention, and the surgeon general to dispense naloxone to discharged ED patients at risk for opioid overdose, there remain numerous logistic, financial, and administrative barriers to implementing "take-home naloxone" programs at individual hospitals. This article describes the recent collective experience of 7 Chicago-area hospitals in implementing take-home naloxone programs. We highlight key barriers, such as hesitancy from hospital administrators, lack of familiarity with relevant rules and regulations in regard to medication dispensing, and inability to secure a supply of naloxone for dispensing. We also highlight common facilitators of success, such as early identification of a "C-suite" champion and the formation of a multidisciplinary team of program leaders. Finally, we provide recommendations that will assist emergency departments planning to implement their own take-home naloxone programs and will inform policymakers of specific needs that may facilitate dissemination of naloxone to the public.


Asunto(s)
Sobredosis de Droga/prevención & control , Servicio de Urgencia en Hospital/legislación & jurisprudencia , Implementación de Plan de Salud/legislación & jurisprudencia , Naloxona/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , Trastornos Relacionados con Opioides/prevención & control , Alta del Paciente , Chicago , Humanos , Gobierno Estatal
20.
Expert Opin Pharmacother ; 21(8): 883-891, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-32129103

RESUMEN

INTRODUCTION: Due to the increased use of opioids for pain and their abuse globally, the rate of restrictive side effects is elevating. Opioid-induced constipation (OIC) is probably the most widespread, underdiagnosed, and yet common adverse effect. Naloxegol, as an opioid antagonist, is associated with beneficial impacts in OIC. Indeed, blocking mu (µ)-opioid receptors in the gastrointestinal tract (GI) may lead to neutralization of the GI adverse events of opioids. AREAS COVERED: This review is based on a PubMed and Clinicaltrials.gov search for studies undertaken over the past 20 years (2000-2020) using the following keywords: Movantik®, Moventig®, Naloxegol, Opioids, Opioid-induced constipation and Opioid antagonists. EXPERT OPINION: Similar to the management of functional constipation, non-pharmacological therapies are applied as the first step of the procedure. However, in most cases, laxative therpaies with or without stool softeners, which may not result in satisfactory relief are applied. In these instances, administration of prokinetic agents is recommended. Furthermore, studies have shown that the best second-line therapy option is a peripherally acting µ-opioid receptor antagonist (PAMORA), which antagonizes GI adverse events.


Asunto(s)
Analgésicos Opioides/efectos adversos , Morfinanos/uso terapéutico , Antagonistas de Narcóticos/uso terapéutico , Estreñimiento Inducido por Opioides/tratamiento farmacológico , Polietilenglicoles/uso terapéutico , Receptores Opioides mu/antagonistas & inhibidores , Analgésicos Opioides/uso terapéutico , Humanos , Laxativos/uso terapéutico , Morfinanos/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , Estreñimiento Inducido por Opioides/metabolismo , Dolor/tratamiento farmacológico , Polietilenglicoles/administración & dosificación
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