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2.
Crit Care ; 24(1): 44, 2020 02 07.
Artigo em Inglês | MEDLINE | ID: mdl-32033582

RESUMO

BACKGROUND: Naloxone is the usual drug used in opioid-induced respiratory depression but it has a short half-life, precipitates withdrawal in dependent patients, and thus for persistent reversal of long-acting opioids has to be given by titrated doses and infusions. The partial agonist buprenorphine has a much longer duration of action and causes less severe withdrawal, but still should largely reverse respiratory depression induced by full agonist opioids. We aimed to compare the efficacy/safety of buprenorphine and naloxone in reversing respiratory depression in methadone-poisoned opioid-dependent patients. METHODS: Patients with methadone-induced respiratory depression were randomized to receive naloxone (titrated doses), or lower or higher doses of buprenorphine (10 µg/kg or 15 µg/kg). The primary outcome was immediate reversal of respiratory depression. We also recorded acute opioid withdrawal, need for intubation/recurrent apnea, repeated doses of opioid antagonists, length of hospital stay, other morbidity, and mortality. The study was registered with the Iranian Registry of Clinical Trials (Trial ID: 18265; Approval code: IRCT2015011020624N1). RESULTS: Eighty-five patients were randomized; 55/56 patients who received buprenorphine had rapid reversal of respiratory depression, which persisted for at least 12 h. Naloxone was effective in 28/29 patients, but often required very high titrated doses (thus delaying time to respond) and prolonged infusions. Intubation (8/29 vs 5/56) and opioid withdrawal (15/29 vs 7/56) were less common with buprenorphine. There were no serious complications or deaths in those receiving buprenorphine. The 15-µg/kg buprenorphine dose appeared to provide a longer duration of action, but precipitated withdrawal more frequently than the 10-µg/kg dose. CONCLUSION: Buprenorphine appears to be a safe and effective substitute for naloxone in overdosed opioid-dependent patients. Further studies are warranted to explore the optimal dosing strategy for buprenorphine to consistently maintain reversal of respiratory depression but not precipitate withdrawal. TRIAL REGISTRATION NUMBER: IRCT2015011020624N1. Registered 30 September 2015.


Assuntos
Analgésicos Opioides , Buprenorfina , Metadona , Antagonistas de Entorpecentes , Adulto , Analgésicos Opioides/envenenamento , Buprenorfina/uso terapêutico , Overdose de Drogas/tratamento farmacológico , Feminino , Humanos , Masculino , Metadona/envenenamento , Pessoa de Meia-Idade , Naloxona , Antagonistas de Entorpecentes/uso terapêutico , Insuficiência Respiratória/tratamento farmacológico , Adulto Jovem
3.
Expert Opin Pharmacother ; 21(3): 287-296, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31928246

RESUMO

Introduction: Gambling disorder is classified as an addictive disorder and is associated with significant distress and impairment in personal, social, occupational or other important areas of functioning. Although no pharmacotherapy has a formal indication for gambling disorder, data suggest potential benefits of specific medications.Area covered: This systematic review evaluated findings from 19 randomized controlled trials testing pharmacotherapies for the treatment of gambling disorder.Expert opinion: Few randomized controlled trials have studied pharmacotherapies for gambling disorder. Though results are limited, opioid antagonists like naltrexone showed promise in the pharmacological treatment of gambling disorder. Pharmacotherapy combined with psychotherapy treatments for gambling disorder may provide better rates of patient retention in comparison to pharmacology-only treatments, though further research is needed in this area. Future studies should address gaps relating to considerations of racial, ethnic, gender and other individual differences in clinical studies. Because gambling disorder often co-occurs with other psychiatric disorders, additional research is needed to test treatments for dually diagnosed patients.


Assuntos
Comportamento Aditivo/tratamento farmacológico , Jogo de Azar/tratamento farmacológico , Diagnóstico Duplo (Psiquiatria) , Humanos , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Psicoterapia , Ensaios Clínicos Controlados Aleatórios como Assunto , Transtornos Relacionados ao Uso de Substâncias/tratamento farmacológico
6.
BMC Health Serv Res ; 19(1): 822, 2019 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-31703741

RESUMO

BACKGROUND: As the drug poisoning crisis worsens in North America and opioid use disorder (OUD)-related hospital admissions increase, policymakers and hospital administrators are beginning to recognize the important role of hospitals in the OUD care continuum. This study explores and describes how U.S. addiction medicine physicians created and presented business propositions to hospital administrators to support the development of addiction medicine consult (AMC) services. METHODS: Fifteen qualitative interviews were completed with board-certified or board-eligible addiction medicine physicians from 14 U.S. hospitals. The interviews occurred as part of a broader mixed methods study exploring hospital service delivery for patients admitted with OUD. Using a directed content analysis, the transcribed interviews were coded, analyzed, and final themes consolidated. RESULTS: Semi-structured interviews completed with addiction medicine physicians from established (n = 9) and developing (n = 5) AMC services at 14 U.S. hospitals explored how clinical champions persuaded hospital administrators to support AMC service development. Four elements were foundational to making the "business case": 1) describing the prevalence of substance use disorder (SUD) or OUD in the hospital; 2) identifying the negative financial impacts of not treating SUDs during hospitalization; 3) highlighting the ongoing care quality and treatment gap for hospitalized patients with SUDs; and 4) noting the success of other institutional AMC services. Study findings informed the creation of tools to support AMC service development: 1) an AMC service business case template, and 2) an AMC service design and operations resource list. CONCLUSIONS: OUD-related hospital admissions are unlikely to abate. Hospital administrators should consider innovative care delivery mechanisms to improve care for persons with OUD. AMC services may be a promising delivery mechanism to achieve this aim. For clinical and administrative champions, understanding how to communicate the potential effectiveness of this intervention to hospital leaders is an essential first step to AMC service creation.


Assuntos
Medicina do Vício/organização & administração , Transtornos Relacionados ao Uso de Opioides/reabilitação , Continuidade da Assistência ao Paciente , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Antagonistas de Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Aceitação pelo Paciente de Cuidados de Saúde , Qualidade da Assistência à Saúde , Encaminhamento e Consulta , Estados Unidos
7.
PLoS Med ; 16(11): e1002963, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31743335

RESUMO

BACKGROUND: In light of the accelerating and rapidly evolving overdose crisis in the United States (US), new strategies are needed to address the epidemic and to efficiently engage and retain individuals in care for opioid use disorder (OUD). Moreover, there is an increasing need for novel approaches to using health data to identify gaps in the cascade of care for persons with OUD. METHODS AND FINDINGS: Between June 2018 and May 2019, we engaged a diverse stakeholder group (including directors of statewide health and social service agencies) to develop a statewide, patient-centered cascade of care for OUD for Rhode Island, a small state in New England, a region highly impacted by the opioid crisis. Through an iterative process, we modified the cascade of care defined by Williams et al. for use in Rhode Island using key national survey data and statewide health claims datasets to create a cross-sectional summary of 5 stages in the cascade. Approximately 47,000 Rhode Islanders (5.2%) were estimated to be at risk for OUD (stage 0) in 2016. At the same time, 26,000 Rhode Islanders had a medical claim related to an OUD diagnosis, accounting for 55% of the population at risk (stage 1); 27% of the stage 0 population, 12,700 people, showed evidence of initiation of medication for OUD (MOUD, stage 2), and 18%, or 8,300 people, had evidence of retention on MOUD (stage 3). Imputation from a national survey estimated that 4,200 Rhode Islanders were in recovery from OUD as of 2016, representing 9% of the total population at risk. Limitations included use of self-report data to arrive at estimates of the number of individuals at risk for OUD and using a national estimate to identify the number of individuals in recovery due to a lack of available state data sources. CONCLUSIONS: Our findings indicate that cross-sectional summaries of the cascade of care for OUD can be used as a health policy tool to identify gaps in care, inform data-driven policy decisions, set benchmarks for quality, and improve health outcomes for persons with OUD. There exists a significant opportunity to increase engagement prior to the initiation of OUD treatment (i.e., identification of OUD symptoms via routine screening or acute presentation) and improve retention and remission from OUD symptoms through improved community-supported processes of recovery. To do this more precisely, states should work to systematically collect data to populate their own cascade of care as a health policy tool to enhance system-level interventions and maximize engagement in care.


Assuntos
Transtornos Relacionados ao Uso de Opioides/terapia , Transtornos Relacionados ao Uso de Substâncias/terapia , Analgésicos Opioides/uso terapêutico , Protocolos Clínicos , Estudos Transversais , Overdose de Drogas/psicologia , Overdose de Drogas/terapia , Humanos , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos , Rhode Island/epidemiologia , Medição de Risco/métodos , Fatores de Risco , Serviço Social , Participação dos Interessados , Estados Unidos/epidemiologia
8.
BMC Med ; 17(1): 174, 2019 09 16.
Artigo em Inglês | MEDLINE | ID: mdl-31526369

RESUMO

BACKGROUND: Different methodological choices such as inclusion/exclusion criteria and analytical models can yield different results and inferences when meta-analyses are performed. We explored the range of such differences, using several methodological choices for indirect comparison meta-analyses to compare nalmefene and naltrexone in the reduction of alcohol consumption as a case study. METHODS: All double-blind randomized controlled trials (RCTs) comparing nalmefene to naltrexone or one of these compounds to a placebo in the treatment of alcohol dependence or alcohol use disorders were considered. Two reviewers searched for published and unpublished studies in MEDLINE (August 2017), the Cochrane Library, Embase, and ClinicalTrials.gov and contacted pharmaceutical companies, the European Medicines Agency, and the Food and Drug Administration. The indirect comparison meta-analyses were performed according to different inclusion/exclusion criteria (based on medical condition, abstinence of patients before inclusion, gender, somatic and psychiatric comorbidity, psychological support, treatment administered and dose, treatment duration, outcome reported, publication status, and risk of bias) and different analytical models (fixed and random effects). The primary outcome was the vibration of effects (VoE), i.e. the range of different results of the indirect comparison between nalmefene and naltrexone. The presence of a "Janus effect" was investigated, i.e. whether the 1st and 99th percentiles in the distribution of effect sizes were in opposite directions. RESULTS: Nine nalmefene and 51 naltrexone RCTs were included. No study provided a direct comparison between the drugs. We performed 9216 meta-analyses for the indirect comparison with a median of 16 RCTs (interquartile range = 12-21) included in each meta-analysis. The standardized effect size was negative at the 1st percentile (- 0.29, favouring nalmefene) and positive at the 99th percentile (0.29, favouring naltrexone). A total of 7.1% (425/5961) of the meta-analyses with a negative effect size and 18.9% (616/3255) of those with a positive effect size were statistically significant (p < 0.05). CONCLUSIONS: The choice of inclusion/exclusion criteria and analytical models for meta-analysis can result in entirely opposite results. VoE evaluations could be performed when overlapping meta-analyses on the same topic yield contradictory result. TRIAL REGISTRATION: This study was registered on October 19, 2016, in the Open Science Framework (OSF, protocol available at https://osf.io/7bq4y/ ).


Assuntos
Metanálise como Assunto , Projetos de Pesquisa , Consumo de Bebidas Alcoólicas/tratamento farmacológico , Alcoolismo/tratamento farmacológico , Humanos , Naltrexona/análogos & derivados , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico
9.
J Addict Nurs ; 30(3): 219-223, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31478970

RESUMO

BACKGROUND: The ongoing drug crisis in the United States continues to be headlined with numbers of deaths related to opioid overdose. Less known to the public and health care providers is the rise in methamphetamine use, often in conjunction with opioids or adulterated with fentanyl. An old practice with a new twist is the use of methamphetamine in conjunction with an opioid such as heroin. PURPOSE: Although there are no Food and Drug Administration-approved medications to treat individuals with stimulant use disorders, a review of available studies suggests a few promising medications that may be helpful for patients in early recovery from methamphetamine. OUTCOME: Some individuals are more likely to respond to medications such as long-acting naltrexone, bupropion, and mirtazapine, who have light-to-moderate use of methamphetamine. Naloxone kits should be considered for all patients who are actively using stimulants because of a high potential of adulterated methamphetamine.


Assuntos
Transtornos Relacionados ao Uso de Anfetaminas/reabilitação , Estimulantes do Sistema Nervoso Central , Metanfetamina , Transtornos Relacionados ao Uso de Anfetaminas/epidemiologia , Bupropiona/uso terapêutico , Dextroanfetamina/uso terapêutico , Aprovação de Drogas , Humanos , Metilfenidato/uso terapêutico , Mirtazapina/uso terapêutico , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/reabilitação , Resultado do Tratamento , Estados Unidos/epidemiologia
10.
BMC Health Serv Res ; 19(1): 632, 2019 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-31488142

RESUMO

BACKGROUND: Overdose deaths can be prevented by distributing take home naloxone (THN) kits. The emergency department (ED) is an opportune setting for overdose prevention, as people who use opioids frequently present for emergency care, and those who have overdosed are at high risk for future overdose death. We evaluated the implementation of an ED-based THN program by measuring the extent to which THN was offered to patients presenting with opioid overdose. We analyzed whether some patients were less likely to be offered THN than others, to identify areas for program improvement. METHODS: We retrospectively reviewed medical records from all ED visits between April 2016 and May 2017 with a primary diagnosis of opioid overdose at a large, urban tertiary hospital located in Alberta, Canada. A wide array of patient data was collected, including demographics, opioid intoxicants, prescription history, overdose severity, and whether a naloxone kit was offered and accepted. Multivariable analyses were used to identify patient characteristics and situational variables associated with being offered THN. RESULTS: Among the 342 ED visits for opioid overdose, THN was offered in 49% (n = 168) of cases. Patients were more likely to be offered THN if they had been found unconscious (Adjusted Odds Ratio 3.70; 95% Confidence Interval [1.63, 8.37]), or if they had smoked or injected an illegal opioid (AOR 6.05 [2.15,17.0] and AOR 3.78 [1.32,10.9], respectively). In contrast, patients were less likely to be offered THN if they had a current prescription for opioids (AOR 0.41 [0.19, 0.88]), if they were admitted to the hospital (AOR 0.46 [0.22,0.97], or if they unexpectedly left the ED without treatment or before completing treatment (AOR 0.16 [0.22, 0.97). CONCLUSIONS: In this real-world evaluation of an ED-based THN program, we observed that only half of patients with opioid overdose were offered THN. ED staff readily identify patients who use illegal opioids or experience a severe overdose as potentially benefitting from THN, but may miss others at high risk for future overdose. We recommend that hospital EDs provide additional guidance to staff to ensure that all eligible patients at risk of overdose have access to THN.


Assuntos
Analgésicos Opioides/envenenamento , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Adulto , Alberta , Overdose de Drogas/reabilitação , Serviços Médicos de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Serviços de Assistência Domiciliar/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Masculino , Registros Médicos , Transtornos Relacionados ao Uso de Opioides/reabilitação , Estudos Retrospectivos
11.
J Consult Clin Psychol ; 87(10): 952-961, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31556671

RESUMO

OBJECTIVE: This retrospective study describes the role of behavioral health in an addiction medicine program integrated in a primary care clinic, and evaluates retention, substance use, and mental health symptoms for patients in a rural underserved community. METHOD: Data were abstracted from records of patients referred for buprenorphine treatment of opioid use disorder (N = 101; 45% female, 23% Native Hawaiian or Pacific Islander, Mage = 42.5, SD = 12.75). Among patients prescribed buprenorphine (n = 61), most had comorbid substance-related diagnoses (72% with tobacco use, 75% with at least one other substance use disorder) and non-substance-related mental health diagnoses (77%), most commonly depression and anxiety. Integrated sessions with a behavioral health provider and a buprenorphine-waivered prescriber occurred weekly to monthly. Participants completed depression and anxiety questionnaires (Patient Health Questionnaire-9 and Generalized Anxiety Disorder Scale-7) and provided urine samples at each visit. RESULTS: Most patients (72%) were retained for at least 3 months, with early dropout associated with higher initial depression and anxiety scores. Inconsistent urine drug tests (i.e., those positive for illicit/nonprescribed substances) were significantly more common at treatment initiation (74%) than during the most recent visit (43%, p < .001), and were associated with baseline substance and other mental health factors, as well as shorter treatment duration. Generalized estimating equations models suggested time-based improvements in depression and anxiety symptoms, especially for patients retained for at least 3 months. CONCLUSIONS: Integrating wraparound addiction treatment within a rural primary care setting is feasible and associated with improved mental health and retention outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).


Assuntos
Medicina do Vício , Buprenorfina/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Atenção Primária à Saúde , Saúde da População Rural , Adulto , Transtornos de Ansiedade/complicações , Buprenorfina/administração & dosagem , Transtorno Depressivo/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Antagonistas de Entorpecentes/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/complicações , Estudos Retrospectivos
12.
Dtsch Med Wochenschr ; 144(16): 1145-1157, 2019 08.
Artigo em Alemão | MEDLINE | ID: mdl-31416107

RESUMO

The most relevant risk factors for the development of chronic constipation are neurologic disorders such as Parkinson's disease, immobility, and some drugs, in particular opioids. A proctologic exam and exclusion of red flags form part of the basic assessment. The currently available laxatives are effective and safe, habituation and tolerance (tachyphylaxis) being an exception. Also long-term intake of laxatives is of no concern when taken in recommended doses (no relevant hypokalemia!). Though the newer compounds (e. g., prucalopride, linaclotide, lubiprostone) are not more effective than the older ones, developing new drugs with alternative mode of action is reasonable since there are patients not satisfied with the currently available substances. Macrogol, Bisacodyl, and sodium picosulfate are the laxatives of first choice. Their selection depends on the individual preference of the patient. Opioids often induce constipation which can be ameliorated by laxatives or PAMORAs (peripherally acting µ-opioid antagonists).


Assuntos
Constipação Intestinal , Analgésicos Opioides/efeitos adversos , Doença Crônica , Constipação Intestinal/diagnóstico , Constipação Intestinal/epidemiologia , Constipação Intestinal/fisiopatologia , Constipação Intestinal/terapia , Humanos , Laxantes/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Doença de Parkinson/complicações , Fatores de Risco
13.
Int Immunopharmacol ; 75: 105785, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31404891

RESUMO

Endogenous opioids are neuro-peptides with multifunctional properties. Historically, opioids are used to mediate pain; however, excess opiate consumption can lead to addiction. One endogenous opioid, methionine enkephalin (MENK), was reported to modulate cell growth, MENK was identified as an opioid growth factor (OGF) that interacts with the OGF receptor (OGFr) and regulates cell proliferation. Further, opioid antagonists, including naltrexone and naloxone are widely used to reverse drug and alcohol overdoses. Naltrexone (NTX) acts on all opioid receptors, blocking the interaction between OGF and OGFr, and thus influencing cell growth. During the last decades, insights have been made concerning the interaction between OGF and OGFr, confirming that both opioids and opioid antagonists have an important role in balancing host homeostasis, host immunity and mediating cancer therapy. This review provides insight into the interactions between OGF and OGFr in the treatment of cancers.


Assuntos
Encefalina Metionina/uso terapêutico , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Neoplasias/tratamento farmacológico , Animais , Encefalina Metionina/farmacologia , Humanos , Naltrexona/farmacologia , Antagonistas de Entorpecentes/farmacologia , Neoplasias/imunologia , Neoplasias/metabolismo
14.
Drugs ; 79(11): 1241-1247, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31267482

RESUMO

Naldemedine [Symproic® (Japan; USA); Rizmoic® (EU)], an orally available peripherally acting µ-opioid receptor antagonist (PAMORA), is approved in several countries for the treatment of opioid-induced constipation. In phase III trials, naldemedine was more effective than placebo at increasing the frequency of bowel movements in patients with constipation induced by opioid treatment for cancer pain or chronic non-cancer pain. Naldemedine was also associated with improvements in patient-rated constipation-related symptoms and quality of life. Naldemedine was generally well tolerated, including over the longer term. Because naldemedine specifically targets opioid receptors in the gastrointestinal (GI) tract and does not cross the blood-brain barrier, it does not cause opioid withdrawal symptoms or interfere with centrally mediated opioid analgesia. Consistent with its mechanism of action, the most commonly reported adverse events were GI in nature. In conclusion, current data indicate that naldemedine is an effective and generally well-tolerated treatment option for opioid-induced constipation in patients with cancer pain or chronic non-cancer pain, with the convenience of once-daily oral dosing.


Assuntos
Analgésicos Opioides/efeitos adversos , Constipação Intestinal/tratamento farmacológico , Naltrexona/análogos & derivados , Antagonistas de Entorpecentes/uso terapêutico , Dor do Câncer/tratamento farmacológico , Dor Crônica/tratamento farmacológico , Ensaios Clínicos Fase III como Assunto , Constipação Intestinal/induzido quimicamente , Humanos , Naltrexona/uso terapêutico , Qualidade de Vida
17.
Health Serv Res ; 54(5): 1055-1064, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31313839

RESUMO

OBJECTIVE: Academic detailing in partnership with the Opioid Overdose Education and Naloxone Distribution (OEND) program was implemented to increase naloxone access for the prevention of opioid overdose mortality in veterans at the U.S. Department of Veterans Affairs (VA). However, implementation was not uniform leading to varying levels of intervention exposure potentially impacting naloxone prescribing. We examined the impact of implementation strength (proportion of providers exposed to academic detailing) at each station on naloxone prescribing from September 2014 to December 2017. STUDY DESIGN AND SETTING: Retrospective cohort design with fixed effects models at the VA. DATA COLLECTION/EXTRACTION METHODS: We used VA Corporate Data Warehouse for data on pharmacy dispensing, station-, provider- and patient-level characteristics. OEND-specific academic detailing activities came from data recorded by academic detailers using Salesforce.com. PRINCIPAL FINDINGS: VA stations wherein 100 percent of providers exposed to an OEND-related academic detailing educational outreach visit experienced an increased incident rate of naloxone prescribing that was 5.52 times the incident rate of stations where no providers were exposed; alternatively, this is equivalent to an average monthly increase of 2.60 naloxone prescriptions per 1000 population at risk for opioid overdose. CONCLUSIONS: Our findings highlight the importance of academic detailing's implementation strength on naloxone prescribing. Decision makers must carefully consider the implementation process to achieve the greatest effectiveness from the intervention.


Assuntos
Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Assistência Farmacêutica/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Padrões de Prática Médica/tendências , United States Department of Veterans Affairs/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Previsões , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos
18.
J Med Econ ; 22(10): 1073-1079, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31314616

RESUMO

Objectives: To extend a previously published manuscript on a model for estimating potential avoided medical events and cost savings in the US associated with the introduction of extended-release abuse-deterrent opioids and incorporate new methods of evaluating abuse deterrence using human abuse potential studies. Methods: A model was developed to estimate reductions in abuse-related events and annual savings in the US. Model inputs included: opioid abuse prevalence, abuse-deterrent opioid cost and effectiveness at deterring abuse, and opioid abuse-related events and costs. Direct (medical and drug) and indirect (work loss) cost savings (2017 US$) and abuse-related events were estimated assuming the replacement of the entire extended-release opioid market (brand and generic) by brand abuse-deterrent opioids. Results: Replacing the extended-release opioid market with abuse-deterrent opioids is estimated to lower annual abuse-related medical events by ∼13-31% (e.g. 78,000-186,000 emergency department visits) and lower annual medical costs by ∼$640 M-$1,538 M, depending on the abuse-deterrent technology (physical/chemical barrier or agonist/antagonist). Replacement of extended-release oxycodone with extended-release abuse-deterrent oxycodone is associated with the largest amount of cost savings and highest number of avoided medical events, followed by replacing extended-release morphine with an extended-release abuse-deterrent opioid. Replacement of transdermal fentanyl is associated with the smallest amount of cost savings and lowest number of avoided medical events. Conclusion: Agonist/antagonist abuse-deterrent opioid technology is associated with higher annual medical cost savings and more avoided events than physical/chemical barrier technology. Total net savings are dependent upon the abuse-deterrent opioid price relative to non-abuse-deterrent opioids.


Assuntos
Antagonistas de Entorpecentes/economia , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Aceitação pelo Paciente de Cuidados de Saúde , Redução de Custos , Análise Custo-Benefício , Preparações de Ação Retardada/economia , Humanos , Modelos Teóricos , Antagonistas de Entorpecentes/uso terapêutico , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estados Unidos
19.
Am J Health Syst Pharm ; 76(7): 424-435, 2019 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-31361827

RESUMO

PURPOSE: The purpose of this review is to (1) provide information concerning the opioid crisis including origins, trends, and some important related laws/policies; and (2) summarize the current involvement and impact of pharmacists in helping to address the crisis, as well as examine practices in other healthcare disciplines from which pharmacists might derive guidance and strategies. SUMMARY: Contributors to the opioid crisis included campaigns to treat pain as a fifth vital sign and to use opioids in treatment of non-cancer-related pain, as well as aggressive marketing of opioid analgesics by pharmaceutical companies. To address the crisis, numerous strategies have been implemented at the policy/legislative, health-system, and patient levels, such as prescription drug monitoring programs (PDMPs), increased regulation of pain clinics, and expanded use of naloxone. Pharmacists have a critical role to play in interventions to address opioid misuse and reduce harm resulting from misuse. Such interventions include patient screening and risk stratification, patient and community education and outreach concerning appropriate pain management, medication reviews/medication therapy management, education on safe storage and disposal, distribution of naloxone/opioid rescue kits and training on their proper use, and referral of patients to addiction treatment, among other strategies. CONCLUSION: Pharmacists have multiple, complex roles in addressing the opioid crisis. Outcomes of several studies provide substantial evidence that pharmacists can make an impact through appropriate pain management, use of PDMPs, opioid overdose prevention training, and medication reviews and counseling, among other interventions.


Assuntos
Analgésicos Opioides/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Manejo da Dor/métodos , Farmacêuticos/organização & administração , Aconselhamento , Publicidade Direta ao Consumidor/legislação & jurisprudência , Revisão de Uso de Medicamentos/organização & administração , Política de Saúde , Humanos , Prescrição Inadequada/efeitos adversos , Prescrição Inadequada/legislação & jurisprudência , Prescrição Inadequada/prevenção & controle , Conduta do Tratamento Medicamentoso/organização & administração , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/terapia , Assistência Farmacêutica/organização & administração , Uso Indevido de Medicamentos sob Prescrição/efeitos adversos , Uso Indevido de Medicamentos sob Prescrição/legislação & jurisprudência , Uso Indevido de Medicamentos sob Prescrição/prevenção & controle , Papel Profissional , Estados Unidos/epidemiologia
20.
Am J Health Syst Pharm ; 76(15): 1097-1103, 2019 Jul 18.
Artigo em Inglês | MEDLINE | ID: mdl-31361869

RESUMO

PURPOSE: The use of buprenorphine, methadone, and long-acting naltrexone for treatment of opioid use disorder (OUD) is discussed, including a review of current literature detailing treatment approaches and action steps to optimize treatment in acute care and office-based settings. SUMMARY: The U.S. epidemic of opioid-related deaths has been driven by misuse of prescription opioids and, increasingly, illicit drugs such as heroin, fentanyl, and fentanyl analogs, necessitating a refocusing of treatment efforts on expanding access to life-saving, evidence-based OUD pharmacotherapy. Inpatient treatment of opioid withdrawal includes acute symptom control through a combination of nonopioid medications and long-term pharmacotherapy to lessen opioid craving and facilitate stabilization and recovery. Methadone and buprenorphine reduce opioid craving, increase treatment retention, reduce illicit opioid use, and increase overall survival. Buprenorphine has logistical advantages over methadone, such as greater flexibility of treatment setting and less risk of adverse effects. Studies have shown the efficacy of long-acting injectable naltrexone to be comparable to that of buprenorphine if patients are detoxified prior to initiation of therapy; however, patients with active OUD are often not able to complete the week-long period of opioid abstinence needed prior to initiation of naltrexone injections. Although buprenorphine is preferred by many patients and can be prescribed in office-based settings, there remains a paucity of physicians certified to prescribe it. CONCLUSION: Buprenorphine has become the medication of choice for many patients with OUD, but its use is limited by the low number of physicians certified to prescribe the agent. Other agents studied for treatment of OUD include methadone and naltrexone.


Assuntos
Analgésicos Opioides/efeitos adversos , Medicina Baseada em Evidências/métodos , Antagonistas de Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Buprenorfina/uso terapêutico , Prescrições de Medicamentos , Humanos , Metadona/uso terapêutico , Naltrexona/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia
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