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1.
J Addict Med ; 18(3): 335-338, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38833558

RESUMO

OBJECTIVES: Overdose mortality has risen most rapidly among racial and ethnic minority groups while buprenorphine prescribing has increased disproportionately in predominantly non-Hispanic White urban areas. To identify whether buprenorphine availability equitably meets the needs of diverse populations, we examined the differential geographic availability of buprenorphine in areas with greater concentrations of racial and ethnic minority groups. METHODS: Using IQVIA longitudinal prescription data, IQVIA OneKey data, and Microsoft Bing Maps, we calculated 2 outcome measures across the continental United States: the number of buprenorphine prescribers per 1000 residents within a 30-minute drive of a ZIP code, and the number of buprenorphine prescriptions dispensed per capita at retail pharmacies among nearby buprenorphine prescribers. We then estimated differences in these outcomes by ZIP codes' racial and ethnic minority composition and rurality with t tests. RESULTS: Buprenorphine prescribers per 1000 residents within a 30-minute drive decreased by 3.8 prescribers per 1000 residents in urban ZIP codes (95% confidence interval = -4.9 to -2.7) and 2.6 in rural ZIP codes (95% confidence interval = -3.0 to -2.2) whose populations consisted of ≥5% racial and ethnic minority groups. There were 45% to 55% fewer prescribers in urban areas and 62% to 79% fewer prescribers in rural areas as minority composition increased. Differences in dispensed buprenorphine per capita were similar but larger in magnitude. CONCLUSIONS: Achieving more equitable buprenorphine access requires not only increasing the number of buprenorphine-prescribing clinicians; in urban areas with higher racial and ethnic minority group populations, it also requires efforts to promote greater buprenorphine prescribing among already prescribing clinicians.


Assuntos
Buprenorfina , Disparidades em Assistência à Saúde , Buprenorfina/uso terapêutico , Humanos , Estados Unidos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Antagonistas de Entorpecentes/uso terapêutico , População Urbana/estatística & dados numéricos , População Rural/estatística & dados numéricos , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/etnologia , Minorias Étnicas e Raciais/estatística & dados numéricos , Etnicidade/estatística & dados numéricos
2.
Ann Med ; 56(1): 2355566, 2024 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-38823420

RESUMO

BACKGROUND: Racial and ethnic disparities are evident in the accessibility of treatment for opioid use disorder (OUD). Even when medications for OUD (MOUD) are accessible, racially and ethnically minoritized groups have higher attrition rates from treatment. Existing literature has primarily identified the specific racial and ethnic groups affected by these disparities, but has not thoroughly examined interventions to address this gap. Recovery peer navigators (RPNs) have been shown to improve access and overall retention on MOUD. PATIENTS AND METHODS: In this retrospective cohort study, we evaluate the role of RPNs on patient retention in clinical care at an outpatient program in a racially and ethnically diverse urban community. Charts were reviewed of new patients seen from January 1, 2019 through December 31, 2019. Sociodemographic and clinical visit data, including which providers and services were utilized, were collected, and the primary outcome of interest was continuous retention in care. Bivariate analysis was done to test for statistically significant associations between variables by racial/ethnic group and continuous retention in care using Student's t-test or Pearson's chi-square test. Variables with p value ≤0.10 were included in a multivariable regression model. RESULTS: A total of 131 new patients were included in the study. RPNs improved continuous retention in all-group analysis (27.6% pre-RPN compared to 80.2% post-RPN). Improvements in continuous retention were observed in all racial/ethnic subgroups but were statistically significant in the non-Hispanic Black (NHB) group (p < 0.001). Among NHB, increases in continuous retention were observed post-RPN in patients with male sex (p < 0.001), public health insurance (p < 0.001), additional substance use (p < 0.001), medical comorbidities (p < 0.001), psychiatric comorbidities (p = 0.001), and unstable housing (p = 0.005). Multivariate logistic regression demonstrated that patients who lacked insurance had lower odds of continuous retention compared to patients with public insurance (aOR = 0.17, 95% CI 0.039-0.70, p = 0.015). CONCLUSIONS: RPNs can improve clinical retention for patients with OUD, particularly for individuals experiencing several sociodemographic and clinical factors that are typically correlated with discontinuation of care.


Recovery peer navigators improve continuous clinical retention following initiation of outpatient treatment for opioid use disorder.Recovery peer navigators may be especially beneficial for patients with factors and identifiers commonly associated with discontinuation of care.


Assuntos
Buprenorfina , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Navegação de Pacientes , Retenção nos Cuidados , Humanos , Estudos Retrospectivos , Masculino , Feminino , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Buprenorfina/uso terapêutico , Buprenorfina/administração & dosagem , Adulto , Tratamento de Substituição de Opiáceos/métodos , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Navegação de Pacientes/organização & administração , Pessoa de Meia-Idade , Retenção nos Cuidados/estatística & dados numéricos , Grupo Associado , Assistência Ambulatorial/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Etnicidade , Pacientes Ambulatoriais
3.
Comput Biol Med ; 177: 108493, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38833799

RESUMO

OBJECTIVES: Buprenorphine is an effective evidence-based medication for opioid use disorder (OUD). Yet premature discontinuation undermines treatment effectiveness, increasing the risk of mortality and overdose. We developed and evaluated a machine learning (ML) framework for predicting buprenorphine care discontinuity within 12 months following treatment initiation. METHODS: This retrospective study used United States (US) 2018-2021 MarketScan commercial claims data of insured individuals aged 18-64 who initiated buprenorphine between July 2018 and December 2020 with no buprenorphine prescriptions in the previous six months. We measured buprenorphine prescription discontinuation gaps of ≥30 days within 12 months of initiating treatment. We developed predictive models employing logistic regression, decision tree classifier, random forest, extreme gradient boosting, Adaboost, and random forest-extreme gradient boosting ensemble. We applied recursive feature elimination with cross-validation to reduce dimensionality and identify the most predictive features while maintaining model robustness. For model validation, we used several statistics to evaluate performance, such as C-statistics and precision-recall curves. We focused on two distinct treatment stages: at the time of treatment initiation and one and three months after treatment initiation. We employed SHapley Additive exPlanations (SHAP) analysis that helped us explain the contributions of different features in predicting buprenorphine discontinuation. We stratified patients into risk subgroups based on their predicted likelihood of treatment discontinuation, dividing them into decile subgroups. Additionally, we used a calibration plot to analyze the reliability of the models. RESULTS: A total of 30,373 patients initiated buprenorphine and 14.98% (4551) discontinued treatment. C-statistic varied between 0.56 and 0.76 for the first-stage models including patient-level demographic and clinical variables. Inclusion of proportion of days covered (PDC) measured after one month and three months following treatment initiation significantly increased the models' discriminative power (C-statistics: 0.60 to 0.82). Random forest (C-statistics: 0.76, 0.79 and 0.82 with baseline predictors, one-month PDC and three-months PDC, respectively) outperformed other ML models in discriminative performance in all stages (C-statistics: 0.56 to 0.77). Most influential risk factors of discontinuation included early stage medication adherence, age, and initial days of supply. CONCLUSION: ML algorithms demonstrated a good discriminative power in identifying patients at higher risk of buprenorphine care discontinuity. The proposed framework may help healthcare providers optimize treatment strategies and deliver targeted interventions to improve buprenorphine care continuity.


Assuntos
Buprenorfina , Aprendizado de Máquina , Transtornos Relacionados ao Uso de Opioides , Humanos , Buprenorfina/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Adulto , Feminino , Masculino , Estudos Retrospectivos , Pessoa de Meia-Idade , Adolescente , Estados Unidos , Adulto Jovem , Tratamento de Substituição de Opiáceos , Analgésicos Opioides/uso terapêutico
4.
Harm Reduct J ; 21(1): 114, 2024 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-38849912

RESUMO

BACKGROUND: As the opioid public health crisis evolves to include fentanyl and other potent synthetic opioids, more patients are admitted to the hospital with serious complications of drug use and frequently require higher levels of care, including intensive care unit (ICU) admission, for acute and chronic conditions related to opioid use disorder (OUD). This patient population poses a unique challenge when managing sedation and ensuring adequate ventilation while intubated given their high opioid requirements. Starting a patient on medications such as buprenorphine may be difficult for inpatient providers unfamiliar with its use, which may lead to undertreatment of patients with OUD, prolonged mechanical ventilation and length of stay. METHODS: We developed a 7-day buprenorphine low dose overlap initiation (LDOI) schedule for patients with OUD admitted to the ICU (Table 1). Buprenorphine tablets were split by pharmacists and placed into pre-made blister packs as a kit to be loaded into the automated medication dispensing machine for nursing to administer daily. An internal quality review validated the appropriate dosing of split-dose tablets. To simplify order entry and increase prescriber comfort with this new protocol, we generated an order set within our electronic health record software with prebuilt buprenorphine titration orders. This protocol was implemented alongside patient and healthcare team education and counseling on the LDOI process, with follow-up offered to all patients upon discharge. RESULTS: Here we report a series of 6 ICU patients started on buprenorphine using the LDOI schedule with split buprenorphine tablets. None of the 6 patients experienced precipitated withdrawal upon buprenorphine initiation using the LDOI schedule, and 5/6 patients were successfully extubated during the buprenorphine initiation. Four of six patients had a decrease in daily morphine milligram equivalents, with 3 patients transitioning to buprenorphine alone. CONCLUSION: Initiating buprenorphine via LDOI was found to be successful in the development of a protocol for critically ill patients with OUD. We examined LDOI of buprenorphine in intubated ICU patients and found no events of acute precipitated withdrawal. This protocol can be used as a guide for other institutions seeking to start critically ill patients on medication treatment for OUD during ICU admission.


Assuntos
Analgésicos Opioides , Buprenorfina , Unidades de Terapia Intensiva , Transtornos Relacionados ao Uso de Opioides , Humanos , Buprenorfina/administração & dosagem , Buprenorfina/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Masculino , Analgésicos Opioides/administração & dosagem , Feminino , Tratamento de Substituição de Opiáceos/métodos , Adulto , Pessoa de Meia-Idade , Antagonistas de Entorpecentes/uso terapêutico , Antagonistas de Entorpecentes/administração & dosagem , Intubação Intratraqueal/métodos
6.
JMIR Res Protoc ; 13: e53784, 2024 Jun 06.
Artigo em Inglês | MEDLINE | ID: mdl-38843513

RESUMO

BACKGROUND: Chronic pain affects tens of millions of US adults and continues to rise in prevalence. Nonpharmacologic behavioral pain treatments are greatly needed and yet are often inaccessible, particularly in settings where medication prescribing is prioritized. OBJECTIVE: This study aims to test the feasibility of a live-instructor, web-based 1-session pain relief skills class in an underserved and potentially at-risk population: people with chronic pain prescribed methadone or buprenorphine either solely for pain or for comorbid opioid use disorder (OUD). METHODS: This is a national, prospective, single-arm, uncontrolled feasibility trial. The trial is untethered from medical care; to enhance participants' willingness to join the study, no medical records or drug-monitoring records are accessed. At least 45 participants will be recruited from outpatient pain clinics and from an existing research database of individuals who have chronic pain and are taking methadone or buprenorphine. Patient-reported measures will be collected at 6 time points (baseline, immediately post treatment, 2 weeks, and months 1-3) via a web-based platform, paper, or phone formats to include individuals with limited internet or computer access and low literacy skills. At baseline, participants complete demographic questions and 13 study measures (Treatment Expectations, Body Pain Map, Medication Use, Pain Catastrophizing Scale [PCS], Patient-Reported Outcomes Measurement Information System [PROMIS] Measures, and Opioid Craving Scale). Immediately post treatment, a treatment satisfaction and acceptability measure is administered on a 0 (very dissatisfied) to 10 (completely satisfied) scale, with 3 of these items being the primary outcome (perceived usefulness, participant satisfaction, and likelihood of using the skills). At each remaining time point, the participants complete all study measures minus treatment expectations and satisfaction. Participants who do not have current OUD will be assessed for historical OUD, with presence of OUD (yes or no), and history of OUD (yes or no) reported separately. Feasibility threshold is set as an overall group treatment satisfaction rating of 8 of 10. In-depth qualitative interviews will be conducted with about 10 participants to obtain additional data on patient perceptions, satisfactions, needs, and wants. To assess preliminary efficacy, we will examine changes in pain catastrophizing, pain intensity, pain bothersomeness, sleep disturbance, pain interference, depression, anxiety, physical function, global impression of change, and opioid craving at 1 month post treatment. RESULTS: This project opened to enrollment in September 2021 and completed the recruitment in October 2023. The data collection was completed in February 2024. Results are expected to be published in late 2024. CONCLUSIONS: Results from this trial will inform the feasibility and preliminary efficacy of Empowered Relief in this population and will inform the design of a future randomized controlled trial testing web-based Empowered Relief in chronic pain and comorbid OUD. TRIAL REGISTRATION: ClinicalTrials.gov NCT05057988; https://clinicaltrials.gov/study/NCT05057988. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53784.


Assuntos
Buprenorfina , Dor Crônica , Estudos de Viabilidade , Metadona , Humanos , Buprenorfina/uso terapêutico , Buprenorfina/administração & dosagem , Dor Crônica/tratamento farmacológico , Dor Crônica/psicologia , Metadona/uso terapêutico , Metadona/administração & dosagem , Estudos Prospectivos , Masculino , Feminino , Analgésicos Opioides/uso terapêutico , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/administração & dosagem , Adulto , Manejo da Dor/métodos , Tratamento de Substituição de Opiáceos/métodos , Intervenção Baseada em Internet , Internet , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Pessoa de Meia-Idade
7.
PLoS One ; 19(6): e0304461, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38870144

RESUMO

OBJECTIVES: Insomnia symptoms are negatively related to opioid use disorder (OUD) treatment outcomes, possibly reflecting the influence of sleep on neurofunctional domains implicated in addiction. Moreover, the intersection between OUD recovery and sleep represents an area well-suited for the development of novel, personalized treatment strategies. This study assessed the prevalence of clinically significant insomnia symptoms and characterized its neurofunctional correlates among a clinical sample of adults with OUD receiving buprenorphine. METHODS: Adults (N = 129) receiving buprenorphine for OUD from an outpatient clinic participated in a cross-sectional survey. Participants completed an abbreviated version of NIDA's Phenotyping Assessment Battery, which assessed 6 neurofunctional domains: sleep, negative emotionality, metacognition, interoception, cognition, and reward. Bivariate descriptive statistics compared those with evidence of clinically significant insomnia symptoms (Insomnia Severity Index [ISI] score of ≥11) to those with minimal evidence of clinically significant insomnia symptoms (ISI score of ≤10) across each of the neurofunctional domains. RESULTS: Roughly 60% of participants reported clinically significant insomnia symptoms (ISI score of ≥11). Experiencing clinically significant insomnia symptoms was associated with reporting greater levels of depression, anxiety, post-traumatic stress, stress intolerance, unhelpful metacognition, and interoceptive awareness (ps<0.05). Participants with evidence of clinically significant insomnia were more likely to report that poor sleep was interfering with their OUD treatment and that improved sleep would assist with their treatment (ps<0.05). CONCLUSIONS: Insomnia was prevalent among adults receiving buprenorphine for OUD. Insomnia was associated with neurofunctional performance, which may impact OUD treatment trajectories. Our findings indicate potential targets in the development of personalized treatment plans for patients with co-morbid insomnia and OUD. To inform the development of novel treatment strategies, more research is needed to understand the potential mechanistic links between sleep disturbances and substance use.


Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Distúrbios do Início e da Manutenção do Sono , Humanos , Distúrbios do Início e da Manutenção do Sono/tratamento farmacológico , Distúrbios do Início e da Manutenção do Sono/fisiopatologia , Masculino , Feminino , Adulto , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/fisiopatologia , Buprenorfina/uso terapêutico , Estudos Transversais , Pessoa de Meia-Idade , Cognição/efeitos dos fármacos , Sono/efeitos dos fármacos , Sono/fisiologia , Tratamento de Substituição de Opiáceos , Interocepção , Recompensa
9.
Emerg Med Pract ; 26(6): 1-24, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38768011

RESUMO

As the United States continues to grapple with the opioid crisis, emergency clinicians are on the front lines of managing patients with opioid use disorder. This issue reviews tools and best practices in emergency department management of patients with opioid overdose and opioid withdrawal, and how substance use history will inform treatment planning and disposition. As growing evidence shows that medications for opioid use disorder (MOUD)- buprenorphine, methadone, and naltrexone-can have lasting impacts on patients' addiction recovery, strategies for assessing patient readiness for MOUD and overcoming barriers to emergency department initiation of these medications are reviewed. Newer approaches to buprenorphine dosing (high-dose, low-dose, home induction, and long-acting injectable dosing) are also reviewed.


Assuntos
Buprenorfina , Serviço Hospitalar de Emergência , Transtornos Relacionados ao Uso de Opioides , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Buprenorfina/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Antagonistas de Entorpecentes/uso terapêutico , Metadona/uso terapêutico , Naltrexona/uso terapêutico , Estados Unidos , Analgésicos Opioides/uso terapêutico
10.
JAMA Netw Open ; 7(5): e2411742, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38758556

RESUMO

Importance: The National Health Service Corps (NHSC) Loan Repayment Program (LRP) expansion in fiscal year (FY) 2019 intended to improve access to medication for opioid use disorder (MOUD) by adding more clinicians who could prescribe buprenorphine. However, some clinicians still face barriers to prescribing, which may vary between rural and nonrural areas. Objective: To examine the growth in buprenorphine prescribing by NHSC clinicians for Medicaid beneficiaries during the NHSC LRP expansion and describe the challenges to prescribing that persist in rural and nonrural areas. Design, Setting, and Participants: This cross-sectional study analyzed preexpansion and postexpansion Medicaid claims data to evaluate the percentage of prescriptions of buprenorphine filled during FY 2017 through 2021. This study also analyzed challenges and barriers to prescribing MOUD between rural and urban areas, using results from annual surveys conducted with NHSC clinicians and sites from FY 2019 through FY 2021. Exposure: Prescribing of buprenorphine by NHSC clinicians. Main Outcomes and Measures: The main outcomes were the percentage and number of Medicaid beneficiaries with opioid use disorder (OUD) who filled a prescription for buprenorphine before and after the LRP expansion and the challenges NHSC clinicians and sites faced in providing substance use disorder and OUD services. Survey results were analyzed using descriptive statistics. Results: During FYs 2017 through 2021, 7828 NHSC clinicians prescribed buprenorphine (standard LRP: mean [SD] age, 38.1 [8.4] years and 4807 females [78.9%]; expansion LRPs: mean [SD] age, 39.4 [8.1] years and 1307 females [75.0%]). A total of 3297 NHSC clinicians and 4732 NHSC sites responded to at least 1 survey question to the 3 surveys. The overall percentage of Medicaid beneficiaries with OUD who filled a prescription for buprenorphine during the first 2.5 years post expansion increased significantly from 18.9% before to 43.7% after expansion (an increase of 123 422 beneficiaries; P < .001). The percentage more than doubled among beneficiaries living in areas with a high Social Vulnerability Index score (from 17.0% to 36.7%; an increase of 31 964) and among beneficiaries living in rural areas (from 20.8% to 55.7%; an increase of 45 523). However, 773 of 2140 clinicians (36.1%; 95% CI, 33.6%-38.6%) reported a lack of mental health services to complement medication for OUD treatment, and 290 of 1032 clinicians (28.1%; 95% CI, 24.7%-31.7%) reported that they did not prescribe buprenorphine due to a lack of supervision, mentorship, or peer consultation. Conclusions and Relevance: These findings suggest that although the X-waiver requirement has been removed and Substance Abuse and Mental Health Services Administration guidelines encourage all eligible clinicians to screen and offer patients with OUD buprenorphine, as permissible by state law, more trained health care workers and improved care coordination for counseling and referral services are needed to support comprehensive OUD treatment.


Assuntos
Buprenorfina , Medicaid , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Padrões de Prática Médica , Buprenorfina/uso terapêutico , Humanos , Estados Unidos , Estudos Transversais , Feminino , Masculino , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Medicaid/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Pessoa de Meia-Idade , Antagonistas de Entorpecentes/uso terapêutico
11.
JAMA Health Forum ; 5(5): e241077, 2024 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-38758569

RESUMO

Importance: Controlled substances have regulatory requirements under the US Federal Controlled Substance Act that must be met before pharmacies can stock and dispense them. However, emerging evidence suggests there are pharmacy-level barriers in access to buprenorphine for treatment for opioid use disorder even among pharmacies that dispense other opioids. Objective: To estimate the proportion of Medicaid-participating community retail pharmacies that dispense buprenorphine, out of Medicaid-participating community retail pharmacies that dispense other opioids and assess if the proportion dispensing buprenorphine varies by Medicaid patient volume or rural-urban location. Design, Setting, and Participants: This serial cross-sectional study included Medicaid pharmacy claims (2016-2019) data from 6 states (Kentucky, Maine, North Carolina, Pennsylvania, Virginia, West Virginia) participating in the Medicaid Outcomes Distributed Research Network (MODRN). Community retail pharmacies serving Medicaid-enrolled patients were included, mail-order pharmacies were excluded. Analyses were conducted from September 2022 to August 2023. Main Outcomes and Measures: The proportion of pharmacies dispensing buprenorphine approved for opioid use disorder among pharmacies dispensing an opioid analgesic or buprenorphine prescription to at least 1 Medicaid enrollee in each state. Pharmacies were categorized by median Medicaid patient volume (by state and year) and rurality (urban vs rural location according to zip code). Results: In 2016, 72.0% (95% CI, 70.9%-73.0%) of the 7038 pharmacies that dispensed opioids also dispensed buprenorphine to Medicaid enrollees, increasing to 80.4% (95% CI, 79.5%-81.3%) of 7437 pharmacies in 2019. States varied in the percent of pharmacies dispensing buprenorphine in Medicaid (range, 73.8%-96.4%), with significant differences between several states found in 2019 (χ2 P < .05), when states were most similar in the percent of pharmacies dispensing buprenorphine. A lower percent of pharmacies with Medicaid patient volume below the median dispensed buprenorphine (69.1% vs 91.7% in 2019), compared with pharmacies with above-median patient volume (χ2 P < .001). Conclusions and Relevance: In this serial cross-sectional study of Medicaid-participating pharmacies, buprenorphine was not accessible in up to 20% of community retail pharmacies, presenting pharmacy-level barriers to patients with Medicaid seeking buprenorphine treatment. That some pharmacies dispensed opioid analgesics but not buprenorphine suggests that factors other than compliance with the Controlled Substance Act influence pharmacy dispensing decisions.


Assuntos
Buprenorfina , Acessibilidade aos Serviços de Saúde , Medicaid , Transtornos Relacionados ao Uso de Opioides , Humanos , Medicaid/estatística & dados numéricos , Buprenorfina/uso terapêutico , Buprenorfina/provisão & distribuição , Estados Unidos , Estudos Transversais , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Farmácias/estatística & dados numéricos , Serviços Comunitários de Farmácia/estatística & dados numéricos , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Antagonistas de Entorpecentes/uso terapêutico , Antagonistas de Entorpecentes/provisão & distribuição
12.
West J Emerg Med ; 25(3): 303-311, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38801034

RESUMO

Introduction: Emergency departments (ED) are in the unique position to initiate buprenorphine, an evidence-based treatment for opioid use disorder (OUD). However, barriers at the system and clinician level limit its use. We describe a series of interventions that address these barriers to ED-initiated buprenorphine in one urban ED. We compare post-intervention physician outcomes between the study site and two affiliated sites without the interventions. Methods: This was a cross-sectional study conducted at three affiliated urban EDs where the intervention site implemented OUD-related electronic note templates, clinical protocols, a peer navigation program, education, and reminders. Post-intervention, we administered an anonymous, online survey to physicians at all three sites. Survey domains included demographics, buprenorphine experience and knowledge, comfort with addressing OUD, and attitudes toward OUD treatment. Physician outcomes were compared between the intervention site and the control sites with bivariate tests. We used logistic regression controlling for significant demographic differences to compare physicians' buprenorphine experience. Results: Of 113 (51%) eligible physicians, 58 completed the survey: 27 from the intervention site, and 31 from the control sites. Physicians at the intervention site were more likely to spend <75% of their work week in clinical practice and to be in medical practice for <7 years. Buprenorphine knowledge (including status of buprenorphine prescribing waiver), comfort with addressing OUD, and attitudes toward OUD treatment did not differ significantly between the sites. Physicians were 4.5 times more likely to have administered buprenorphine at the intervention site (odds ratio [OR] 4.5, 95% confidence interval 1.4-14.4, P = 0.01), which remained significant after adjusting for clinical time and years in practice, (OR 3.5 and 4.6, respectively). Conclusion: Physicians exposed to interventions addressing system- and clinician-level implementation barriers were at least three times as likely to have administered buprenorphine in the ED. Physicians' buprenorphine knowledge, comfort with addressing and attitudes toward OUD treatment did not differ significantly between sites. Our findings suggest that ED-initiated buprenorphine can be facilitated by addressing implementation barriers, while physician knowledge, comfort, and attitudes may be harder to improve.


Assuntos
Buprenorfina , Serviço Hospitalar de Emergência , Antagonistas de Entorpecentes , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Padrões de Prática Médica , Humanos , Buprenorfina/uso terapêutico , Estudos Transversais , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Masculino , Feminino , Padrões de Prática Médica/estatística & dados numéricos , Antagonistas de Entorpecentes/uso terapêutico , Adulto , Pessoa de Meia-Idade , Inquéritos e Questionários , Atitude do Pessoal de Saúde , Médicos
13.
Subst Abuse Treat Prev Policy ; 19(1): 26, 2024 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-38711108

RESUMO

BACKGROUND: Physical or mental health comorbidities are common among people with substance use disorders undergoing opioid agonist therapy. As both a preventive and treatment strategy, exercise offers various health benefits for several conditions. Exercise interventions to people with substance use disorders receiving opioid agonist therapy are limited. This study aims to explore experiences with physical activity, perceived barriers, and facilitators among people receiving opioid agonist therapy. METHOD: Fourteen qualitative interviews were conducted with individuals receiving opioid agonist therapy in outpatient clinics in Western Norway. RESULTS: Most were males in the age range 30 to 60 years. Participants had diverse and long-term substance use histories, and most received buprenorphine-based opioid agonist therapy. The identified themes were (1) Physical limitations: Participants experienced health-related problems like breathing difficulties, pain, and reduced physical function. (2) Social dynamics: Social support was essential for participating in physical activities and many argued for group exercises, but some were concerned about the possibility of meeting persons influenced by substances in a group setting, fearing temptations to use substances. (3) Shift in focus: As participants felt the weight of the health burden, their preference for activities shifted from sports aiming for "adrenaline" to a health promoting focus. (4) COVID-19's impact on exercise: because of the pandemic, group activities were suspended, and participants described it as challenging to resume. (5) Implementation preferences in clinics: Not interfering with opioid medication routines was reported to be essential. CONCLUSION: This study offers valuable insights for the development of customized exercise interventions aimed at enhancing the health and well-being of patients undergoing opioid agonist therapy. These findings underscore the significance of addressing social dynamics, overcoming physical limitations, and implementing a practical and effective exercise regimen.


Assuntos
Exercício Físico , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Pesquisa Qualitativa , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Feminino , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/psicologia , Tratamento de Substituição de Opiáceos/psicologia , Noruega , Analgésicos Opioides/uso terapêutico , COVID-19/psicologia , Buprenorfina/uso terapêutico , Apoio Social
14.
Am J Emerg Med ; 81: 127-128, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38723364

RESUMO

Extended-release formulations of buprenorphine offer less frequent dosing, provide consistent medication delivery, and improve adherence for treatment of opioid use disorder (OUD). Although buprenorphine is a partial agonist with seemingly less precipitated withdrawal and easier initiation than full opioid agonists used for OUD, its use is not benign and understanding of the different extended-release formulations is necessary. We report a case of a patient that received a long-acting buprenorphine formulation (Sublocade®) administered subcutaneously that presented to the emergency department with tachycardia, hyperglycemia, elevated anion gap, and sustained nausea and vomiting refractory to pharmacotherapy requiring surgical removal of the buprenorphine depot for resolution of nausea and vomiting symptoms.


Assuntos
Buprenorfina , Preparações de Ação Retardada , Transtornos Relacionados ao Uso de Opioides , Humanos , Buprenorfina/administração & dosagem , Buprenorfina/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Masculino , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/administração & dosagem , Antagonistas de Entorpecentes/administração & dosagem , Antagonistas de Entorpecentes/uso terapêutico , Antagonistas de Entorpecentes/efeitos adversos , Adulto , Feminino , Vômito/induzido quimicamente , Vômito/tratamento farmacológico , Náusea/induzido quimicamente , Náusea/tratamento farmacológico
15.
Cells ; 13(10)2024 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-38786059

RESUMO

In recent decades, there has been a dramatic rise in the rates of children being born after in utero exposure to drugs of abuse, particularly opioids. Opioids have been shown to have detrimental effects on neurons and glia in the central nervous system (CNS), but the impact of prenatal opioid exposure (POE) on still-developing synaptic circuitry is largely unknown. Astrocytes exert a powerful influence on synaptic development, secreting factors to either promote or inhibit synapse formation and neuronal maturation in the developing CNS. Here, we investigated the effects of the partial µ-opioid receptor agonist buprenorphine on astrocyte synaptogenic signaling and morphological development in cortical cell culture. Acute buprenorphine treatment had no effect on the excitatory synapse number in astrocyte-free neuron cultures. In conditions where neurons shared culture media with astrocytes, buprenorphine attenuated the synaptogenic capabilities of astrocyte-secreted factors. Neurons cultured from drug-naïve mice showed no change in synapses when treated with factors secreted by astrocytes from POE mice. However, this same treatment was synaptogenic when applied to neurons from POE mice, indicating a complex neuroadaptive response in the event of impaired astrocyte signaling. In addition to promoting morphological and connectivity changes in neurons, POE exerted a strong influence on astrocyte development, disrupting their structural maturation and promoting the accumulation of lipid droplets (LDs), suggestive of a maladaptive stress response in the developing CNS.


Assuntos
Analgésicos Opioides , Astrócitos , Neurônios , Efeitos Tardios da Exposição Pré-Natal , Transdução de Sinais , Sinapses , Astrócitos/efeitos dos fármacos , Astrócitos/metabolismo , Astrócitos/patologia , Animais , Sinapses/metabolismo , Sinapses/efeitos dos fármacos , Feminino , Gravidez , Camundongos , Analgésicos Opioides/farmacologia , Analgésicos Opioides/efeitos adversos , Efeitos Tardios da Exposição Pré-Natal/patologia , Efeitos Tardios da Exposição Pré-Natal/metabolismo , Neurônios/metabolismo , Neurônios/efeitos dos fármacos , Neurônios/patologia , Transdução de Sinais/efeitos dos fármacos , Buprenorfina/farmacologia , Células Cultivadas , Camundongos Endogâmicos C57BL
16.
Curr Opin Psychiatry ; 37(4): 251-257, 2024 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-38726819

RESUMO

PURPOSE OF REVIEW: Collaborative models of care where pharmacists work alongside physicians have been developed for a range of physical health conditions, with benefits including improved patient outcomes and increased access to ongoing care. Opioid agonist treatment (methadone and buprenorphine) is a clinically effective and cost-effective treatment for opioid use disorder that is under-utilized in many countries due to a shortage of prescribers. In recent years, there has been increased interest in the development of collaborative models that utilize pharmacists to overcome barriers to treatment. In this article, we present a narrative review to synthesise recent work in this rapidly developing area. RECENT FINDINGS: Two key aspects of opioid agonist treatment were identified: Collaborative models have utilized pharmacists to facilitate buprenorphine induction, and collaborative models provide increased capacity for delivering ongoing care in a variety of settings and patient groups where prescriber access is limited. Pharmacists have undertaken direct patient care responsibilities with varying degrees of autonomy, with benefits including a reduction in prescriber workload, and improvements in treatment retention and continuity of care. SUMMARY: Collaborative models in which pharmacists are responsible for buprenorphine induction and ongoing management with methadone and buprenorphine have been shown to reduce demands on prescribers while improving or maintaining patient outcomes, and appear feasible and acceptable in a wide range of outpatient settings.


Assuntos
Buprenorfina , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Farmacêuticos , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Tratamento de Substituição de Opiáceos/métodos , Buprenorfina/uso terapêutico , Metadona/uso terapêutico , Médicos , Colaboração Intersetorial
17.
Neurosci Lett ; 834: 137846, 2024 Jun 21.
Artigo em Inglês | MEDLINE | ID: mdl-38821204

RESUMO

OPRM1 gene encoding mu-opioid receptor (MOR) is the primary candidate gene for buprenorphine (BUP) pharmacogenetics. OPRM1 undergoes alternative splicing leading to multiple MOR subtypes. Thus, in the current study 2 SNPs (rs1799972 and rs562859) were selected due to evidence for their contribution to alternative splicing of OPRM1. The effects of 2 SNPs of OPRM1 gene on plasma buprenorphine and norbuprenorphine levels in a sample of 233 OUD patients receiving BUP/naloxone were examined. Polymorphisms were analyzed by PCR and RFLP. BUP and norbuprenorphine concentrations in plasma were measured by LC-MS/MS. OPRM1 rs2075572 GC + CC (0.12 ng/ml) had significantly higher plasma BUP level compared to GG (0.084 ng/ml) (p = 0.043). Although there was not a statistically significant difference between OPRM1 rs562859 genotypes (p = 0.46), patients with OPRM1 rs562859 CT + TT had higher plasma BUP and BUP-related values as compared to those with CC. In conclusion, the effect of OPRM1 rs2075572 on BUP levels in opioid users' plasma was shown in a Caucasian population for the first time. On the other hand, OPRM1 rs562859 seems not to influence the BUP pharmacology.


Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Polimorfismo de Nucleotídeo Único , Receptores Opioides mu , Humanos , Receptores Opioides mu/genética , Masculino , Feminino , Adulto , Buprenorfina/sangue , Buprenorfina/uso terapêutico , Buprenorfina/análogos & derivados , Polimorfismo de Nucleotídeo Único/genética , Transtornos Relacionados ao Uso de Opioides/genética , Transtornos Relacionados ao Uso de Opioides/sangue , Pessoa de Meia-Idade , Analgésicos Opioides/sangue , Genótipo
18.
Am J Public Health ; 114(7): 696-704, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38696736

RESUMO

Objectives. To evaluate changes in monthly buprenorphine dispensation associated with federal prescribing policies in Washington State from 2012 to 2022. Methods. We conducted an interrupted time series analysis comparing monthly buprenorphine prescriptions dispensed per 1000 population after the Comprehensive Addiction and Recovery Act (CARA), Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT), and new prescribing rules during the COVID-19 pandemic. Buprenorphine formulated for opioid use disorder was included from the Washington State Prescription Monitoring Program. A log-linear autoregressive model measured linear trend changes. Results. Physician prescribing increased by 1.63% (95% confidence interval [CI] = 1.41%, 1.85%) per month after CARA with sustained declines after SUPPORT. Nurse practitioner (NP) prescribing increased by 19.48% (95% CI = 18.8%, 20.16%) per month after CARA with physician assistants (PAs) showing similar trends. Following the implementation of SUPPORT, NP and PA trends continued to increase at a reduced growth rate of 3.96% (95% CI = 2.01%, 5.94%) and 1.87% (95% CI = 0.56%, 3.19%), respectively. No prescribers experienced increases during the COVID-19 pandemic. Conclusions. CARA nearly tripled the buprenorphine prescribing rate. The SUPPORT Act initiated sustained declines for physician prescribing, and the COVID-19 period reversed gains for PAs and NPs. The current opioid crisis requires expanded efforts in Washington State. (Am J Public Health. 2024;114(7):696-704. https://doi.org/10.2105/AJPH.2024.307649).


Assuntos
Buprenorfina , COVID-19 , Transtornos Relacionados ao Uso de Opioides , Padrões de Prática Médica , Buprenorfina/uso terapêutico , Humanos , Washington , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Padrões de Prática Médica/estatística & dados numéricos , COVID-19/epidemiologia , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Prescrições de Medicamentos/estatística & dados numéricos , Análise de Séries Temporais Interrompida , Antagonistas de Entorpecentes/uso terapêutico , Analgésicos Opioides/uso terapêutico
20.
NEJM Evid ; 3(5): EVIDccon2300275, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38815158

RESUMO

AbstractA growing number of patients are prescribed buprenorphine for opioid use disorder (OUD). Consequently, clinicians are likely to encounter hospitalized patients with acute surgical or nonsurgical pain who are also prescribed buprenorphine for OUD. This scenario evokes the clinical question of how to adequately manage acute pain among hospitalized patients receiving buprenorphine for OUD. This article reviews buprenorphine's pharmacology, describes various buprenorphine products used to treat pain and OUD, and provides pain management recommendations for patients prescribed buprenorphine in the setting of acute surgical and nonsurgical pain.


Assuntos
Dor Aguda , Analgésicos Opioides , Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Manejo da Dor , Buprenorfina/uso terapêutico , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Dor Aguda/tratamento farmacológico , Analgésicos Opioides/uso terapêutico , Analgésicos Opioides/efeitos adversos , Manejo da Dor/métodos , Tratamento de Substituição de Opiáceos/métodos
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