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1.
J Subst Abuse Treat ; 123: 108260, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33612194

RESUMO

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.


Assuntos
Buprenorfina/uso terapêutico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Avaliação de Resultados em Cuidados de Saúde , Padrões de Prática Médica , Buprenorfina/administração & dosagem , California , Humanos , Antagonistas de Entorpecentes/administração & dosagem
2.
J Subst Abuse Treat ; 123: 108263, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33612196

RESUMO

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.


Assuntos
Necessidades e Demandas de Serviços de Saúde , Tratamento de Substituição de Opiáceos/tendências , Transtornos Relacionados ao Uso de Opioides/reabilitação , Buprenorfina/administração & dosagem , Buprenorfina/uso terapêutico , Humanos , Metadona , Antagonistas de Entorpecentes/administração & dosagem , Antagonistas de Entorpecentes/uso terapêutico , Estados Unidos
3.
Value Health ; 24(2): 182-187, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33518024

RESUMO

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.


Assuntos
Buprenorfina/economia , Buprenorfina/uso terapêutico , Medicaid/economia , Antagonistas de Entorpecentes/economia , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Buprenorfina/administração & dosagem , Combinação Buprenorfina e Naloxona/economia , Combinação Buprenorfina e Naloxona/uso terapêutico , Uso de Medicamentos , Medicamentos Genéricos/economia , Medicamentos Genéricos/uso terapêutico , Competição Econômica , Humanos , Antagonistas de Entorpecentes/administração & dosagem , Tratamento de Substituição de Opiáceos/economia , Tratamento de Substituição de Opiáceos/métodos , Patentes como Assunto , Estados Unidos
4.
Value Health ; 24(2): 188-195, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33518025

RESUMO

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.


Assuntos
Buprenorfina/uso terapêutico , Acesso aos Serviços de Saúde/estatística & dados numéricos , Antagonistas de Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Buprenorfina/administração & dosagem , Estudos Transversais , Acesso aos Serviços de Saúde/economia , Humanos , Antagonistas de Entorpecentes/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Características de Residência , População Rural/estatística & dados numéricos , Análise de Pequenas Áreas , Fatores Socioeconômicos , Estados Unidos , População Urbana/estatística & dados numéricos
5.
J Subst Abuse Treat ; 120: 108163, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33298301

RESUMO

Historically, federal and state policies have narrowly defined treatment models that have resulted in limited access to and engagement in counseling for individuals receiving medications for opioid use disorder (MOUD; e.g., methadone and buprenorphine). In response to the coronavirus pandemic, outpatient MOUD treatment providers rapidly transitioned from traditional, in-person care delivery models to revised COVID-19 protocols that prioritized telehealth counseling to protect the health of patients and staff and ensure continuity in MOUD care. These telehealth innovations appear to mitigate many of the longstanding barriers to counseling in the traditional system and have the potential to forever alter MOUD care delivery. Drawing on data from a Rhode Island-based clinic, we argue that MOUD counseling is achievable via telehealth and outline the need for, and anticipated benefits of, hybrid telehealth/in-person MOUD treatment models moving forward.


Assuntos
Aconselhamento/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Telemedicina/organização & administração , Buprenorfina/administração & dosagem , Continuidade da Assistência ao Paciente/organização & administração , Assistência à Saúde/organização & administração , Humanos , Metadona/administração & dosagem , Tratamento de Substituição de Opiáceos/métodos , Rhode Island
6.
J Subst Abuse Treat ; 120: 108149, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33303086

RESUMO

The Youth Opioid Recovery Support (YORS) intervention is a novel treatment for young adults with opioid use disorder (OUD) that uses developmentally informed strategies to reduce barriers to treatment engagement. YORS strategies, such as home delivery of extended-release buprenorphine and extended-release naltrexone for OUD, are designed to increase engagement in treatment, but with the COVID-19 pandemic these strategies increase risk of virus exposure and spread to patients and staff entering homes. We present mobile van service delivery as a potential solution to continuing to provide low-barrier care for young adults with OUD while reducing risk associated with COVID-19. Initial feedback from patients and staff is positive and lays the groundwork to test feasibility and acceptability of this intervention rigorously in future work. Mobile van delivery of extended-release medications for OUD may be a promising treatment modification for mitigating risk of COVID-19, as well as a useful option for ongoing enhancement of care.


Assuntos
Buprenorfina/administração & dosagem , Unidades Móveis de Saúde , Naltrexona/administração & dosagem , Preparações de Ação Retardada , Humanos , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Adulto Jovem
7.
J Subst Abuse Treat ; 121: 108161, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33371945

RESUMO

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.


Assuntos
Buprenorfina/administração & dosagem , Antagonistas de Entorpecentes/administração & dosagem , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/reabilitação , Prisões , Telemedicina , Humanos , Minnesota
8.
JAMA Netw Open ; 3(12): e2029676, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-33320266

RESUMO

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.


Assuntos
Buprenorfina , Overdose de Drogas , Hospitalização/estatística & dados numéricos , Pacientes Internados/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Pacientes Ambulatoriais/estatística & dados numéricos , Adulto , Buprenorfina/administração & dosagem , Buprenorfina/efeitos adversos , Pesquisa Comparativa da Efetividade , Overdose de Drogas/epidemiologia , Overdose de Drogas/etiologia , Overdose de Drogas/terapia , Feminino , Humanos , Masculino , Antagonistas de Entorpecentes/administração & dosagem , Antagonistas de Entorpecentes/efeitos adversos , Avaliação de Processos e Resultados em Cuidados de Saúde
9.
J Subst Abuse Treat ; 119: 108139, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33138924

RESUMO

The COVID-19 pandemic led government regulators to relax prescribing rules for buprenorphine and methadone, the agonist medications that effectively treat opioid use disorder, allowing for take home supplies of up to 28 days. These changes prioritized the availability of these medications over concerns about their misuse and diversion, and they provided a means for overdose prophylaxis during the highly uncertain conditions of the pandemic. In considering how to capitalize on this shift, research should determine the extent to which increased diversion has occurred as a result, and what the consequences may have been. The shifts also set the stage to consider if methadone can be safely prescribed in primary care settings, and if the monthly injectable formulation of buprenorphine is a suitable alternative to increased supplies of sublingual strips if concerns about diversion persist. The disruptions of the pandemic have caused a surge in overdose deaths, so carefully considering the prophylactic potential of agonist medications, in addition to their role as a treatment, may help us address this mortality crisis.


Assuntos
Analgésicos Opioides/administração & dosagem , Infecções por Coronavirus , Transtornos Relacionados ao Uso de Opioides/reabilitação , Pandemias , Pneumonia Viral , Padrões de Prática Médica/estatística & dados numéricos , Desvio de Medicamentos sob Prescrição/estatística & dados numéricos , Analgésicos Opioides/efeitos adversos , Buprenorfina/administração & dosagem , Overdose de Drogas/epidemiologia , Humanos , Metadona/administração & dosagem , Tratamento de Substituição de Opiáceos/métodos
11.
J Subst Abuse Treat ; 118: 108124, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32893047

RESUMO

OBJECTIVE: The COVID-19 pandemic has transformed care delivery for patients with opioid use disorder (OUD); however, little is known about the experiences of front-line clinicians in the transition to telemedicine. This study described how, in the context of the early stages of the pandemic, clinicians used telemedicine for OUD in conjunction with in-person care, barriers encountered, and implications for quality of care. METHODS: In April 2020, we conducted semistructured interviews with clinicians waivered to prescribe buprenorphine. We used maximum variation sampling. We used standard qualitative analysis techniques, consisting of both inductive and deductive approaches, to identify and characterize themes. RESULTS: Eighteen clinicians representing 10 states participated. Nearly all interview participants were doing some telemedicine, and more than half were only doing telemedicine visits. Most participants reported changing their typical clinical care patterns to help patients remain at home and minimize exposure to COVID-19. Changes included waiving urine toxicology screening, sending patients home with a larger supply of OUD medications, and requiring fewer visits. Although several participants were serving new patients via telemedicine during the early weeks of the pandemic, others were not. Some clinicians identified positive impacts of telemedicine on the quality of their patient interactions, including increased access for patients. Others noted negative impacts including less structure and accountability, less information to inform clinical decision-making, challenges in establishing a connection, technological challenges, and shorter visits. CONCLUSIONS: In the context of the pandemic, buprenorphine prescribers quickly transitioned to providing telemedicine visits in high volume; nonetheless, there are still many unknowns, including the quality and safety of widespread use of telemedicine for OUD treatment.


Assuntos
Buprenorfina/administração & dosagem , Infecções por Coronavirus/epidemiologia , Transtornos Relacionados ao Uso de Opioides/terapia , Pneumonia Viral/epidemiologia , Telemedicina/estatística & dados numéricos , Tomada de Decisão Clínica , Infecções por Coronavirus/prevenção & controle , Assistência à Saúde/organização & administração , Assistência à Saúde/estatística & dados numéricos , Pessoal de Saúde/estatística & dados numéricos , Humanos , Entrevistas como Assunto , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Detecção do Abuso de Substâncias/estatística & dados numéricos
12.
J Pharmacol Sci ; 144(1): 9-15, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32586692

RESUMO

Since 2015 slow-release oral morphine (SROM) is approved for opioid substitution treatment (OST) in Germany. The SROMOS study (efficacy and tolerability of slow-release oral morphine in opioid substitution treatment) evaluates the efficacy and safety of SROM in routine care. This article describes the switching process from racemic methadone, levomethadone and buprenorphine to SROM. Between July 2016 and November 2017 180 patients in 23 study centers in Germany were included in the prospective, non-interventional, naturalistic observational study. Patients were already in OST and switched from a previous medication to SROM. The switching process was analyzed during a period of fourteen days. Data were available for 169 participants. The switching process had a different progression depending on premedication and pre dosage. On the fourteenth day of SROM treatment patients switched from racemic methadone took an average dosage of 922.2 mg/day, from levomethadone 801.0 mg/day and from buprenorphine 626.7 mg/day. Average conversion ratio racemic methadone to SROM was 1:11.8, levomethadone to SROM 1:17.4 and buprenorphine to SROM 1:58.0. This study provides the first data on the switching process from buprenorphine to SROM. Average dose ratio racemic methadone to SROM on the fourteenth day of treatment was considerably higher than recommended in the prescribing information.


Assuntos
Buprenorfina/administração & dosagem , Preparações de Ação Retardada/administração & dosagem , Substituição de Medicamentos/métodos , Metadona/administração & dosagem , Morfina/administração & dosagem , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Administração Oral , Adulto , Relação Dose-Resposta a Droga , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto Jovem
13.
Medicine (Baltimore) ; 99(24): e20405, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32541462

RESUMO

BACKGROUND: The efficacy and safety of buprenorphine transdermal patch (BTP) has been well established in chronic pain, but data regarding acute postoperative pain relief is still very limited. Therefore, we design a prospective, randomized, controlled study to evaluate the effectiveness and safety of the BTP for postoperative analgesia in total hip arthroplasty. METHODS: This study is designed as a single-center, prospective, double-blind, randomized controlled trial. Group A receives a 10 mg patch of buprenorphine at the conclusion of surgery which is continued for 14 days. Group B receives a conventional analgesic regimen, that is, IV paracetamol 1 mg every 8 hours alternating with parenteral tramadol 50 mg every 8 hours for the first 2 postoperative days followed by oral administration of the same drug still the end of 2 weeks. A total of 160 patients are needed with an allowance for 10% drop-out. The primary outcome of this noninferiority study is opioid consumption within the first 24 hours following surgery. The secondary outcomes included numerical rating scale scores at rest, postoperative complications, length of hospital stay, and patient satisfaction. RESULTS: This trial is expected to be the largest randomized trial assessing the efficacy of BTP after primary total hip arthroplasty and powered to detect a potential difference in the primary outcome. TRIAL REGISTRATION NUMBER: This study protocol was registered in Research Registry (researchregistry5524).


Assuntos
Analgésicos Opioides/uso terapêutico , Artroplastia de Quadril/efeitos adversos , Buprenorfina/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Adesivo Transdérmico/efeitos adversos , Acetaminofen/administração & dosagem , Acetaminofen/uso terapêutico , Administração Intravenosa , Administração Oral , Analgésicos não Entorpecentes/administração & dosagem , Analgésicos não Entorpecentes/uso terapêutico , Analgésicos Opioides/administração & dosagem , Buprenorfina/administração & dosagem , Estudos de Casos e Controles , Método Duplo-Cego , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Medição da Dor/estatística & dados numéricos , Medição da Dor/tendências , Satisfação do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Tramadol/administração & dosagem , Tramadol/uso terapêutico
14.
J Addict Med ; 14(4): e136-e138, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32433364

RESUMO

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.


Assuntos
Buprenorfina/administração & dosagem , Infecções por Coronavirus/epidemiologia , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/terapia , Pneumonia Viral/epidemiologia , Centros de Tratamento de Abuso de Substâncias , Telecomunicações/organização & administração , Adulto , Betacoronavirus , Combinação Buprenorfina e Naloxona/uso terapêutico , Pessoas em Situação de Rua , Humanos , Masculino , Antagonistas de Entorpecentes/administração & dosagem , Inovação Organizacional , Pandemias , Centros de Tratamento de Abuso de Substâncias/métodos , Centros de Tratamento de Abuso de Substâncias/organização & administração , Telemedicina/métodos , Telemedicina/organização & administração
15.
JAMA Netw Open ; 3(5): e204561, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-32391893

RESUMO

Importance: Treatment of opioid use disorder (OUD) with buprenorphine decreases opioid use and prevents morbidity and mortality. Emergency departments (EDs) are an important setting for buprenorphine initiation for patients with untreated OUD; however, readiness varies among ED clinicians. Objective: To characterize barriers and facilitators of readiness to initiate buprenorphine for the treatment of OUD in the ED and identify opportunities to promote readiness across multiple clinician types. Design, Setting, and Participants: Using data collected from April 1, 2018, to January 11, 2019, this mixed-methods formative evaluation grounded in the Promoting Action on Research Implementation in Health Services framework included 4 geographically diverse academic EDs. Attending physicians (n = 113), residents (n = 107), and advanced practice clinicians (APCs) (n = 48) completed surveys electronically distributed to all ED clinicians (n = 396). A subset of participants (n = 74) also participated in 1 of 11 focus group discussions. Data were analyzed from June 1, 2018, to February 22, 2020. Main Outcomes and Measures: Clinician readiness to initiate buprenorphine and provide referral for ongoing treatment for patients with OUD treated in the ED was assessed using a visual analog scale. Responders (268 of 396 [67.7%]) were dichotomized as less ready (scores 0-6) or most ready (scores 7-10). An ED-adapted Organizational Readiness to Change Assessment (ORCA) and 11 focus groups were used to assess ratings and perspectives on evidence and context-related factors to promote ED-initiated buprenorphine with referral for ongoing treatment, respectively. Results: Among the 268 survey respondents (153 of 260 were men [58.8%], with a mean [SD] of 7.1 [9.8] years since completing formal training), 56 (20.9%) indicated readiness to initiate buprenorphine for ED patients with OUD. Nine of 258 (3.5%) reported Drug Addiction Treatment Act of 2000 training completion. Compared with those who were less ready, clinicians who were most ready to initiate buprenorphine had higher mean scores across all ORCA Evidence subscales (3.50 [95% CI, 3.35-3.65] to 4.33 [95% CI, 4.13-4.53] vs 3.11 [95% CI, 3.03-3.20] to 3.60 [95% CI, 3.49-3.70]; P < .001) and on the Slack Resources of the ORCA Context subscales (3.32 [95% CI, 3.08-3.55] vs 3.0 [95% CI, 2.87-3.12]; P = .02). Barriers to ED-initiated buprenorphine included lack of training and experience in treating OUD with buprenorphine, concerns about ability to link to ongoing care, and competing needs and priorities for ED time and resources. Facilitators to ED-initiated buprenorphine included receiving education and training, development of local departmental protocols, and receiving feedback on patient experiences and gaps in quality of care. Conclusions and Relevance: Only a few ED clinicians had a high level of readiness to initiate buprenorphine; however, many expressed a willingness to learn with sufficient supports. Efforts to promote adoption of ED-initiated buprenorphine will require clinician and system-level changes.


Assuntos
Buprenorfina/uso terapêutico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Padrões de Prática Médica , Encaminhamento e Consulta , Adulto , Buprenorfina/administração & dosagem , Feminino , Grupos Focais , Humanos , Masculino , Pessoa de Meia-Idade , Epidemia de Opioides/prevenção & controle , Inquéritos e Questionários , Estados Unidos
18.
PLoS One ; 15(3): e0230079, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32142538

RESUMO

This study aimed to evaluate the analgesic efficacy of two dosage regimens using two different concentrations of buprenorphine in cats undergoing dental extractions. Twenty-three cats with oral disease (8.2 ± 2.2 years old; 4.9 ± 0.9 kg) were included in a prospective, blinded, randomized clinical trial. Cats randomly received either Simbadol (1.8 mg/mL; 0.24 mg/kg, subcutaneously, every 24h: SG, n = 11) or Vetergesic (0.3 mg/mL; 0.02 mg/kg, intramuscularly, every 8h: VG, n = 12) throughout the study. They were admitted at day 0, underwent oral examination/radiographs/treatment under general anesthesia (buprenorphine-propofol-isoflurane-meloxicam-local anesthetic blocks) at day 1 and discharged at day 4. Sedation and pain were scored using the dynamic interactive visual analog scale (day 1) and the Glasgow Composite Measure Pain Scale-Feline (CMPS-F; up to postoperative 8 hours at day 1, 8 am, 4 pm and midnight at days 2 and 3, and 8 am at day 4), respectively. Rescue analgesia was administered with hydromorphone (0.05 mg/kg intravenously on day 1 or 0.1 mg/kg intramuscularly after day 2) when CMPS-F ≥ 5. Resentment defined as any type of escape behavior associated with aversion to drug administration was recorded. Sedation and pain scores, the prevalence of rescue analgesia and resentment during drug administration were analyzed using linear mixed models and Fisher's exact test, respectively (p < 0.05). Pain and sedation scores were not significantly different between groups. Sedation scores were significantly higher up to postoperative 2 hours in both groups. Pain scores in SG and VG were significantly higher up to postoperative 8 hours and 8 am of day 2, respectively, than baseline. Prevalence of rescue analgesia and resentment were not significantly different between groups (SG: 27.3%, VG: 33.3% and SG: 0%, VG: 25%, respectively). Simbadol produced similar analgesic effects to Vetergesic without resentment during drug administration.


Assuntos
Analgesia/métodos , Analgésicos/administração & dosagem , Buprenorfina/administração & dosagem , Dor/patologia , Animais , Gatos , Método Duplo-Cego , Feminino , Masculino , Dor/veterinária , Doenças Periodontais/patologia , Doenças Periodontais/terapia , Doenças Periodontais/veterinária , Período Pós-Operatório , Estudos Prospectivos , Índice de Gravidade de Doença , Extração Dentária
19.
Mo Med ; 117(1): 59-64, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32158052

RESUMO

The opioid crisis has shaped the national public health dialogue for some time now. A "call to action" is a strong and resounding cry from multiple disciplines. This piece intends to detail the nuts and bolts of prescribing medications used for the treatment of opioid use disorder. The underlying message here is that opioid use disorder is a chronic, treatable illness and physicians of all specialties have a responsibility to not turn a blind eye.


Assuntos
Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Buprenorfina/administração & dosagem , Buprenorfina/efeitos adversos , Medicina Baseada em Evidências , Humanos , Metadona/administração & dosagem , Metadona/efeitos adversos , Naltrexona/administração & dosagem , Naltrexona/efeitos adversos , Antagonistas de Entorpecentes/administração & dosagem , Antagonistas de Entorpecentes/efeitos adversos , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Guias de Prática Clínica como Assunto
20.
Pain Physician ; 23(2): E163-E174, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32214293

RESUMO

BACKGROUND: Acute pain management in patients on buprenorphine opioid agonist therapy (BOAT) can be challenging. It is unclear whether BOAT should be continued or interrupted for optimization of postoperative pain control. OBJECTIVES: To determine an evidence-based approach for pain management in patients on BOAT in the perioperative setting, particularly whether BOAT should be continued or interrupted with or without bridging to another mu opioid agonist and to identify benefits and harms of either perioperative strategy. STUDY DESIGN: Systematic literature review with qualitative data synthesis. SETTING: Hospital, perioperative. METHODS: The study protocol was registered on PROSPERO (Registration number 9030276355). Medline via OVID, EMBASE, CINAHL, and the Cochrane CENTRAL register of trials were searched for prospective or retrospective observational or controlled studies, case series, and case reports that described perioperative or acute pain care for patients on BOAT. References of narrative and systematic reviews addressing acute pain management in patients on BOAT and references of included articles were hand-searched to identify additional original articles for inclusion. The full text of publications were reviewed for final inclusion, and data were extracted using a standardized data extraction form. Results were summarized qualitatively. Primary outcomes were postoperative pain intensity and total opioid use and identification of benefits and harms of perioperative strategies. RESULTS: Eighteen publications presenting data on the perioperative management of patients on BOAT were identified: 10 case reports, 5 case series, and 3 retrospective cohort studies. Eleven articles reported continuation of BOAT, 2 concerned bridging BOAT, and 4 articles described stopping BOAT without planned bridging. In one retrospective cohort study, BOAT was continued in half and interrupted in half of patients. Patients on BOAT may have pain that is more difficult to treat than those who are not on OAT. There is no clear evidence that one particular strategy provides superior postoperative pain control, but interruption of BOAT may result in harm, including failure to return to baseline BOAT doses, continuing non-BOAT opioid use, or relapse of opioid use disorder. LIMITATIONS: There were a limited number of articles relevant to the study question consisting of case reports and retrospective observational studies. Some omitted relevant details. No prospective studies were found. CONCLUSIONS: There is no clear benefit to bridging or stopping BOAT but failure to restart it may pose concerns for relapse. We recommend continuing BOAT in the perioperative period when possible and incorporating an interdisciplinary approach with multimodal analgesia. KEY WORDS: Opioid use disorder, opiate substitution treatment, buprenorphine, buprenorphine-naloxone, buprenorphine opioid agonist therapy, postoperative pain, acute pain, multimodal analgesia.


Assuntos
Analgésicos Opioides/administração & dosagem , Buprenorfina/administração & dosagem , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Esquema de Medicação , Humanos , Estudos Observacionais como Assunto/métodos , Tratamento de Substituição de Opiáceos/tendências , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Dor Pós-Operatória/epidemiologia , Estudos Prospectivos , Estudos Retrospectivos
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