"But I didn't drink!": What to do with discordant phosphatidylethanol results.

Liver transplantation (LT) teams must be adept at detecting, evaluating, and treating patients' alcohol use, given its prominence among psychological and behavioral phenomena which cause and contribute to liver diseases. Phosphatidylethanol (PEth) is a highly useful alcohol biomarker increasingly recommended for routine use in hepatology and LT. PEth is unique among alcohol biomarkers because of its wide detection window, high sensitivity and specificity, and the correlation of its numerical value with different patterns of alcohol use. Alongside myriad clinical opportunities in hepatology and LT, PEth also confers numerous challenges: little guidance exists about its clinical use; fearing loss of LT access and the reactions of their clinicians and families, candidates and recipients are incentivized to conceal their alcohol use; and liver clinicians report lack of expertise diagnosing and treating substance-related challenges. Discordance between patient self-reported alcohol use and toxicology is yet another common and particularly difficult circumstance. This article discusses the general toxicological properties of PEth; explores possible scenarios of concordance and discordance among PEth results, patient history, and self-reported drinking; and provides detailed clinical communication strategies to explore discordance with liver patients, a key aspect of its use.

The possible clinical utility of the alcohol biomarker phosphatidylethanol for managing suspected alcohol withdrawal in hospitalized patients: A case report.

BACKGROUND AND OBJECTIVES: The decision to initiate pharmacotherapy for alcohol withdrawal is typically based on examining self-reported use of alcohol and symptoms of withdrawal. Phosphatidylethanol (PEth) is a biomarker that could aim in clinical decision-making in withdrawal management. METHODS: This report describes three cases highlighting the potential clinical utility of PEth in caring for individuals at risk for alcohol withdrawal. RESULTS: Two of the cases received phenobarbital when their PEth showed that the risk of withdrawal was low and one case where PEth could have shown this was needed. The results were only available in a delayed fashion, however, could have been useful in informing clinical care. DISCUSSION AND CONCLUSION: PEth can be a useful tool if available without delay. PEth can be used to quickly rule out alcohol withdrawal and avoid misdiagnoses and prolonged hospital stays. SCIENTIFIC SIGNIFICANCE: This is a clinical case study available looking at PEth and withdrawal in hospitalized patients. It proposes that PEth can be used as a way to quickly rule out alcohol withdrawal to avoid misdiagnoses and the possibility of a prolonged hospital stay.

Moderate-high intensity exercise associates with reduced incident alcohol-associated liver disease in high-risk patients.

BACKGROUND: Therapies to prevent alcohol-associated liver disease (ALD) in high-risk patients are needed. AIMS: In this retrospective association study, we examined whether patients with alcohol use disorder (AUD) who reported greater exercise were less likely to develop liver disease. METHODS: In this retrospective cohort study, we used the Mass General Brigham Biobank to investigate the impact of both moderate-high and light-intensity exercise on the development of ALD in patients with AUD, using clinician-provided diagnostic International Classification of Diseases 10 codes. Exercise was evaluated using a questionnaire completed after an AUD diagnosis, and before evidence of liver disease. Cox regressions were used to generate hazard ratios (HRs) for the development of ALD. RESULTS: 1987 patients met inclusion criteria. These patients were followed for an average of 10.7 years. In multivariable analyses, we found that patients that reported at least 2.5 h of moderate-high intensity exercise/week (confidence interval recommendation for exercise) were less likely to develop ALD compared to patients that did not exercise (HR: 0.26, 95%CI: 0.085-0.64, P = 0.007). Indeed, each hour of moderate-high intensity exercise was associated with progressively decreasing odds of developing ALD (HR: 0.76, 95%CI: 0.58-0.91, P = 0.02). Conversely, patients who did not engage in any moderate-high intensity exercise were more likely to develop ALD (HR: 2.76, 95%CI: 1.44-5.40, P = 0.003). CONCLUSIONS: In our cohort, patients with AUD who reported moderate-high intensity exercise showed a lower association with incidence of ALD development than patients who did not exercise.

Addiction specialists' attitudes toward psychedelics: A National Survey.

BACKGROUND AND OBJECTIVES: In recent years, there has been accelerating scientific and public interest in the use of psychedelics to treat mental health disorders. Our study's objective was to assess the attitudes of addiction specialists regarding therapeutic psychedelics. METHODS: Our study utilized an anonymous online survey to assess the opinions of 145 addiction specialists regarding the therapeutic promise, potential risks, and legalization of psychedelics in the treatment of psychiatric illness and substance use disorders. Psychedelics were defined in the survey as inclusive of nonserotonergic hallucinogens such as ketamine or MDMA in addition to "classic" serotonergic psychedelics. RESULTS: Most respondents expressed positive attitudes to the therapeutic use of psychedelics, but a sizeable minority expressed concern for their addictive potential. Familiarity with psychedelic scientific literature was the strongest positive predictor of belief in the therapeutic potential of psychedelics, while concern for addictive potential was the strongest negative predictor. DISCUSSION AND CONCLUSIONS: Participants overall expressed more positive attitudes to the therapeutic use of psychedelics than we had hypothesized. This may be attributable to the accelerating pace of psychedelics research in recent years. Given the strong influence of concern for addiction risk on attitudes, future study is warranted to explore the findings regarding these concerns. These findings may also represent an opportunity for improved education of physicians regarding the addictive potential, and relative risks/benefits of psychedelics. SCIENTIFIC SIGNIFICANCE: Though there have been several prior studies assessing psychiatrist and psychologist attitudes toward psychedelics, we are unaware of any specifically examining the opinions of addiction specialists.

Case series: Voluntary discontinuation of sublingual buprenorphine treatment for opioid use disorder using extended-release buprenorphine.

BACKGROUND AND OBJECTIVES: Despite its efficacy, patients may still seek to voluntarily discontinue sublingual (SL) buprenorphine treatment, but little guidance exist on how to safely conduct a taper. We, therefore, report on the use of extended-release buprenorphine (XR-BUP) to facilitate voluntary treatment discontinuation. METHODS: A case series (n = 4). RESULTS: Four individuals interested in voluntary discontinuation of sublingual buprenorphine treatment were transitioned to varying durations of XR-BUP, after which all were able to discontinue buprenorphine with minimal withdrawal symptoms. One individual had a brief recurrence to illicit opioid use. All remained engaged in treatment. DISCUSSION AND CONCLUSIONS: The use of XR-BUP, given its long terminal half-life, may be a helpful option for individuals who are interested in voluntary buprenorphine discontinuation. Collaboration with the patient must include information about the risk of lapse to use and overdose following discontinuation. SCIENTIFIC SIGNIFICANCE: The cases reported here provide preliminary support for the use of XR-BUP to help individuals discontinue buprenorphine treatment. There is only one other case series showing the use of XR-BUP in helping individuals successfully discontinue buprenorphine treatment. Buprenorphine discontinuation is clinically relevant and there is little guidance in the current literature.

Patients' experiences with continuation or discontinuation of buprenorphine before painful procedures: A brief report.

BACKGROUND AND OBJECTIVES: Patients with opioid use disorder may be asked by their clinicians to discontinue maintenance buprenorphine treatment before surgical operations due to concerns that buprenorphine will interfere with acute pain management. However, discontinuation of buprenorphine may not be well tolerated or safe for all patients. We, therefore, administered a survey to better understand the experiences of patients on buprenorphine treatment who had previously undergone painful procedures and had their buprenorphine maintenance treatment either continued or discontinued before the procedure. METHODS: After this study received institutional review board approval, patients were invited to participate if they were being prescribed sublingual buprenorphine for treatment of opioid use disorder and had also previously undergone a painful procedure requiring treatment with full agonist opioids. Patients who were eligible and agreed to participate (n = 32) then completed a survey of basic demographics; medical, psychiatric, and substance use histories; and their experience and satisfaction with the treatment of pain and substance use in the perioperative period, including whether buprenorphine was continued or discontinued before their procedure. RESULTS: Compared with patients whose home dose of buprenorphine was continued (n = 15), patients whose buprenorphine was discontinued preoperatively (n = 17) reported less satisfaction with pain management and were more likely to be prescribed full agonist opioids upon discharge. DISCUSSION AND CONCLUSIONS: Consistent with prior studies, these survey findings suggest that discontinuation of buprenorphine before painful surgeries may be associated with poorer clinical outcomes. SCIENTIFIC SIGNIFICANCE: This survey study adds patients' perspective to a growing body of scientific literature suggesting that discontinuation of maintenance buprenorphine treatment before painful procedures may decrease patient satisfaction and increase clinical risk.

Microinduction of Buprenorphine/Naloxone: A Review of the Literature.

BACKGROUND AND OBJECTIVES: Buprenorphine's high-binding affinity as a partial µ-opioid agonist displaces preexisting full agonists causing precipitated withdrawal, which requires most individuals starting buprenorphine to endure moderate withdrawal prior to induction to avoid precipitated withdrawal. A novel approach called microinduction has emerged to remove this prerequisite. Our aim is to review the literature on these alternative approaches. METHODS: Using keywords including buprenorphine, buprenorphine/naloxone, transdermal buprenorphine, suboxone, microinduction, microdosing, rapid induction, buprenorphine-dosing protocol, the authors searched PubMed/Medline, EMBASE, PsycINFO, PsychARTICLES, and Scopus databases from the date of inception through April 30, 2020, which yielded 1726 results, which, in turn, after manual exclusion for irrelevant content and publication in languages other than English, generated a total of 18 papers. RESULTS: On the basis of 18 papers included in this review, 63 patients were successfully transitioned to buprenorphine using different microdosing techniques, primarily in the inpatient setting. From the available data, patients were transitioned from a variety of opioids over a range of dosing without significant withdrawal, and initial doses ranged most frequently from 0.2 to 0.5 mg. While the timeframe for the various schedules ranged from 3 to 112 days, most transitioned over a period of 4 to 8 days, and most participants completed the cross titration at 8 to 16 mg. DISCUSSION AND CONCLUSIONS: The growing literature demonstrates some initial promise for alternative induction models, specifically targeting patients averse to withdrawal, patients prescribed opioids for chronic pain, patients on high-dose methadone, and patients using illicit or pharmaceutical fentanyl. SCIENTIFIC SIGNIFICANCE: This manuscript provides a review of the existing literature to help clinicians better understand the approaches to microdosing of buprenorphine in various clinical settings and populations. (Am J Addict 2020;00:00-00).

Feasibility and Safety of Outpatient Parenteral Antimicrobial Therapy in Conjunction With Addiction Treatment for People Who Inject Drugs.

BACKGROUND: Research is limited on combining outpatient parenteral antimicrobial therapy (OPAT) with addiction treatment for people who inject drugs (PWID) with serious infections. METHODS: This is a retrospective study of PWID (n = 68) requiring intravenous antibiotics evaluated for suitability for our OPAT program with concurrent addiction treatment. RESULTS: Most common infections were bacteremia and/or endocarditis (73.5%), bone and/or joint infections (32.4%), and epidural abscess (22.1%). Of the 20 patients (29.4%) who qualified, 100.0% completed the course of antibiotics, 30.0% experienced a 30-day readmission, and 15.0% relapsed. No overdoses, deaths, or peripherally inserted central catheter-line complications were reported. CONCLUSIONS: Outpatient parenteral antimicrobial therapy with addiction treatment may be feasible and safe for PWID with serious infections.

Disparities in United States hospitalizations for serious infections in patients with and without opioid use disorder: A nationwide observational study.

BACKGROUND: Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD. METHODS AND FINDINGS: We utilized the 2016 National Inpatient Sample-a nationally representative database of all discharges from US acute care hospitals. The population of interest was all hospitalizations for infective endocarditis, epidural abscess, septic arthritis, or osteomyelitis. The exposure was OUD, and the primary outcome was LOS until discharge, assessed by using a competing risks analysis to estimate adjusted hazard ratios (aHRs). Adjusted odds ratio (aOR) of discharge disposition and adjusted differences in hospital charges were also reported. Of 95,470 estimated hospitalizations for serious infections (infective endocarditis, epidural abscess, septic arthritis, and osteomyelitis), the mean age was 49 years and 35% were female. 46% had Medicare (government-based insurance coverage for people age 65+ years), and 70% were non-Hispanic white. After adjustment for potential confounders, OUD was associated with a lower probability of discharge at any given LOS (aHR 0.61; 95% CI 0.59-0.63; p < 0.001). OUD was also associated with lower odds of discharge to home (aOR 0.38; 95% CI 0.33-0.43; p < 0.001) and higher odds of discharge to a post-acute care facility (aOR 1.85; 95% CI 1.57-2.17; p < 0.001) or patient-directed discharge (also referred to as "discharge against medical advice") (aOR 3.47; 95% CI 2.80-4.29; p < 0.001). There was no significant difference in average total hospital charges, though daily hospital charges were significantly lower for patients with OUD. Limitations include the potential for unmeasured confounders and the use of billing codes to identify cohorts. CONCLUSIONS: Our findings suggest that among hospitalizations for some serious infections, those involving patients with OUD were associated with longer LOS, higher odds of discharge to post-acute care facilities or patient-directed discharge, and similar total hospital charges, despite lower daily charges. These findings highlight opportunities to improve care for patients with OUD hospitalized with serious infections, and to reduce the growing associated costs.

Motivational Interviewing Techniques to Improve Psychotherapy Adherence and Outcomes for Patients With Psychogenic Nonepileptic Seizures.

Psychogenic nonepileptic seizures (PNES) are a highly disabling disorder frequently encountered by neurologists, psychiatrists, and emergency medicine physicians. There is accumulating evidence for the efficacy of psychological therapies, yet the majority of patients do not complete treatment. A range of health care system-based, clinician-based, and patient-based barriers to treatment exists, including stigma, poor clinician-patient communication, and patient ambivalence about the diagnosis and treatment of PNES. These barriers frequently lead to treatment nonadherence. Motivational interviewing (MI) is a patient-centered counseling style targeting ambivalence about behavior change, which has been shown to be effective in improving psychotherapy adherence and outcomes among patients with PNES. The authors review MI processes and techniques that may be useful to health care providers helping patients with PNES and other functional neurological disorders to engage in psychotherapy. The authors examine common challenges arising during MI for patients with PNES, including somatic symptoms distracting from clinician-patient communication, ambivalence about making concrete plans for treatment, and psychiatric comorbidities. Strategies for overcoming these obstacles are reviewed, including the use of complex reflections to enhance patient engagement; the use of an ask-tell-ask format and specific, measurable, achievable, relevant, and time-limited (SMART) goals to facilitate treatment planning; and close collaboration between the neurology and psychotherapy teams.

Evaluation of a Novel Protocol for Assessment and Treatment of Alcohol Withdrawal Syndrome in Psychiatric Inpatients.

BACKGROUND AND OBJECTIVES: Despite the high incidence of alcohol withdrawal syndrome (AWS) in psychiatric inpatients, standardized methods for assessing and treating AWS have been studied only once before in this population. We evaluated a novel AWS assessment and treatment protocol designed for psychiatric inpatients. METHODS: This retrospective cohort study evaluated outcomes before and after implementation of the protocol. We collected consecutive data on patients (N = 138) admitted to inpatient psychiatric units at a single center. Participants were patients admitted for nonsubstance-related psychiatric reasons, who were also at risk for developing AWS. Those who developed AWS were treated with either (a) treatment as usual (TAU) or (b) a novel standardized protocol. The primary outcome was duration of benzodiazepine treatment for symptoms of alcohol withdrawal. Secondary outcomes included cumulative benzodiazepine dose administered, treatment duration, and incidence of complications. RESULTS: Of 138 participants, 83 received TAU and 55 were assessed and treated with the novel protocol. Median duration of benzodiazepine treatment following protocol implementation was 19.7 hours (interquartile range [IQR], 0-46) prior to implementation (TAU) and 0 hours (IQR, 0-15) following protocol implementation (protocol group) (P < .0001). Median benzodiazepine dose (in diazepam equivalents) administered to participants was 30 mg (IQR, 0-65) for TAU and 5 mg (IQR, 0-30) for the protocol group (P < .001). Adverse events before and after implementation occurred in 4.8% and 0%, respectively (P = .15). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: This study provides preliminary evidence for the efficacy and safety of a novel standardized AWS protocol for psychiatric inpatients. This is the first known study assessing an AWS assessment and treatment protocol designed for psychiatric inpatients. (Am J Addict 2020;29:500-507).

Impact of Medications for Opioid Use Disorder on Discharge Against Medical Advice Among People Who Inject Drugs Hospitalized for Infective Endocarditis.

BACKGROUND AND OBJECTIVES: The impact of medications for opioid use disorder (MOUD) on against medical advice (AMA) discharges among people who inject drugs (PWID) hospitalized for endocarditis is unknown. METHODS: A retrospective review of all PWID hospitalized for endocarditis at our institution between 2016 and 2018 (n = 84). RESULTS: PWID engaged with MOUD at admission, compared with those who were not, were less likely to be discharged AMA but this did not reach statistical significance in adjusted analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.033-1.41; P = .11). Among out-of-treatment individuals, newly initiating MOUD did not lead to significantly fewer AMA discharges (OR, 0.98; 95% CI, 0.26-3.7; P = .98). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: PWID hospitalized for endocarditis are at high risk for discharge AMA but more research is needed to understand the impact of MOUD. (Am J Addict 2020;29:155-159).

A Systematic Review of Noninvasive Brain Stimulation for Opioid Use Disorder.

BACKGROUND: There is a great public health need to identify novel treatment strategies for opioid use disorder (OUD) in order to reduce relapse and overdose. Noninvasive brain stimulation (NIBS) has demonstrated preliminary effectiveness for substance use, but little is known about its use in OUD. Neuromodulation may represent a potential adjunctive treatment modality for OUD, so we conducted a systematic review to understand the state of the current research in this field. METHODS: We conducted a systematic review of studies using noninvasive brain stimulation to affect clinical outcomes related to substance use for adults with opioid use disorder. We searched the following online databases: PubMed, The Cochrane Library, PsycINFO (EBSCOhost, 1872-present), and Science Citation Index Expanded (ISI Web of Science, 1945-present). All studies that measured clinical outcomes related to substance use, including cue-induced craving, were included. We assessed risk of bias using the Cochrane Handbook. RESULTS: The initial search yielded 5590 studies after duplicates were removed. After screening titles and abstracts, 14 full-text studies were assessed for eligibility. Five studies were determined to meet inclusion criteria with a combined total subjects of N = 150. Given the paucity of studies and small number of total subjects, no quantitative analysis was performed. These studies used TMS (n = 3), tDCS (n = 1), and the BRIDGE device (n = 1), a noninvasive percutaneous electrical nerve field stimulator, to reduce cue-induced craving (n = 3), reduce clinical withdrawal symptoms (n = 1), or measure substance-use-related cortical plasticity (n = 1). CONCLUSIONS: There is a dearth of research in the area of noninvasive brain stimulation for OUD. NIBS represents a novel treatment modality that should be further investigated for OUD.

Randomized controlled trial of motivational interviewing for psychogenic nonepileptic seizures.

OBJECTIVE: We conducted a randomized controlled trial of motivational interviewing (MI) as an intervention to improve psychotherapy adherence and outcomes, including frequency of psychogenic nonepileptic seizures (PNES), quality of life, and emergency department utilization, among participants with PNES. METHODS: Sixty participants were randomized to receive either psychotherapy alone or MI plus psychotherapy. Participants and therapists were contacted at 16-week follow-up. Participants were considered adherent with psychotherapy if they attended at least eight sessions within 16 weeks following referral. RESULTS: Among control participants, 31.0% were adherent, whereas among MI participants, 65.4% were adherent (P = 0.015, absolute risk reduction = 34.4%, number needed to treat = 2.9). In the control arm, PNES frequency decreased by 34.8% (standard deviation [SD] = 89.7%), whereas in the MI arm, PNES frequency decreased by 76.2% (SD = 39.2%; P = 0.034, Cohen's d = 0.59). Among control participants, 10.7% achieved PNES freedom versus 30.8% of MI participants (P = 0.095). Quality of Life in Epilepsy-10 scores (a 40-point scale) improved by an average of 1.8 (SD = 7.9) points among control participants, and by 7.2 (SD = 10.0) points among MI participants (P = 0.047, Cohen's d = 0.60). Monthly emergency department visits increased by 0.06 (SD = 0.47) visits per month among control participants versus a decrease of 0.15 (SD = 0.76) among MI participants (P = 0.23). SIGNIFICANCE: Motivational interviewing improved treatment adherence, PNES frequency, and quality of life among our participants with PNES. Our study is limited in that it was conducted at a single quaternary care medical center, and MI was provided by a single neurologist, which may limit generalization of results.

A Health System-Wide Initiative to Decrease Opioid-Related Morbidity and Mortality.

BACKGROUND: The opioid overdose crisis now claims more than 40,000 lives in the United States every year, and many hospitals and health systems are responding with opioid-related initiatives, but how best to coordinate hospital or health system-wide strategy and approach remains a challenge. METHODS: An organizational opioid stewardship program (OSP) was created to reduce opioid-related morbidity and mortality in order to provide an efficient, comprehensive, multidisciplinary approach to address the epidemic in one health system. An executive committee of hospital leaders was convened to empower and launch the program. To measure progress, metrics related to care of patients on opioids and those with opioid use disorder (OUD) were evaluated. RESULTS: The OSP created a holistic, health system-wide program that addressed opioid prescribing, treatment of OUD, education, and information technology tools. After implementation, the number of opioid prescriptions decreased (-73.5/month; p < 0.001), mean morphine milligram equivalents (MME) per prescription decreased (-0.4/month; p < 0.001), the number of unique patients receiving an opioid decreased (-52.6/month; p < 0.001), and the number of prescriptions ≥ 90 MME decreased (-48.1/month; p < 0.001). Prescriptions and providers for buprenorphine increased (+6.0 prescriptions/month and +0.4 providers/month; both p < 0.001). Visits for opioid overdose did not change (-0.2 overdoses/month; p = 0.29). CONCLUSION: This paper describes a framework for a new health system-wide OSP. Successful implementation required strong executive sponsorship, ensuring that the program is not housed in any one clinical department in the health system, creating an environment that empowers cross-disciplinary collaboration and inclusion, as well as the development of measures to guide efforts.

Rapid transition from methadone to buprenorphine using naltrexone-induced withdrawal: A case report.

Background: Patients taking methadone for opioid use disorder may desire transition to buprenorphine for a number of reasons. However, the current recommended approach for this transition generally takes weeks to months as an outpatient, causing considerable discomfort to the patient and a heightened risk of relapse during the transition period. Case: We describe the case of a patient on methadone maintenance who was rapidly transitioned to buprenorphine because of her desire to not return to her methadone clinic. In order to rapidly transition the patient from methadone to buprenorphine, naltrexone was administered to precipitate acute opioid withdrawal, which was followed soon after by buprenorphine induction. Discussion: Rapid transition from methadone maintenance to buprenorphine can be accomplished in inpatients by precipitating acute withdrawal with naltrexone, providing an effective alternative for patients who cannot tolerate the typical protracted methadone taper required prior to buprenorphine induction as an outpatient.

Psychiatry residents' and fellows' confidence and knowledge in interpreting urine drug testing results related to opioids.

BACKGROUND: Prior studies have suggested that physicians and residents may not have sufficient knowledge to appropriately interpret urine drug tests (UDTs) in patients who are prescribed opioids or using illicit substances. Therefore, the aim of this study was to survey psychiatry residents and fellows about their confidence and knowledge in interpreting UDTs in patients with chronic pain or receiving office-based opioid treatment. METHODS: All psychiatry residency and fellowship program directors in the New England states were approached to recruit their trainees to participate in an anonymous online survey including a 7-item knowledge test. RESULTS: A total of 93 residents and fellows completed the survey. Only a minority (24.7%) reported any prior training in UDT interpretation. A majority (62.6%) felt confident about interpreting UDTs. The mean total score for the knowledge test was 3.5 (SD =1.1, range: 1-6). There were no significant differences in total score by confidence in UDT interpretation (3.7 vs. 3.4, t = -1.17, nonsignificant [NS]), nor by prior training in UDT interpretation (3.8 vs. 3.5, t = -1.22, NS). CONCLUSIONS: Psychiatry residents and fellows infrequently receive training in UDT interpretation, score poorly on the knowledge test, and their confidence in UDT interpretation does not reflect their knowledge. Future research should evaluate educational interventions that improve UDT interpretation among psychiatry residents and fellows.

Feasibility of collaborative care treatment of opioid use disorders with buprenorphine during pregnancy.

BACKGROUND: Medication-assisted treatment with buprenorphine or methadone is recommended for pregnant patients with opioid use disorders (OUDs) to minimize adverse maternal and neonatal outcomes. Collaborative care approaches have been successfully utilized with office-based opioid treatment with buprenorphine in primary care settings, but research is significantly limited in the obstetric setting. Our aim with this study is to demonstrate the feasibility of a collaborative care model for pregnant patients with opioid use disorder. METHODS: This is a case series of 16 pregnancies in 14 women initiated on office-based opioid treatment with buprenorphine in a perinatal mental health service embedded in 2 obstetric clinics. Patients are treated by a psychiatrist alongside their prenatal care provider and followed for up to 6 months postpartum and referred to ongoing substance abuse treatment to a community prescriber. RESULTS: The average age of the patients was 30.3 years, and an average gestational age of 23.6 weeks at the time of referral. Treatment continued until delivery in 15 (93.8%) pregnancies, with an average duration of treatment of 14.5 weeks. The majority (60%) had a cesarean delivery. Twelve (80%) infants were admitted to the Neonatal Intensive Care Unit (NICU) for monitoring or treatment of neonatal abstinence syndrome, 14 (87.5%) patients continued or resumed treatment with buprenorphine postpartum at the time of discharge from our program, and 13 (81.3%) were referred to a community prescriber. CONCLUSIONS: A collaborative care approach to buprenorphine treatment is feasible during pregnancy. Further research is needed to improve the treatment of OUD during pregnancy.

Quantitative testing of buprenorphine and norbuprenorphine to identify urine sample spiking during office-based opioid treatment.

BACKGROUND: Patients may spike urine samples with buprenorphine during office-based opioid treatment to simulate adherence to prescribed buprenorphine, potentially to conceal diversion of medications. However, routine immunoassay screens do not detect instances of spiking, as these would simply result in a positive result. The aim of this study was to report on the experience of using quantitative urine testing for buprenorphine and norbuprenorphine to facilitate the identification of urine spiking. METHODS: This is a retrospective chart review of 168 consecutive patients enrolled in outpatient buprenorphine treatment at an urban academic medical setting between May 2013 and August 2014. All urine samples submitted were subjected to quantitative urine toxicology testing for buprenorphine and norbuprenorphine. Norbuprenorphine-to-buprenorphine ratio of less than 0.02 were further examined for possible spiking. Demographic and clinical variables were also extracted from medical records. Clinical and demographic variables of those who did and did not spike their urines were compared. Statistically significant variables from the univariate testing were entered as predictors of spiking in a regression analysis. RESULTS: A total of 168 patients were included, submitting a total of 2275 urine samples. Patients provided on average 13.6 (SD = 9.9) samples, and were in treatment for an average 153.1 days (SD = 142.2). In total, 8 samples (0.35%) from 8 patients (4.8%) were deemed to be spiked. All of the samples suspected of spiking contained buprenorphine levels greater than 2000 ng/mL, with a mean norbuprenorphine level of 11.9 ng/mL. Spiked samples were submitted by 6 patients (75.0%) during the intensive outpatient (IOP) phase of treatment, 2 patients (25.0%) during the weekly phase, and none from the monthly phase. Regression analysis indicated that history of intravenous drug use and submission of cocaine-positive urine samples at baseline were significant predictors of urine spiking. CONCLUSIONS: Even though only a small number of patients were identified to have spiked their urine samples, quantitative testing may help identify urine spiking during office-based opioid treatment with buprenorphine.