Transdermal opioids for cancer pain control in patients with renal impairment.
J Opioid Manag. 2014 Mar-Apr;10(2):85-93
Authors: Melilli G, Samolsky Dekel BG, Frenquelli C, Mellone R, Pannuti F
OBJECTIVES: As guidelines for opioid use in renal-impaired patients with cancer are limited, the authors sought to assess the efficacy, safety, and tolerability, of transdermal buprenorphine for moderate/severe cancer pain in renal-impaired outpatients.
METHODS: In a prospective parallel-group active-controlled study, n = 42 consecutively recruited outpatients with or without renal impairment (serum creatinine ≥1.3 or ≤1.2 mg/dL, respectively) were treated with transdermal buprenorphine (group BUP) or fentanyl (group FEN), respectively. Patients were followed up, at home, by the nonprofit ANT-Italia-foundation physicians in Bologna, Italy. Measurements at 10 (T1), 30 (T2), and 90 (T3) days after enrollment (T0) were pain intensity (Numerical Rating Scale [NRS]), Karnofski score, opioid dose (μg/h), rescue-dose consumption, and occurrence of adverse effects. Patients recorded subjective measurements in a personal diary. Upon data analysis, investigators were blinded to the patient group.
RESULTS: At T0, in groups BUP and FEN, median NRS score was 8.0 (CI, 7.4-8.4); its reduction over time (T3; NRS = 3.0; CI, 2.1-3.8 and 2.0-4.0, respectively) was significant and constant in both groups (t-test; T0-T1, T1-T2, and T2-T3; p < 0.0001, p < 0.001, and p < 0.05, respectively). At all times, there were no significant differences in pain scores between the groups. In all evaluations, adverse effects were reported n = 73/126 times (60.8 percent) and showed no significant association (X(2), p > 0.05) with the study groups.
CONCLUSIONS: Transdermal buprenorphine, in outpatients with cancer and renal impairment, is as effective, safe, and tolerable as fentanyl in patients without such impairment. These results add further evidence to the notion that buprenorphine, with its peculiar pharmacokinetics, may be an appropriate choice for opioid treatment in patients with renal impairment.
PMID: 24715663 [PubMed - in process]
Hair analysis for long-term monitoring of buprenorphine intake in opiates withdrawal.
Ther Drug Monit. 2014 Apr 7;
Authors: Pirro V, Fusari I, Di Corcia D, Gerace E, De Vivo E, Salomone A, Vincenti M
BACKGROUND:: Buprenorphine is a psychoactive pharmaceutical drug largely used to treat opiate addiction. Short-term therapeutic monitoring is supported by toxicological analysis of blood and urine samples, whereas long-term monitoring by means of hair analysis is rarely used. Aim of this work was to develop and validate a highly sensitive UHPLC-MS/MS method to detect buprenorphine and norbuprenorphine in head hair.
METHODS:: Inter-individual correlation between oral dosage of buprenorphine and head hair concentration was investigated. Furthermore, an intra-individual study by means of segmental analysis was performed on subjects with variable maintenance dosage. Hair samples from a population of 79 patients in treatment for opiate addiction were analyzed.
RESULTS:: The validated UHPLC-MS/MS protocol allowed to obtain limits of detection and quantification at 0.6 and 2.2 pg/mg for buprenorphine, and 5.0 and 17 pg/mg for norbuprenorphine, respectively. Validation criteria were satisfied, assuring selective analyte identification, high detection capability, precise and accurate quantification. Significant positive correlation was found between constant oral buprenorphine dosage (1-32 mg/day) and the summed up head hair concentrations of buprenorphine and norbuprenorphine. Nevertheless, substantial inter-individual variability limits the chance to predict the oral dosage taken by each subject from the measured concentrations in head hair. In contrast, strong correlation is observed in the results of intra-individual segmental analysis, which proved reliable to detect oral dosage variations during therapy.
CONCLUSIONS:: Remarkably, all hair samples yielded buprenorphine concentrations higher than 10 pg/mg, even when the lowest dosage was administered. Thus, these results support the selection of 10 pg/mg as a cut-off value.
PMID: 24713865 [PubMed - as supplied by publisher]
Every few years the media report an epidemic of heroin overdose deaths; often after a celebrity like Phillip Seymour Hoffman dies to set off the spark. This time the spike in deaths—which is real– is being attributed to heroin mixed with fentanyl. Attention will fade but the deaths will continue. We wring our hands about overdoses, but do little to make effective treatment widely available. Our continuing refusal to prevent and treat addiction is a medical and social scandal.
Here are the policy changes I believe we must make to end this scandal:
1) Complete the transition to individual health insurance with complete coverage for addiction treatment. The bulk of addiction treatment today is provided by small free standing programs that depend on contracts with public entities for treatment “slots” or individual out of pocket payment. The programs with contracts are responsive to their funders, not to the patients who may be filling a slot at the moment. The organization and funding of our treatment system works against developing a long term relationship between patient and provider that is key to successful long-term recovery. When a patient leaves, the treatment entity has no continuing contact with that person. Obamacare can cover almost all the people with addiction in the country if states, employers and insurers implement it properly. Sadly, some existing treatment programs are dragging their heels or opposed to getting their patients covered because they find it easier to bill the state or because they cannot meet the administrative and clinical requirements for accepting insurance payments.
2) Integrate addiction, mental illness and medical treatment around individuals with severe addiction. Telling a patient who is unemployed, homeless, addicted and mentally ill to go someplace different for each service or to wait weeks for an appointment is malpractice because the providers know it will not happen. We should force consolidation of addiction treatment, mental illness and medical care providers to coordinate and take care of the most severely ill patients in one place. The few places where this kind of care is provided now get much better results for their patients.
3) Increase insurance payment rates for addiction treatment to a level that meets providers’ costs, draws in new responsible providers, and pays for the required coordination. Very low Medicaid and private insurance payment rates create and perpetuate the shortage of quality treatment. Appropriate payment rates will attract higher quality providers.
4) Reward longer stays in treatment and stop using providers that are unable to successfully retain patients in treatment long enough for it to be effective. Longer time in treatment, inpatient or outpatient, improves outcomes. Research shows that drug treatment for less than 90 days is generally not effective, but very few public or private insurance programs authorize that much treatment now. It is shocking that some treatment programs still throw a patient out if he relapses during treatment. Relapse is part of the disease and a signal for more treatment, not a reason to end it.
5) Require hospitals, health centers, HMO’s and other primary providers, as a condition of their participation in Medicaid, Medicare, and public employee health programs, to demonstrate that they diagnose all patients with alcohol and drug disease and that they have a clinically sound program that gets individuals the care they need. Today, most hospitals refuse to provide addiction treatment at any appropriate scale even though many of their patients would have better clinical outcomes if they got brief interventions or treatment.
6) Stop the revolving door at detoxification programs. Current policy and reimbursement get the patient out the door as soon as he or she is “medically stable,” whether or not the person is connected or ready to enter real addiction treatment. The vast majority of people who leave detox without directly entering and staying in treatment quickly relapse. Many think they “failed” treatment but the truth is they never had any treatment, just detoxification.
7) Stop arresting people for non-violent drug offenses. And stop putting people back in jail or prison for non-violent addiction related probation violations. Our current policies ruin thousands of young lives. Addiction is a disease, not a crime. Drug court programs are fine, but they touch only a tiny proportion of the people in the criminal justice system who need treatment.
David L. Rosenbloom, PhD, is Professor, Boston University School of Public Health and former Director of Join Together.
This feature was originally published on the BU Today website.
Blue Cross Blue Shield of Massachusetts, the state’s largest health insurer, announced it has reduced prescriptions of narcotic painkillers by about 6.6 million pills in the past 18 months. The insurer limited the amount of opioids that members could obtain without prior approval of the company, WBUR reports.
Since the changes were implemented in July 2012, prescriptions for opioids including Percocet have declined by 20 percent, and those for long-lasting drugs such as OxyContin have declined by 50 percent, Blue Cross Blue Shield of Massachusetts President Andrew Dreyfus told The Boston Globe.
An initial review of prescription information, launched in 2011, revealed more than 30,000 of the company’s members received opioid prescriptions that lasted for more than 30 days. “What we found out is in looking at patients who deserved to get pain medications or needed pain medications, many of them were getting significantly more than they would need,” Dr. John Fallon, Senior Vice President and Chief Physician Executive, told WBUR.
Under the program, patients are initially given shorter-term prescriptions for opioids. Patients seeking long-term prescriptions must go through a review process. Before patients are given more medication beyond the new limits, they must be assessed for the risk of addiction, and must agree on a treatment plan with their doctor.
Patients with cancer or other terminal illnesses are exempt from the rules.
“In the past, physicians said that no one should be in pain, and people gave more prescription medication than they probably needed, and that led to supply sitting around, which was then used for inappropriate reasons,” Fallon said. “Now I think there’s an awareness in the physician community how hazardous these medications are.”
People seeking treatment for heroin addiction face a number of obstacles, including a lack of treatment beds, expensive care, and insurance companies that refuse to pay for inpatient rehab, according to ABC News.
Most insurance companies will not pay for inpatient heroin detoxification or rehab because withdrawal from the drug is generally not deadly, according to Anthony Rizzuto, a provider relations representative at Seafield Center, a rehabilitation clinic on Long Island, N.Y. He says insurance companies either claim the patient does not meet the “criteria for medical necessity” for inpatient care, or they require the patient to first try outpatient rehab and “fail” before being considered for inpatient treatment.
Most experts say inpatient care is often needed for a person addicted to heroin. Withdrawal, which in regular abusers may occur as early as a few hours after the last administration, produces drug craving, restlessness, muscle and bone pain, insomnia, diarrhea and vomiting, cold flashes with goose bumps, kicking movements and other symptoms. Major withdrawal symptoms peak between 48 and 72 hours after the last dose, and subside after about a week. Sudden withdrawal by heavily dependent users who are in poor health can be fatal.
The symptoms of withdrawal are so bad that many people go back to using heroin, often with deadly consequences. Even people who are able to stop using heroin without treatment often relapse. They may overdose because they use as much heroin as they did before, but their system can’t handle the same level of drug as before they went through withdrawal.
Even patients who do get some insurance coverage for heroin treatment generally don’t get 30 days in a residential center. The average duration is 11 to 14 days, according to Tom McLellan, CEO of the nonprofit Treatment Research Institute in Philadelphia. After insurance companies stop paying, facilities discharge patients, even if they are not done with treatment.
The average cost of a 30-day inpatient stay is about $30,000.
About 3.7 million Americans, who live in states that have not expanded their Medicaid programs under the Affordable Care Act, suffer from mental illness, psychological distress or a substance use disorder and don’t have health insurance, according to a recent report.
Twenty-four states have not expanded their Medicaid programs, according to USA Today. In the states that did expand Medicaid, about 3 million people with a mental health or substance use disorder, who were formerly uninsured, now are eligible for coverage. The findings come from the American Mental Health Counselors Association (AMHCA).
The Affordable Care Act originally required states to expand Medicaid benefits, but in 2012, the U.S. Supreme Court allowed states to opt out of participating in the expansion.
“It is really a tragedy,” said Joel Miller, Executive Director of AMHCA. “When uninsured people with mental health conditions, such as depression, gain Medicaid coverage, they become healthier and life expectancy increases, but in states that refuse to expand Medicaid, citizens will see their hopes dashed for a better life and better health.”
The report findings come from the National Survey on Drug Use and Health, which counted people with serious mental illness, serious psychological distress, and substance use disorders. The group found almost 75 percent (2.7 million adults) of all uninsured persons with a mental health condition or substance use disorder who are eligible for coverage in the non-expansion states live in 11 southern states that have rejected the Medicaid expansion: Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas and Virginia.
More than 1.1 million uninsured people who have serious mental health and substance abuse conditions live in just two states — Texas (625,000) and Florida (535,000). These more than 1.1 million people are eligible for coverage under the new Medicaid expansion program, but won’t receive it, the report noted.
Employers in states where marijuana is legal for medicinal or recreational use must decide how to handle employees who use the drug when they are not on duty, USA Today reports.
Some workers in Colorado and Washington state, where recreational marijuana use is legal, say they are being punished for using the drug when they aren’t on the job. Employers say they are trying to maintain drug-free workplaces, the article notes.
“I imagine there will be a great deal of upheaval in the future. The law is going to be in flux for another 10 years,” said Curtis Graves, a staff attorney with the Mountain States Employers Council, which advises companies on workplace issues.
In the 20 states that allow medical marijuana, employers do not have to allow any kid of marijuana use in the workplace. In Colorado, workers cannot be fired for legal activities while they are off duty. However, the state’s courts have also ruled marijuana is not lawful, because the federal government still considers it illegal.
A growing number of employers in Colorado are testing prospective employees before hiring, and are continuing to perform random drug testing, according to Tiffany Baker, co-owner of the Denver DNA and Drug Center, which provides drug-testing services to employers. “I think big companies were already testing anyway,” she said. “I think small companies are … now more likely to send their workers over.”
In Washington state, manufacturers and companies working in federally regulated areas, such as the aerospace industry, have long tested job applicants for drug use. Jennifer Lambert, a vice president of the employment agency Terra Staffing Group, says these employers are continuing to test job applicants for drugs. “It’s sort of a Wild West scenario. It’s very, very tricky,” she said. “I feel badly when someone comes to us and doesn’t understand the implication of their pot smoking.”
The Food and Drug Administration (FDA) has approved a handheld device that delivers a single dose of the opioid overdose antidote naloxone, The New York Times reports.
The device, called Evzio, is similar to an EpiPen used to stop allergic reactions to bee stings, the article notes. It can be used by friends or relatives of a person who has overdosed. When the device is turned on, it will give verbal instructions about how to use it. The medication blocks the ability of heroin or opioid painkillers to attach to brain cells. Evzio is expected to be available this summer.
“This is a big deal, and I hope gets wide attention,” said Dr. Carl R. Sullivan III, Director of the Addictions Program at West Virginia University. “It’s pretty simple: Having these things in the hands of people around drug addicts just makes sense because you’re going to prevent unnecessary mortality.”
According to a news release from the FDA, family members or caregivers should become familiar with the instructions for use before administering Evzio. “Family members or caregivers should also become familiar with the steps for using Evzio and practice with the trainer device, which is included along with the delivery device, before it is needed,” the FDA advises. The agency notes that because naloxone may not work as long as opioids, repeat doses may be needed. A person utilizing the device should seek immediate medical care for the patient.
Many states have begun to make naloxone more widely available. The FDA notes existing naloxone drugs require administration via syringe, and are most commonly used by trained medical personnel in emergency departments and ambulances.
Photo source: Medgadget.com
Major obstacles remain to expanded treatment for addiction through the Medicaid program, according to USA Today. Although the Affordable Care Act (ACA) requires treatment be offered to people who are newly insured through insurance exchanges or Medicaid, experts say a federal law is limiting available beds nationwide.
A federal restriction does not allow drug treatment centers with more than 16 beds to bill Medicaid for residential services provided to low-income adults. The law was meant to prevent Medicaid dollars from funding private mental institutions that warehoused patients, according to the article. The result is that addiction treatment centers are turning away new Medicaid patients who are entitled to treatment under the ACA.
“We don’t have enough capacity right now,” Becky Vaughn, Executive Director of State Associations of Addiction Services in Washington, told the newspaper. “The unintended consequence is that you are discriminating against an adult who needs help,” said Elizabeth Stanley-Salazar, a Vice President at the Phoenix House. “We don’t do that for any other illness or disease.”
Toby Douglas, Director of California’s Health Care Services Department, said only 10 percent of the available inpatient beds in the state are in facilities that meet the federal government’s restrictions. Most treatment for substance abuse in Colorado is provided in centers with more than 16 beds, according to Arthur Schut, Chief Executive Officer of Arapahoe House. “Everyone is in agreement about how dumb this is,” he said. “It doesn’t work economically, and it doesn’t work for the people seeking treatment.”
The federal government does not plan to change the law, according to Suzanne Fields, a senior adviser on health care financing for the Substance Abuse and Mental Health Services Administration. She said the federal government is looking at alternatives, such as treating patients under programs already paid for with other federal funds.
Democratic governors around the country are reluctant to support the legalization of marijuana, despite enthusiasm for the idea among voters in their party. The New York Times reports the governors are concerned about managing legalization, as well as being perceived as being soft on crime by Republicans.
In California, where voters strongly favor legalization and its Democratic Party adopted a platform urging the state to follow Colorado and Washington state in legalizing recreational marijuana, Governor Jerry Brown has said he wants to see what happens in those areas.
Some Democratic governors are supporting medical marijuana measures. This year, bills have been introduced in 17 states to legalize recreational marijuana. No sitting governor or member of the Senate has offered a full endorsement of those measures. Governor Peter Shumlin of Vermont, a Democrat, has said he is open to the idea.
“Quite frankly, I don’t think we are ready, or want to go down that road,” said Connecticut Governor Dannel P. Malloy, a Democrat. His state has legalized medical marijuana and decriminalized possession of small amounts of marijuana. “Perhaps the best way to handle this is to watch those experiments that are underway. I don’t think it’s necessary, and I don’t think it’s appropriate,” he told the newspaper.
The Democratic governors of Colorado and Washington opposed legalization, but said they would follow through on voters’ wishes to set up recreational marijuana marketplaces. Washington Governor Jay Inslee said, “As a grandfather, I have the same concerns every grandfather has about misuse of any drug, including alcohol and marijuana. All of us want to see our kids make smart decisions and not allow any drug to become injurious in our life. I recognized the really rational decision that people made that criminalization efforts were not a successful public policy. But frankly, I really don’t want to send a message to our kids that this is a route that is without risk.”
Poison control centers are reporting an increase in the number of calls they are receiving for nicotine poisoning from e-cigarettes. This February, centers received 215 calls, compared with about one per month in 2010.
About half of calls related to nicotine poisoning from e-cigarettes involved children age 5 or younger, HealthDay reports. Dr. Tim McAfee, Director of the Centers for Disease Control and Prevention’s (CDC) Office on Smoking and Health, which published the findings, said many people don’t know liquid nicotine is toxic. “The time has come to start thinking about what we can do to keep this from turning into an even worse public health problem,” he said.
McAfee said the Food and Drug Administration is expected to propose regulations for e-cigarettes, and he hopes they include childproof caps and warning labels. “These things can be hardwired into these products, rather than being left to the whim of the manufacturer,” he said. McAfee urged e-cigarette users to keep the devices and their refills out of the reach of children. “These should be treated with the same caution one would use for bleach. In some ways, this is more toxic than bleach,” he said.
He explained liquid nicotine can be poisonous if it is swallowed, inhaled, or absorbed through the skin or membranes in the mouth, lips or eyes. It can cause nausea, vomiting or seizures.
In a CDC news release, Director Dr. Tom Frieden said, “E-cigarette liquids as currently sold are a threat to small children because they are not required to be childproof, and they come in candy and fruit flavors that are appealing to children.”
Opioid maintenance therapy in Switzerland: an overview of the Swiss IMPROVE study.
Swiss Med Wkly. 2014;144:w13933
Authors: Besson J, Beck T, Wiesbeck G, Hämmig R, Kuntz A, Abid S, Stohler R
BACKGROUND/AIMS: Switzerland's drug policy model has always been unique and progressive, but there is a need to reassess this system in a rapidly changing world. The IMPROVE study was conducted to gain understanding of the attitudes and beliefs towards opioid maintenance therapy (OMT) in Switzerland with regards to quality and access to treatment. To obtain a "real-world" view on OMT, the study approached its goals from two different angles: from the perspectives of the OMT patients and of the physicians who treat patients with maintenance therapy. The IMPROVE study collected a large body of data on OMT in Switzerland. This paper presents a small subset of the dataset, focusing on the research design and methodology, the profile of the participants and the responses to several key questions addressed by the questionnaires.
METHODS: IMPROVE was an observational, questionnaire-based cross-sectional study on OMT conducted in Switzerland. Respondents consisted of OMT patients and treating physicians from various regions of the country. Data were collected using questionnaires in German and French. Physicians were interviewed by phone with a computer-based questionnaire. Patients self-completed a paper-based questionnaire at the physicians' offices or OMT treatment centres.
RESULTS: A total of 200 physicians and 207 patients participated in the study. Liquid methadone and methadone tablets or capsules were the medications most commonly prescribed by physicians (60% and 20% of patient load, respectively) whereas buprenorphine use was less frequent. Patients (88%) and physicians (83%) were generally satisfied with the OMT currently offered. The current political framework and lack of training or information were cited as determining factors that deter physicians from engaging in OMT. About 31% of OMT physicians interviewed were ≥60 years old, indicating an ageing population. Diversion and misuse were considered a significant problem in Switzerland by 45% of the physicians.
CONCLUSION: The subset of IMPROVE data presented gives a present-day, real-life overview of the OMT landscape in Switzerland. It represents a valuable resource for policy makers, key opinion leaders and drug addiction researchers and will be a useful basis for improving the current Swiss OMT model.
PMID: 24706398 [PubMed - in process]
Buprenorphine Treatment for Probationers and Parolees.
Subst Abus. 2014 Apr 4;
Authors: Gordon MS, Kinlock TW, Schwartz RP, Couvillion KA, Sudec LJ, O'Grady KE, Vocci FJ, Shabazz H
ABSTRACT Background: Pharmacotherapy studies involving buprenorphine have rarely been conducted with US community corrections populations. This is one of the first reports of buprenorphine treatment outcomes of adult opioid-dependent probationers and parolees. Methods: This longitudinal study examined the 3-month treatment outcomes for a sample of probation and parole clients (N=64) who received community-based buprenorphine treatment. Results: Approximately two-thirds of the sample (67%) were still in treatment at three months post-baseline. Furthermore, there was a significant decline in the number of self-reported heroin use days and crime days from baseline to three months post-baseline. While there was not a significant reduction in reincarcerations, there was no evidence that they had increased. Conclusions: Given that buprenorphine is approved by the FDA as a safe, effective treatment for opioid use disorders, individuals on parole or probation should have the opportunity to benefit from it through community-based programs.
PMID: 24701967 [PubMed - as supplied by publisher]
Comparison of intrathecal dexmedetomidine with buprenorphine as adjuvant to bupivacaine in spinal asnaesthesia.
Comparison of intrathecal dexmedetomidine with buprenorphine as adjuvant to bupivacaine in spinal asnaesthesia.
J Clin Diagn Res. 2014 Feb;8(2):114-7
Authors: Gupta M, Shailaja S, Hegde KS
Background: The supplementation of local anaesthetics with adjuvants to improve the efficacy of subarachnoid block has been recognised since long. The most preferred drug has been opioids, but newer drugs like dexmedetomidine has also been introduced and investigated as an effective adjuvant. Aim: This study was conducted to evaluate and compare the characteristics of subarachnoid blockade, hemodynamic stability and adverse effects of intrathecal buprenorphine and intrathecal dexmedetomidine as an adjuvant to 0.5% hyperbaric bupivacaine for lower abdominal surgeries. Materials and Methods: The present study included 60 patients aged between 18-60 years classified as American Society of Anesthesiologists (ASA) Physical Status (PS) I/II scheduled for elective lower abdominal surgeries. The patients were randomly allotted to two groups to receive intrathecal 3ml of 0.5% bupivacine with 60µg of buprenorphine (Group B; n=30) or 3ml of 0.5% bupivacaine with 5µg of dexmedetomidine (Group D; n=30). The onset time to peak sensory level, motor block, sedation, Haemodynamic variables, duration of motor block, analgesia and any adverse effects were noted. Results: There was no significant difference between groups regarding demographic characteristics and type of surgery. The motor, sensory blockade and time of rescue analgesia were significantly prolonged in Group D compared to Group B. The sedation level was higher in Group D compared to Group B. There was no significant difference in haemodynamic variables although Group B had lower Heart Rate (HR) than Group D. Conclusion: Intrathecal dexmedetomidine when compared to intrathecal buprenorphine causes prolonged anaesthesia and analgesia with reduced need for sedation and rescue analgesics.
PMID: 24701498 [PubMed]
Naltrexone implant treatment for buprenorphine dependence - Mauritian case series.
J Psychopharmacol. 2014 Apr 2;
Authors: Jhugroo A, Ellayah D, Norman A, Hulse G
Although substitution therapy with opiate agonist treatments such as methadone and buprenorphine has resulted in a reduction of illicit drug use related harm, such treatment has also resulted in severe problems in some countries where opioid-dependent individuals now inject illicitly sold buprenorphine or buprenorphine-naloxone instead of heroin. There is no approved treatment for buprenorphine dependence. Naltrexone is an opioid antagonist which has been used for the treatment of both alcohol and opioid dependencies. Although both buprenorphine and heroin resemble each other concerning their effects, buprenorphine has a higher affinity to opioid receptors than heroin. Therefore, it is not known if naltrexone can block the psychoactive effects of buprenorphine as it does for heroin. This paper presents observational case series data on the use of a sustained-release naltrexone implant for the treatment of buprenorphine dependence. To the authors' knowledge this is the first use of sustained-release naltrexone for this indication.
PMID: 24695742 [PubMed - as supplied by publisher]
A Retrospective Study of Retention of Opioid-Dependent Adolescents and Young Adults in an Outpatient Buprenorphine/Naloxone Clinic.
A Retrospective Study of Retention of Opioid-Dependent Adolescents and Young Adults in an Outpatient Buprenorphine/Naloxone Clinic.
J Addict Med. 2014 Apr 1;
Authors: Matson SC, Hobson G, Abdel-Rasoul M, Bonny AE
OBJECTIVES:: Opioid abuse and dependence rates continue to rise among US adolescents. Medication-assisted treatment with buprenorphine/naloxone (BUP/NAL) has been shown to be effective up to 12 weeks. Few data are available regarding extended treatment outcomes. The objective of this study was to describe 1-year retention and compliance of a specific pediatric, outpatient BUP/NAL treatment program for opioid-dependent adolescents and young adults.
METHODS:: Retrospective chart review was conducted of all opioid-dependent adolescents and young adults (N = 103) who sought treatment from January 12, 2010, to January 9, 2011. Participants were classified as prescription opioid-dependent or combined heroin/prescription opioid-dependent. Opioid abstinence and BUP/NAL compliance were assessed by urine drug screen (UDS) at each visit. A Kaplan-Meier curve was fit to describe patients' retention time over 1 year.
RESULTS:: Mean age was 19.2 ± 1.6 years, 50.5% male, 98.1% white non-Hispanic, and 31.9% prescription opioid-dependent. Overall rates of opioid abstinence and BUP/NAL compliance were high (85.2% and 86.6%, respectively). Seventy-five percent of patients returned for a second visit. Patient retention was 45% at 60 days and 9% at 1 year. Female sex (P < 0.05), negative UDS for opioids (P < 0.001) or tetrahydrocannabinol (P < 0.001), and positive UDS for BUP/NAL (P < 0.001) were associated with longer retention time.
CONCLUSIONS:: Although patient retention was the largest barrier to success, a subset of opioid-dependent adolescents and young adults achieved long-term sobriety in our specific clinic program with continued outpatient BUP/NAL therapy. Retention correlated with UDS negative for opioids, negative for tetrahydrocannabinol, and positive for BUP/NAL.
PMID: 24695018 [PubMed - as supplied by publisher]
Primary care management of opioid dependence: the addition of CBT gives no extra benefit compared to standard physician management alone.
Primary care management of opioid dependence: the addition of CBT gives no extra benefit compared to standard physician management alone.
Evid Based Ment Health. 2013 Aug;16(3):76
Authors: Miotto K
PMID: 23616210 [PubMed - indexed for MEDLINE]
A new survey finds 75 percent of Americans think it is inevitable that recreational marijuana will become legal across the country, ABC News reports. The survey also found a growing number of Americans support ending mandatory minimum prison sentences for non-violent drug offenders.
More Americans are in favor of overturning laws that require jail time for possessing small amounts of marijuana, according to the Pew Research Center survey. “Even people who don’t favor the legalization of marijuana think the possession of small amounts shouldn’t result in jail time,” said Carroll Doherty, Pew’s Director of Political Research.
The survey found increasing support for legalization. Four years ago, 52 percent of survey respondents said they thought marijuana should not be legal and 41 percent said it should. This year, 54 percent of respondents said they favor legalization and 42 percent oppose it.
Many people remain concerned about drug abuse, the survey indicates—32 percent of respondents called it a crisis, and 55 percent said it is a serious national problem. In addition, 54 percent said they thought marijuana legalization would lead to more underage people trying the drug.
The findings were released this week as legislators around the country are considering changes to drug policies, the article notes. At least 30 states have modified penalties for drug crimes since 2009. Many of these states have repealed or reduced mandatory minimum sentences for lower-level drug offenses.
The federal government is also changing its approach to low-level drug crimes. Earlier this month, U.S. Attorney General Eric Holder testified in favor of changing federal guidelines to reduce the average sentence for drug dealers. He told the United States Sentencing Commission the Obama Administration supports changing guidelines to reduce the average drug sentence by about one year, from 62 months to 51 months.
Contrary to the advice of many medical groups, more emergency departments are giving headache patients prescriptions for powerful narcotic painkillers, according to a new study. Between 2001 and 2010, there was a 65 percent increase in emergency department use of narcotic prescriptions for headaches. Hydromorphone and oxycodone were two of the most frequently prescribed narcotics.
A number of groups, including the American College of Emergency Physicians and the American Academy of Neurology, say narcotics should not be used as a first-line treatment for headaches, HealthDay reports.
During the same period, there was no increase in ER prescriptions for non-narcotic pain relievers such as acetaminophen, nonsteroidal anti-inflammatory medications, or triptans (drugs used to treat migraines).
The study authors, who presented their findings at the American College of Medical Toxicology annual meeting, said they are concerned about the findings, in part because of the increasing rates of abuse, overdose and deaths due to narcotics.
“These findings are particularly concerning given the magnitude of increase in [narcotic painkiller] prescribing compared to the other non-addictive medications, whose use remained the same or declined,” lead investigator Dr. Maryann Mazer-Amirshahi of George Washington University said in a news release.
Co-researcher Dr. Jeanmarie Perrone of the University of Pennsylvania said several factors could be contributing to the increased narcotic prescriptions for headaches, including an increased focus on pain management, patient satisfaction, and regulatory requirements.
A bill designed to overhaul the mental health care system in the United States has spurred debate among advocates for the mentally ill, The New York Times reports. Some groups oppose the measure because it includes provisions for expanded use of involuntary outpatient treatment.
Congress will hear testimony about The Helping Families in Mental Health Crisis Act on Thursday. The act is considered to be the most ambitious overhaul plan in decades, the newspaper notes. Its prospects are not clear.
Several mental health organizations are supporting the bill, which has more than a dozen Democratic co-sponsors in the House. Last week both the House and Senate voted to expand funding for outpatient treatment programs, one of the bill’s central provisions. The House Energy and Commerce Health Subcommittee will hear testimony on the entire bill today.
Parts of the bill have wide support, including provisions to streamline payment for services under Medicaid, and to provide funds for clinics that meet standards for scientifically supported, rigorous care. The bill would fund suicide prevention programs and remote video therapy for rural areas without adequate mental health services. Police officers and emergency medical works would receive increased training in how to identify and treat people with mental disorders.
The bill would provide grants to states for “assisted outpatient treatment programs” for court-ordered treatment for certain people with mental illness and a history of legal or other problems. In most cases, the programs try to ensure these people take their medication—in some cases, against their will.
Gina Nikkel, President and Chief Executive of the Foundation for Excellence in Mental Health Care, told the newspaper, “This becomes a civil rights issue quickly, and it can drive people away from seeking services when they fear treatment will be forced on them or they’ll be locked up.”