buprenorphine and Mental-Disorders

This comprehensive review on opioids summarizes the scope of the current opioid epidemic, the diagnosis and treatment of opioid use disorder, and the medical and psychiatric complications of opioid use.

Topics: Adult; Analgesics, Opioid; Buprenorphine; Comorbidity; Disease Management; Drug Overdose; Female; Fentanyl; Harm Reduction; Humans; Male; Mental Disorders; Methadone; Middle Aged; Naltrexone; Narcotic Antagonists; Narcotics; Opioid-Related Disorders; Practice Guidelines as Topic; Prevalence

The COVID-19 pandemic is a particularly relevant threat to mentally ill patients, and it constitutes a new challenge for health care providers. To the best of our knowledge, there is not any embracing published review about the use of psychotropic drugs during the COVID-19 pandemic.. Non-systematic literature review. A search in the PubMed database was performed, with the terms 'psychotropic drugs', 'COVID-19', 'psychiatry' and 'pandemic'. Consensus and clinical guidelines about psychotropic drugs and COVID-19 approach, published by scientific societies, governmental entities and drug regulatory agencies were included.. We present the recommendations about the use of psychotropic drugs during the COVID-19 pandemic, in the outpatient and inpatient settings. The treatment of affective bipolar disorder and schizophrenia have now added increased difficulties. Some psychotropic drugs interfere with the pathophysiology of the novel coronavirus infection and they could interact with the drugs used in the treatment of COVID-19. Some patients will need pharmacological interventions due to the presence of delirium. Smoking cessation changes the serum levels of some psychotropic drugs and may influence their use.. The COVID-19 pandemic has created new challenges in clinical practice. Psychiatric patients are a vulnerable population and often a careful clinical, laboratorial and electrocardiographic evaluation may be needed, particularly in those diagnosed with COVID-19. The regular treatment of mentally ill patients with COVID-19 presents increased complexity.. Introdução: A pandemia de COVID-19 constitui uma ameaça particularmente relevante para os portadores de doença mental e um novo desafio para os profissionais que os acompanham. Até à data, tanto quanto sabemos, não existe qualquer revisão abrangente publicada relativamente à utilização de fármacos psicotrópicos durante a pandemia COVID-19. Material e Métodos: Revisão não sistemática da literatura. A pesquisa na PubMed foi realizada com os termos ‘psychotropic drugs’, ‘COVID-19’, ‘psychiatry’ e ‘pandemic’. Foram incluídos os consensos e as normas publicadas pelas sociedades científicas, entidades governamentais e agências regulamentares de medicamentos. Resultados e Discussão: Apresentam-se recomendações relativamente à utilização de psicofármacos durante a pandemia COVID-19, em contexto de ambulatório e de internamento. O tratamento da perturbação afetiva bipolar e da esquizofrenia tem agora dificuldades acrescidas. Alguns psicofármacos interferem com os mecanismos fisiopatológicos envolvidos na infeção pelo novo coronavírus e têm interações com os fármacos utilizados no tratamento da COVID-19. Em doentes com COVID-19 e com delirium, a utilização de psicofármacos poderá ser necessária. A cessação tabágica altera os níveis séricos de alguns psicofármacos e pode condicionar a sua utilização. Conclusão: A pandemia de COVID-19 coloca novos desafios na prática clínica. Os doentes psiquiátricos constituem uma população vulnerável, sendo frequentemente necessária uma avaliação clínica, laboratorial e eletrocardiográfica cuidadosa, naqueles com o diagnóstico de COVID-19. Os doentes mentais com COVID-19 apresentam uma complexidade acrescida na gestão da sua terapêutica habitual.

Topics: Antiviral Agents; Benzodiazepines; Betacoronavirus; Bipolar Disorder; Body Temperature Regulation; Buprenorphine; Clozapine; Coronavirus Infections; COVID-19; Delayed-Action Preparations; Drug Interactions; Hospitalization; Humans; Lithium Compounds; Mental Disorders; Methadone; Narcotic Antagonists; Pandemics; Pneumonia, Viral; Psychotropic Drugs; SARS-CoV-2; Schizophrenia; Smoking Cessation Agents; Valproic Acid

Management of patients with opioid use disorder (OUD) commonly includes opioid agonist therapy (OAT) as a part of an integrated treatment plan. These interventions are associated with proven benefits to the individual and society. Areas covered: The use of methadone and buprenorphine within an integrated treatment plan in the management of patients with OUD: this work provides consensus recommendation on pharmacotherapy in OUD to assist clinicians with practical decision making in this field. Expert opinion: Pharmacotherapy is recommended as part of an integrated OUD treatment approach with psychosocial interventions, with the goal of reducing risks of illicit opioid use, overdose mortality, infection with HIV or HCV, improving health, psychological and social outcomes. Access to OAT should be prioritised in the treatment of OUD. Treatment choices in OUD pharmacotherapy should be based on the needs of the individual and characteristics of medications. Recommendations for choices of OAT are based on clinical efficacy, safety, patient preference, side effects, pharmacological interactions, quality of life, dose titration potential and outcomes (control craving, ongoing opioids consumption or other drugs, and potentially psychiatric comorbidities). Special groups, pregnant women, prisoners, patients with mental health problems have specific needs which must be addressed with expert input.

Topics: Buprenorphine; Consensus; Europe; Humans; Mental Disorders; Methadone; Opiate Substitution Treatment; Opioid-Related Disorders; Patient Preference; Quality of Life; Risk Reduction Behavior

Opioid substitution therapy (OST) for opioid dependence is common, and injection drug users have significant medical and psychiatric comorbidity. Many physicians will encounter OST patients in their usual practice. This article provides guidance on management of common clinical problems in this population, including OST management in hepatic failure, respiratory disease, pain management and potential drug interactions.

Topics: Analgesics; Australia; Buprenorphine; Comorbidity; Drug Interactions; Female; Humans; Liver Diseases; Mental Disorders; Methadone; Naloxone; Opiate Substitution Treatment; Pain; Pain Management; Palliative Care; Polypharmacy; Pregnancy; Pregnancy Complications; Respiratory Insufficiency; Substance-Related Disorders; Virus Diseases

Topics: Buprenorphine; France; Health Policy; Humans; Legislation, Medical; Mental Disorders; Methadone; Narcotic Antagonists; Narcotics; Opioid-Related Disorders; Substance-Related Disorders

Through a novel synthesis of the literature and our own clinical experience, we have derived a set of evidence-based recommendations for consideration as guidance in the management of opioid-dependent pregnant women and infants.. PubMed literature searches were carried out to identify recent key publications in the areas of pregnancy and opioid dependence, neonatal abstinence syndrome (NAS) prevention and treatment, multiple substance abuse and psychiatric comorbidity.. Pregnant women dependent on opioids require careful treatment to minimize harm to the fetus and neonate and improve maternal health. Applying multi-disciplinary treatment as early as possible, allowing medication maintenance and regular monitoring, benefits mother and child both in the short and the long term. However, there is a need for randomized clinical trials with sufficient sample sizes.. Opioid maintenance therapy is the recommended treatment approach during pregnancy. Treatment decisions must encompass the full clinical picture, with respect to frequent complications arising from psychiatric comorbidities and the concomitant consumption of other drugs. In addition to standardized approaches to pregnancy, equivalent attention must be given to the treatment of NAS, which occurs frequently after opioid medication.. Methodological flaws and inconsistencies confound interpretation of today's literature. Based on this synthesis of available evidence and our clinical experience, we propose recommendations for further discussion.

Topics: Buprenorphine; Diagnosis, Dual (Psychiatry); Female; GABA Modulators; Humans; Infant, Newborn; Mental Disorders; Methadone; Narcotics; Neonatal Abstinence Syndrome; Opioid-Related Disorders; Phenobarbital; Pregnancy; Pregnancy Complications

In recent years, we have seen regulatory approval being given for several new pharmacotherapies in the treatment of drug addiction disorders. Within the United States, the most noteworthy development has been the approval of buprenorphine in the treatment of opioid dependence, and its availability for prescribing in an office-based setting has resulted in thousands of additional patients going into treatment. Although approved medications for the treatment of cocaine and methamphetamine dependence are still lacking, the National Institute on Drug Abuse has devoted substantial effort toward meeting these clinical needs. Recent studies of modafinil for the treatment of cocaine dependence have been especially encouraging. Looking to the future, the looming challenge is polydrug addiction, a situation that is often complicated by co-occurring psychiatric disorders. As we strive to address the needs of these complicated patients, studies of buprenorphine/naltrexone may hold the key to a major advance.

Topics: Buprenorphine; Comorbidity; Delayed-Action Preparations; Drug Administration Schedule; Drug Design; Drug Therapy, Combination; Humans; Mental Disorders; Naltrexone; Narcotic Antagonists; Opioid-Related Disorders

Although addiction to heroin and other opiates is a major public health issue in the United States and many other countries, advances in pharmacologic and nonpharmacologic treatment have been made. Some of these advances represent a major shift from traditional treatment philosophies, whereas others are characterized by more subtle, though important, improvements. This review discusses recent advances in opiate-addiction treatment in the context of three main domains: the use of buprenorphine and buprenorphine/naloxone in an office-based paradigm, psychosocial treatment and the addressing of medical and psychiatric comorbidity, and harm reduction strategies.

Topics: Buprenorphine; Comorbidity; Drug Therapy, Combination; Humans; Mental Disorders; Naloxone; Narcotic Antagonists; Office Visits; Opioid-Related Disorders; Psychotherapy

Topics: Buprenorphine; Female; Humans; Mental Disorders; Methadone; Narcotic Antagonists; Narcotics; Opioid-Related Disorders; Patient Selection; Physician's Role; Pregnancy; Pregnancy Complications; Prisoners; Psychotropic Drugs; Social Support

Given the difficulty of achieving sustained recovery, pharmacotherapy of opioid and cocaine addiction is more effective when combined with behavioral and psychosocial approaches. Effective pharmacotherapies for opioid dependence and withdrawal include methadone, L-alpha acetylmethadol (LAAM), naltrexone, buprenorphine, and clonidine. Treatment of cocaine addiction includes anti-craving agents, dopamine agonists or blocking agents, antidepressants, and treatment of co-morbid psychiatric disorders, but all with mixed results. In this paper, we discuss the use of medication in the context of general principles of opioid and cocaine addiction treatment. Both established medications and promising directions in pharmacotherapy will be addressed.

Topics: Buprenorphine; Clonidine; Cocaine-Related Disorders; Comorbidity; Heroin Dependence; Humans; Mental Disorders; Methadone; Methadyl Acetate; Naltrexone; Narcotic Antagonists; Narcotics

Patients with heroin dependence frequently present to internists and other physicians for heroin-related medical, psychiatric, and behavioral health problems and often seek help with reducing their heroin use. Thus, physicians should be familiar with the identification and diagnosis of heroin dependence in their patients and be able to initiate treatment of heroin dependence both directly and by referral. Recent research has provided much information concerning effective pharmacologically based treatment approaches for managing opioid withdrawal and helping patients to remain abstinent Methadone maintenance and newer approaches using L-alpha acetylmethadol and buprenorphine seem to be particularly effective in promoting relapse prevention. Although these treatments are currently provided in special drug treatment settings, recent and ongoing research indicates that the physician's office may be an effective alternative site for these treatments.

Topics: Analgesics, Opioid; Buprenorphine; Counseling; Heroin Dependence; Humans; Mental Disorders; Methadone; Methadyl Acetate; Naltrexone; Narcotic Antagonists; Physician's Role; Substance Withdrawal Syndrome

Suicidal ideation and behavior currently have no quick-acting pharmacological treatments that are suitable for independent outpatient use. Suicidality is linked to mental pain, which is modulated by the separation distress system through endogenous opioids. The authors tested the efficacy and safety of very low dosages of sublingual buprenorphine as a time-limited treatment for severe suicidal ideation.. This was a multisite randomized double-blind placebo-controlled trial of ultra-low-dose sublingual buprenorphine as an adjunctive treatment. Severely suicidal patients without substance abuse were randomly assigned to receive either buprenorphine or placebo (in a 2:1 ratio), in addition to their ongoing individual treatments. The primary outcome measure was change in suicidal ideation, as assessed by the Beck Suicide Ideation Scale at the end of each of 4 weeks of treatment.. Patients who received ultra-low-dose buprenorphine (initial dosage, 0.1 mg once or twice daily; mean final dosage=0.44 mg/day; N=40) had a greater reduction in Beck Suicide Ideation Scale scores than patients who received placebo (N=22), both after 2 weeks (mean difference -4.3, 95% CI=-8.5, -0.2) and after 4 weeks (mean difference=-7.1, 95% CI=-12.0, -2.3). Concurrent use of antidepressants and a diagnosis of borderline personality disorder did not affect the response to buprenorphine. No withdrawal symptoms were reported after treatment discontinuation at the end of the trial.. The time-limited, short-term use of very low dosages of sublingual buprenorphine was associated with decreased suicidal ideation in severely suicidal patients without substance abuse. Further research is needed to establish the efficacy, safety, dosing, and appropriate patient populations for this experimental treatment.

Topics: Administration, Sublingual; Adult; Buprenorphine; Double-Blind Method; Drug Therapy, Combination; Female; Humans; Male; Mental Disorders; Narcotic Antagonists; Psychotropic Drugs; Suicidal Ideation; Time Factors; Treatment Outcome; Young Adult

Given the growing prevalence of prescription opioid dependence and the considerable rates of additional psychopathology in drug dependence, we examined the association between the presence of a co-occurring Axis I psychiatric disorder and sociodemographic and clinical characteristics in this secondary analysis of patients entering a treatment study for dependence on prescription opioids. Treatment outcomes were also compared.. Patients dependent on prescription opioids participated in a multi-site, two-phase, randomized, controlled trial to assess different lengths of buprenorphine-naloxone pharmacotherapy and different intensities of counseling (Clinicaltrials.gov identifier: NCT00316277). Among the 653 participants entering the first phase of the trial, 360 entered the second phase, receiving 12 weeks of buprenorphine-naloxone treatment; they are reported here. Half of those participants (180/360) had a current co-occurring psychiatric disorder in addition to substance dependence.. Sociodemographic characteristics were similar overall between those with and without a co-occurring psychiatric disorder, but women were 1.6 times more likely than men to have a co-occurring disorder. On several clinical indicators at baseline, participants with a co-occurring disorder had greater impairment. However, they had better opioid use outcomes at the conclusion of 12 weeks of buprenorphine-naloxone stabilization than did participants without a co-occurring disorder.. Prescription opioid-dependent patients with a co-occurring psychiatric disorder had a better response to buprenorphine-naloxone treatment despite demonstrating greater impairment at baseline. Additional research is needed to determine the mechanism of this finding and to adapt treatments to address this population.

Topics: Adult; Buprenorphine; Diagnosis, Dual (Psychiatry); Drug Therapy, Combination; Female; Humans; Male; Mental Disorders; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prescription Drugs; Treatment Outcome; Young Adult

HIV-infected prisoners fare poorly after release. Though rarely available, opioid agonist therapy (OAT) may be one way to improve HIV and substance abuse treatment outcomes after release. Of the 69 HIV-infected prisoners enrolled in a randomized controlled trial of directly administered antiretroviral therapy, 48 (70%) met DSM-IV criteria for opioid dependence. Of these, 30 (62.5%) selected OAT, either as methadone (N = 7, 14.5%) or buprenorphine/naloxone (BPN/NLX; N = 23, 48.0%). Twelve-week HIV and substance abuse treatment outcomes are reported as a sub-study for those selecting BPN/NLX. Retention was high: 21 (91%) completed BPN/NLX induction and 17 (74%) remained on BPN/NLX after 12 weeks. Compared with baseline, the proportion with a non-detectable viral load (61% vs 63% log(10) copies/mL) and mean CD4 count (367 vs 344 cells/mL) was unchanged at 12 weeks. Opiate-negative urine testing remained 83% for the 21 who completed induction. Using means from 10-point Likert scales, opioid craving was reduced from 6.0 to 1.8 within 3 days of BPN/NLX induction and satisfaction remained high at 9.5 throughout the 12 weeks. Adverse events were few and mild. BPN/NLX therapy was acceptable, safe and effective for both HIV and opioid treatment outcomes among released HIV-infected prisoners. Future randomized controlled trials are needed to affirm its benefit in this highly vulnerable population.

Topics: Anti-Retroviral Agents; Buprenorphine; Buprenorphine, Naloxone Drug Combination; CD4 Lymphocyte Count; Female; HIV Infections; Humans; Male; Mental Disorders; Methadone; Middle Aged; Naloxone; Narcotic Antagonists; Narcotics; Prisoners; Substance-Related Disorders

Buprenorphine has rarely been administered as an opioid agonist maintenance therapy in a correctional setting. This study introduced buprenorphine maintenance in a large urban jail, Rikers Island in New York City. Heroin-dependent men not enrolled in community methadone treatment and sentenced to 10-90 days in jail (N=116) were voluntarily randomly assigned either to buprenorphine or methadone maintenance, the latter being the standard of care for eligible inmates at Rikers. Buprenorphine and methadone maintenance completion rates in jail were equally high, but the buprenorphine group reported for their designated post-release treatment in the community significantly more often than did the methadone group (48% vs. 14%, p<.001). Consistent with this result, prior to release from Rikers, buprenorphine patients stated an intention to continue treatment after release more often than did methadone patients (93% vs. 44%, p<.001). Buprenorphine patients were also less likely than methadone patients to withdraw voluntarily from medication while in jail (3% vs. 16%, p<.05). There were no post-release differences between the buprenorphine and methadone groups in self-reported relapse to illicit opioid use, self-reported re-arrests, self-reported severity of crime or re-incarceration in jail. After initiating opioid agonist treatment in jail, continuing buprenorphine maintenance in the community appears to be more acceptable to offenders than continuing methadone maintenance.

Topics: Adolescent; Adult; Aged; Buprenorphine; Diagnosis, Dual (Psychiatry); Female; Follow-Up Studies; HIV Infections; Humans; Male; Mental Disorders; Methadone; Middle Aged; Narcotics; Opioid-Related Disorders; Patient Selection; Prisons; Recurrence; Socioeconomic Factors; Treatment Outcome; Young Adult

The authors sought to characterize the 3-year prevalence of mental disorders and nonnicotine substance use disorders among male and female primary care patients with documented opioid use disorder across large U.S. health systems.. This retrospective study used 2014-2016 data from patients ages ≥16 years in six health systems. Diagnoses were obtained from electronic health records or claims data; opioid use disorder treatment with buprenorphine or injectable extended-release naltrexone was determined through prescription and procedure data. Adjusted prevalence of comorbid conditions among patients with opioid use disorder (with or without treatment), stratified by sex, was estimated by fitting logistic regression models for each condition and applying marginal standardization.. Females (53.2%, N=7,431) and males (46.8%, N=6,548) had a similar prevalence of opioid use disorder. Comorbid mental disorders among those with opioid use disorder were more prevalent among females (86.4% vs. 74.3%, respectively), whereas comorbid other substance use disorders (excluding nicotine) were more common among males (51.9% vs. 60.9%, respectively). These differences held for those receiving medication treatment for opioid use disorder, with mental disorders being more common among treated females (83% vs. 71%) and other substance use disorders more common among treated males (68% vs. 63%). Among patients with a single mental health condition comorbid with opioid use disorder, females were less likely than males to receive medication treatment for opioid use disorder (15% vs. 20%, respectively).. The high rate of comorbid conditions among patients with opioid use disorder indicates a strong need to supply primary care providers with adequate resources for integrated opioid use disorder treatment.

Topics: Adolescent; Analgesics, Opioid; Buprenorphine; Female; Humans; Male; Mental Disorders; Opioid-Related Disorders; Primary Health Care; Retrospective Studies; Sex Characteristics

The co-association of benzodiazepines and opioids is associated with an increased risk of overdose, death, and poorer psychosocial prognosis. The aim of this study is to characterize the prevalence, pattern of use, and primary clinical outcomes in benzodiazepines users in a public opioid maintenance treatment unit.. We conducted a cross-sectional study involving 236 patients treated with opioid substitutes (methadone and buprenorphine). We conducted a descriptive, bivariable, and multivariable analysis to determine clinical differences between benzodiazepines users and non-users.. The prevalence of consumption of benzodiazepines was 25.4% (60). The benzodiazepines were obtained with a medical prescription (49.8%) or on the black market (42.6%). The most prescribed benzodiazepine was diazepam (29.1%), and the main reasons were to relieve insomnia (27.7%) or anxiety (26.9%) and to enhance the psychoactive effects of other drugs (19.7%). Regarding the clinical outcomes, we highlight: a very high prevalence of hepatitis C (51.7%); severe ongoing consumption of psychoactive drugs (73.7%); and a high rate of depression and anxiety (> 60%), significantly higher in the benzodiazepines-user group. In the multivariable analysis of benzodiazepine use, we found alcohol consumption (OR 0.482; IC 95% 0.247, 0.238) had a negative association and having hepatitis C (OR 2.544, IC 95% 1.273, 5.084) or anxiety symptoms (OR 5.591; IC 95% 2.345, 13.326) had positive associations.. Our results suggest the BZD users had a complex drug addiction problem and underline the importance of adequately addressing BZD use, contemplating psychological and psychiatric approach in this particular population.. Past or current use of benzodiazepines is associated with poor clinical and psychiatric outcomes. A multidisciplinary approach with a focus on infectious diseases and mental health is critical in order to enhance the treatment effectiveness and overall prognosis.. Introdução: A co-associação entre benzodiazepinas e opióides associa-se a risco aumentado de overdose, morte e pior prognóstico psicossocial. Pretendemos determinar a prevalência, o padrão de consumo e as principais co-morbilidades do uso de benzodiazepinas, em utentes sob tratamento de manutenção opióide. Material e Métodos: Conduzimos um estudo transversal, envolvendo 236 doentes tratados com substitutos opióides (metadona e buprenorfina). Realizou-se uma análise descritiva, bivariável e multivariável das características clínicas entre os usuários de benzodiazepinas e os não-usuários de benzodiazepinas. Resultados: A prevalência do uso de benzodiazepinas foi de 25,4% (60). A obtenção de benzodiazepinas foi através de prescrição médica (49,8%) ou mercado negro (42,6%). A substância mais prescrita foi o diazepam (29,1%), e as principais razões para a toma foi insónia (27,7%), ansiedade (26,9%), e para potenciar os efeitos psicoativos de outras drogas (19,7%). No que respeita aos resultados clínicos sublinhamos: prevalência elevada de hepatite C (51,7%); elevado consumo continuado de substâncias psicoativas (73,7%); elevada taxa de depressão e ansiedade (> 60%), significativamente mais elevada nos utilizadores de benzodiazepinas. Na análise multivariável para o uso de benzodiazepinas, verificámos que o consumo de álcool (OR 0,482; IC 95% 0,247, 0,238) tem associação negativa; a hepatite C (OR 2,544; IC 95% 1,273, 5,084) e a ansiedade (OR 5,591; IC 95% 2,345, 13,326) tiveram associações positivas. Discussão: Os resultados obtidos sugerem que os utilizadores de BZD têm um problema complexo de dependência de drogas e sublinham a importância de abordar adequadamente o uso de BZD, contemplando uma abordagem psicológica e psiquiátrica nesta população em particular. Conclusão: O uso de benzodiazepinas, no passado ou atualmente, associa-se a piores indicadores físicos e psiquiátricos. A abordagem multidisciplinar com foco nas doenças infeciosas e na saúde mental é uma necessidade crítica para a efetividade do tratamento e prognóstico global.

Topics: Adult; Analgesics, Opioid; Anxiety; Benzodiazepines; Buprenorphine; Cross-Sectional Studies; Diazepam; Female; Humans; Male; Mental Disorders; Methadone; Middle Aged; Narcotics; Opiate Substitution Treatment; Opioid-Related Disorders; Portugal; Prevalence; Sleep Initiation and Maintenance Disorders; Surveys and Questionnaires; Treatment Outcome

Outpatients with cancer commonly have nonmedical opioid use (NMOU) behaviors and use opioids to dull emotional and existential suffering. Buprenorphine is often used for cancer pain due to less reported euphoria when compared to other opioids.. A retrospective review was done in patients who were prescribed buprenorphine for cancer pain. Pain scores were reported on a Likert pain scale of 1 to 10. Nonmedical opioid use was defined as patients taking opioids for emotional pain at or above the maximum prescribed amount.. The pain score in those patients without NMOU was significantly lower after rotation to buprenorphine than those with NMOU. We deduce that in those with NMOU, it is more challenging to achieve pain relief with buprenorphine. Overall, for all patients, rotation to buprenorphine resulted in a marginally significantly reduced pain score.

Topics: Analgesics, Opioid; Buprenorphine; Cancer Pain; Comorbidity; Female; Humans; Male; Mental Disorders; Middle Aged; Opioid-Related Disorders; Prescription Drug Overuse; Retrospective Studies

Mental health diagnoses (MHD) are common among those with opioid use disorders (OUD). Methadone/buprenorphine are effective medication-assisted treatment (MAT) strategies; however, treatment receipt is low among those with dual MHDs. Medicaid expansions have broadly increased access to OUD and mental health services over time, but MAT uptake may vary depending on multiple factors, including MHD status, state Medicaid expansion decisions, and race/ethnicity and gender. Examining clinical and policy approaches to promoting MAT uptake may improve services among marginalized groups.. MAT treatment discharges were identified using the Treatment Episodes Dataset-Discharges (TEDS-D; 2014-2017) (n = 1,400,808). We used multivariate logistic regression to model MAT receipt using interactions and adjusted for several potential confounders.. Nearly one-third of OUD treatment discharges received MAT. Dual MHDs in both expansion and non-expansion states were positively associated with MAT uptake over time. Dual MHDs were negatively associated with MAT receipt only among American Indian/Alaska Native women residing in Medicaid expansion states (aOR = 0.58, 95 % CI = 0.52-0.66, p < 0.0001).. Disparities in MAT utilization are nuanced and vary widely depending on dual MHD status, Medicaid expansion, and race/ethnicity/gender. Medicaid is beneficial but not a universal treatment panacea. Clinical decisions to initiate MAT are dependent on multiple factors and should be tailored to meet the needs of high-risk, historically disadvantaged clients.

Topics: Adolescent; Adult; Analgesics, Opioid; Buprenorphine; Diagnosis, Dual (Psychiatry); Ethnicity; Female; Forecasting; Humans; Male; Medicaid; Mental Disorders; Methadone; Middle Aged; Opiate Substitution Treatment; Opioid-Related Disorders; Racial Groups; Sex Factors; United States; Young Adult

Evidence demonstrates that medications for treating opioid use disorder (MOUD) -namely buprenorphine, methadone, and extended-release naltrexone-are effective at treating opioid use disorder (OUD) and reducing associated harms. However, MOUDs are heavily underutilized, largely due to the under-supply of providers trained and willing to prescribe the medications.. To understand comparative beliefs about MOUD and barriers to MOUD, we conducted a mixed-methods study that involved focus group interviews and an online survey disseminated to a random group of licensed U.S. physicians, which oversampled physicians with a preexisting waiver to prescribe buprenorphine. Focus group results were analyzed using thematic analysis. Survey results were analyzed using descriptive and inferential statistical methods.. Study findings suggest that physicians have higher perceptions of efficacy for methadone and buprenorphine than for extended-release naltrexone, including for patients with co-occurring mental health disorders. Insurance obstacles, such as prior authorization requirements, were the most commonly cited barrier to prescribing buprenorphine and extended-release naltrexone. Regulatory barriers, such as the training required to obtain a federal waiver to prescribe buprenorphine, were not considered significant barriers by many physicians to prescribing buprenorphine and naltrexone in office-based settings. Nor did physicians perceive diversion to be a prominent barrier to prescribing buprenorphine. In focus groups, physicians identified financial, logistical, and workforce barriers-such as a lack of addiction treatment specialists-as additional barriers to prescribing medications to treat OUD.. Additional education is needed for physicians regarding the comparative efficacy of different OUD medications. Governmental policies should mandate full insurance coverage of and prohibit prior authorization requirements for OUD medications.

Topics: Analgesics, Opioid; Attitude of Health Personnel; Buprenorphine; Delayed-Action Preparations; Drug and Narcotic Control; Female; Humans; Insurance Coverage; Insurance, Health; Male; Mental Disorders; Methadone; Naltrexone; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; Practice Patterns, Physicians'; Specialization; United States

The purpose of this paper is to examine the current provision of opioid substitution therapy (OST) during and immediately following release from detention in prisons in England and Wales.. A group of experts was convened to comment on current practices and to make recommendations for improving OST management in prison. Current practices were previously assessed using an online survey and a focus group with experience of OST in prison (Webster, 2017).. Disruption to the management of addiction and reduced treatment choice for OST adversely influences adequate provision of OST in prison. A key concern was the routine diversion of opiate substitutes to other prisoners. The new controlled drug formulations were considered a positive development to ensure streamlined and efficient OST administration. The following patient populations were identified as having concerns beyond their opioid use, and therefore require additional considerations in prison: older people with comorbidities and complex treatment needs; women who have experienced trauma and have childcare issues; and those with existing mental health needs requiring effective understanding and treatment in prison.. Integration of clinical and psychosocial services would enable a joint care plan to be tailored for each individual with opioid dependence and include options for detoxification or maintenance treatment. This would better enable those struggling with opioid use to make informed choices concerning their care during incarceration and for the period immediately following their release. Improvements in coordination of OST would facilitate inclusion of strategies to further streamline this process for the benefit of prisoners and prison staff.

Topics: Age Factors; Buprenorphine; Comorbidity; Continuity of Patient Care; Delayed-Action Preparations; Drug Administration Schedule; England; Hepatitis C; HIV Infections; Humans; Mental Disorders; Methadone; Naltrexone; Narcotics; Needle Sharing; Opiate Substitution Treatment; Opioid-Related Disorders; Prisons; Quality Improvement; Social Work; Wales

This qualitative study identifies and describes experiences and challenges to retention of individuals with opioid use disorder (OUD) who participated in a low-threshold combined buprenorphine-peer support treatment program in Baltimore.. In-depth semi-structured interviews with staff and former clients of the Project Connections Buprenorphine Program (PCBP) (9 people) and focus group discussions with current and previous clients of PCBP (7 people) were conducted. Content analysis was used to extract themes regarding barriers to enrolling and remaining in, and transitioning from the program.. Primary challenges identified by the participants included struggles with cravings and symptoms of withdrawal, comorbid mental health issues, criminal justice system involvement, medication stigma, and conflicts over level of flexibility regarding program requirements and the role of employment.. This study identified several obstacles clients face when seeking care through a combined buprenorphine-peer support model. Findings highlight potential programmatic factors that can be improved and additional resources that may support treatment retention rates and better outcomes. Despite challenges, low-threshold and community-based programs can increase access to effective maintenance treatment for OUD, especially among vulnerable populations who may not have access to formal health services.

Topics: Adult; Aged; Analgesics, Opioid; Attitude of Health Personnel; Attitude to Health; Baltimore; Buprenorphine; Community Mental Health Services; Comorbidity; Craving; Criminal Law; Employment; Female; Focus Groups; Humans; Male; Mental Disorders; Mental Health Recovery; Middle Aged; Opiate Substitution Treatment; Opioid-Related Disorders; Peer Group; Qualitative Research; Social Stigma; Substance Withdrawal Syndrome

Psychosocial interventions are often recommended as part of buprenorphine treatment for patients with opioid use disorder, but little is known about prescriber perspectives on their use and how this varies across buprenorphine prescriber specialties.. A large US sample of physicians actively prescribing buprenorphine (n = 1174) was surveyed from July 2014 to January 2017. Analyses examined prescriber characteristics and their perceptions and use of psychosocial interventions across three groups of physicians: primary care providers (PCPs), addiction physicians/psychiatrists, and other physicians.. Across all prescribers, 93.3% (n = 1061) report most patients would benefit from formal counseling during buprenorphine treatment while only 36.4% (n = 414) believe there are adequate number of counselors in their communities. Among addiction physicians/psychiatrists, 75.9% (n = 416) report their treatment settings have the resources to provide psychiatric services to patients with complex psychiatric problems compared to 29.1% (n = 130) of PCPs and 29.6% (n = 39, p < .001) of other physicians. Addiction physicians/psychiatrists report a higher percentage of patients receive counseling from clinicians in their practice while PCPs report a higher percentage of patients receive counseling from external providers.. The majority of prescribers believe patients receiving buprenorphine would benefit from psychosocial interventions and there is variation in how these services are delivered. However, many prescribers, especially those without addiction or psychiatry backgrounds, report their settings do not have adequate psychosocial treatment resources for patients with complex psychosocial needs. Future work developing novel models of psychosocial interventions may be helpful to support prescribers to effectively treat complex patients with opioid use disorders.

Topics: Addiction Medicine; Adult; Aged; Analgesics, Opioid; Attitude of Health Personnel; Buprenorphine; Counseling; Female; Health Services Accessibility; Health Services Needs and Demand; Humans; Male; Mental Disorders; Mental Health Services; Middle Aged; Opiate Substitution Treatment; Opioid-Related Disorders; Physicians, Primary Care; Referral and Consultation; Surveys and Questionnaires; United States

Buprenorphine effectively reduces opioid craving and illicit opioid use. However, some patients may not take their medication as prescribed and thus experience suboptimal outcomes. The study aim was to qualitatively explore buprenorphine adherence and the acceptability of utilizing video directly observed therapy (VDOT) among patients and their providers in an office-based program.. Clinical providers (physicians and staff; n = 9) as well as patients (n = 11) were recruited from an office-based opioid treatment program at an urban academic medical center in the northwestern United States. Using a semi-structured guide, interviewers conducted individual interviews and focus group discussions. Interviews were digitally recorded and transcribed verbatim. Transcripts were independently coded to identify key themes related to non-adherence and then jointly reviewed in an iterative fashion to develop a set of content codes.. Among providers and patients, perceived reasons for buprenorphine non-adherence generally fell into several thematic categories: social and structural factors that prevented patients from consistently accessing medications or taking them reliably (e.g., homelessness, transportation difficulties, chaotic lifestyles, and mental illness); refraining from taking medication in order to use illicit drugs or divert; and forgetting to take medication, especially in the setting of taking split-doses. Some participants perceived non-adherence to be less of a problem for buprenorphine than for other medications. VDOT was viewed as potentially enhancing patient accountability, leading to more trust from providers who are concerned about diversion. On the other hand, some participants expressed concern that VDOT would place undue burden on patients, which could have the opposite effect of eroding patient-provider trust. Others questioned the clinical indication.. Findings suggest potential arenas for enhancing buprenorphine adherence, although structural barriers will likely be most challenging to ameliorate. Providers as well as patients indicated mixed attitudes toward VDOT, suggesting it would need to be thoughtfully implemented.

Topics: Academic Medical Centers; Adult; Attitude of Health Personnel; Buprenorphine; Directly Observed Therapy; Female; Health Knowledge, Attitudes, Practice; Humans; Interviews as Topic; Male; Medication Adherence; Mental Disorders; Middle Aged; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; Qualitative Research; Socioeconomic Factors; United States

Opioid overdose is a leading cause of death in persons experiencing homelessness (PEH), despite effective medications for opioid use disorder (OUD). In 2016, the San Francisco Street Medicine Team piloted a low barrier buprenorphine program with the primary goal of engaging and retaining PEH with OUD in care as a first step toward reducing opioid use and improving overall health.. To characterize the patients; assess treatment retention, retention on buprenorphine, and opioid use; and to describe adverse events.. Retrospective chart review of patients receiving at least one buprenorphine prescription from Street Medicine (November 2016-October 2017). We abstracted demographic, medical, substance use, prescription, and health care utilization data from medical records. We assessed retention in care at 1, 3, 6, 9 and 12 months, defined as a provider visit 1 week prior to or any time after each time point. We considered patients to be retained on buprenorphine if they had active buprenorphine prescriptions for more than 2 weeks of the month. We estimated opioid use by the percentage of patients with any opioid-negative, buprenorphine-positive urine toxicology test. We reviewed emergency department and hospital records for adverse events, including deaths and nonfatal opioid overdoses.. Among the 95 persons eligible for analysis, mean age was 39.2, and 100% reported injecting heroin and homelessness. Medical and psychiatric comorbidities and co-occurring substance use were common. The percentages of patients retained in care at 1, 3, 6, 9 and 12 months were 63%, 53%, 44%, 38%, and 26%, respectively. The percentages of patients retained on buprenorphine at 1, 3, 6, 9 and 12 months were 37%, 27%, 27%, 26%, and 18%, respectively. Twenty-three percent of patients had at least one opioid-negative, buprenorphine-positive test result. One patient died from fentanyl overdose, and four patients presented on six occasions for non-fatal overdoses requiring naloxone.. This program engaged and retained a subset of PEH with OUD in care and on buprenorphine over 12 months. While uninterrupted treatment and abstinence are reasonable outcomes for conventional treatment programs, intermittent treatment with buprenorphine and decreased opioid use were more common in this pilot and may confer important reductions in opioid and injection-related harms.

Topics: Adult; Aged; Buprenorphine; Comorbidity; Drug Overdose; Female; Heroin Dependence; Humans; Ill-Housed Persons; Male; Mental Disorders; Middle Aged; Narcotic Antagonists; Opioid-Related Disorders; Patient Acceptance of Health Care; Retrospective Studies; San Francisco; Socioeconomic Factors; Young Adult

Opioid use disorder (OUD) remains a serious public health issue, and treating adults with OUD is a major priority in the United States. Little is known about trends in the diagnosis of OUD and in buprenorphine prescribing by physicians in office-based medical practices. We sought to characterize OUD diagnoses and buprenorphine prescribing among adults with OUD in the United States between 2006 and 2015.. We used a repeated cross-sectional design, based on data from the 2006-15 National Ambulatory Medical Care Surveys that surveyed nationally representative samples of office-based out-patient physician visits.. Adult patients aged 18 years or older with a diagnosis of OUD (n = 1034 unweighted) were included.. Buprenorphine prescribing was defined by whether visits involved buprenorphine or buprenorphine-naloxone, or not. We also examined other covariates (e.g. age, gender, race and psychiatric comorbidities).. We observed an almost tripling of the diagnosis of OUD from 0.14% in 2006-10 to 0.38% in 2011-15 in office-based medical practices (P < 0.001). Among adults diagnosed with OUD, buprenorphine prescribing increased from 56.1% in 2006-10 to 73.6% in 2011-15 (P = 0.126). Adults with OUD were less likely to receive buprenorphine prescriptions if they were Hispanic [adjusted odds ratio (aOR) = 0.26; 95% confidence interval (CI) = 0.11, 0.60], had Medicaid insurance (aOR = 0.27; 95% CI = 0.10, 0.74) or were diagnosed with other psychiatric disorders (aOR = 0.45; 95% CI = 0.25, 0.83) or substance use disorders (aOR = 0.19; 95% CI = 0.09, 0.41).. In office-based medical practices in the United States, diagnoses for opioid use disorder and buprenorphine prescriptions for adults with opioid use disorder increased from 0.14 and 56.1%, respectively, in 2006-10 to 0.38 and 73.6% in 2011-15.

Topics: Adolescent; Adult; Aged; Ambulatory Care; Black or African American; Buprenorphine; Buprenorphine, Naloxone Drug Combination; Delivery of Health Care; Female; Healthcare Disparities; Hispanic or Latino; Humans; Insurance, Health; Male; Medicaid; Mental Disorders; Middle Aged; Narcotic Antagonists; Opiate Substitution Treatment; Opioid Epidemic; Opioid-Related Disorders; Practice Patterns, Physicians'; United States; White People; Young Adult

Gender and psychiatric comorbidity seem to influence patients' inter-individual response to Opioid Substitution Treatments (OST) in Opioid Use Disorder (OUD) management. The aim of the study was to assess psychopathological dimensions in an Italian sample of OUD individuals entering a methadone/buprenorphine maintenance program; secondary, we evaluated the possible gender-specific differences within the psychopathological profiles.. In a cross-sectional study, we recruited 1052 (792 male; 260 female) OUD subjects receiving OST. All patients underwent a clinical and psychometric evaluation assessing demographics, psychiatric history, psychopathological features via the Symptom Checklist-90-Revised (SCL-90-R), and were prescribed psychopharmacological treatments.. Our results reveal gender-specific differences in a real-world sample of opioid-maintained OUD individuals attending public addiction services in Italy. Compared to men, women reported higher scores in both General Symptomatic Index (GSI) and in all the SCL-90-R sub-scales. No impact of pharmacological treatment was detected. Finally, regression analysis revealed that being in methadone-maintenance group was significantly associated with high GSI scores in the male, but not female, group.. Increasing the knowledge of psychopathological dimensions in patients with OST, with relevance to gender differences, is important for a better understanding of factors that influence the outcome and for further development in gender-tailored strategies.

Topics: Adult; Buprenorphine; Comorbidity; Cross-Sectional Studies; Female; Humans; Italy; Male; Mental Disorders; Methadone; Opiate Substitution Treatment; Opioid-Related Disorders; Psychometrics; Sex Factors

Attention Deficit Hyperactivity Disorder (ADHD) is a risk for substance use disorders. The aim of this study was to investigate the association between adult ADHD symptoms, opioid use disorder, life dysfunction and co-occurring psychiatric symptoms. 1057 heroin dependent patients on opioid substitution treatment participated in the survey. All patients were screened for adult ADHD symptoms using the Adult ADHD Self-Report Scale (ASRS-v1.1). 19.4% of the patients screened positive for concurrent adult ADHD symptoms status and heroin dependence. Education level was lower among patients with ADHD symptoms, but not significant with respect to non-ADHD patients. Patients with greater ADHD symptoms severity were less likely to be employed. A positive association was observed between ADHD symptoms status and psychiatric symptoms. Patients with ADHD symptoms status were more likely to be smokers. Patients on methadone had a higher rate of ADHD symptoms status compared to buprenorphine. Those individuals prescribed psychoactive drugs were more likely to have ADHD symptoms. In conclusion, high rate of ADHD symptoms was found among heroin dependent patients, particularly those affected by the most severe form of addiction. These individuals had higher rates of unemployment, other co-morbid mental health conditions, heavy tobacco smoking. Additional psychopharmacological interventions targeting ADHD symptoms, other than opioid substitution, is a public health need.

Topics: Adult; Attention Deficit Disorder with Hyperactivity; Behavior, Addictive; Buprenorphine; Comorbidity; Female; Heroin Dependence; Humans; Male; Mental Disorders; Methadone; Middle Aged; Opiate Substitution Treatment; Opioid-Related Disorders; Psychiatric Status Rating Scales; Quality of Life; Substance-Related Disorders; Surveys and Questionnaires; Young Adult

Previous research has been inconclusive about whether opioid-dependent patients with psychiatric comorbidities have shorter treatment retention and higher relapse rates. This study aims to evaluate the impact of mental health comorbidities on adherence to buprenorphine using a large, national health insurance claims data base.. We used MarketScan® data from 2012 to 2014 to perform this analysis. Inclusion criteria included all patients with an opioid use disorder-related ICD-9 code who had been prescribed buprenorphine (n = 2947). Medication adherence was defined using the Medication Possession Ratio ≥.8 (MPR) and logistic regression was used to examine the association between medication adherence and mental health diagnoses, which included Alzheimer's/dementia, schizophrenia, other psychosis, major depressive disorder/bipolar disorder (MDDBP), anxiety disorder, personality disorder, and mental health disorder not elsewhere specified (NOS).. Of the 2947 patients included in our analysis, the most common diagnoses were anxiety disorder: n = 648 (22.0%), MDDBP: n = 467 (15.9%), and mental health disorder NOS: n = 959 (32.5%). Patients diagnosed with MDDBP were significantly less likely to adhere to opioid pharmacotherapy (OR = .805, 95%CI = .651, .994) than patients without MDDBP.. The presence of a psychiatric comorbidity can significantly affect adherence to buprenorphine. These trends illustrate the need for clinicians treating opioid use disorder with buprenorphine to screen for psychiatric disorders and monitor their medication adherence. There may also be opportunities to design interventions to help this vulnerable population adhere to buprenorphine and other forms of opioid pharmacotherapy. (Am J Addict 2017;26:859-863).

Topics: Adult; Buprenorphine; Comorbidity; Female; Humans; Insurance Claim Review; Male; Medication Adherence; Mental Disorders; Middle Aged; Opioid-Related Disorders; Patient Dropouts; Recurrence; Risk Factors; United States; Young Adult

Psychiatric comorbidities complicate treatment of patients with chronic pain and opioid use disorder, but the prevalence of specific comorbid psychiatric disorders in this population has not been systematically investigated.. 170 consecutive participants entering a treatment research program for co-occurring chronic pain and opioid use disorder between March 2009 and July 2013 were evaluated with the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I/P) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV).. The prevalence of any lifetime (and current) comorbid Axis I disorder was 91% (75%); 52% met criteria for lifetime anxiety disorder (48% current), 57% for lifetime mood disorder (48% current), and 78% for lifetime nonopioid substance use disorder (34% current). Common current anxiety diagnoses were posttraumatic stress disorder (21%), generalized anxiety disorder (16%), and panic disorder without agoraphobia (16%). Common current mood diagnoses were major depressive disorder (40%) and dysthymia (11%). A majority of patients had a personality disorder (52%).. High rates and persistence of co-occurring psychiatric disorders, including anxiety or mood disorders, may explain in part the difficulty providers have treating patients with co-occurring opioid use disorder and chronic pain and suggest possible targets for improving treatment.. ClinicalTrials.gov identifiers: buprenorphine/naloxone treatment (NCT00634803), opioid treatment program-based methadone maintenance treatment (NCT00727675).

Topics: Adult; Buprenorphine; Chronic Pain; Comorbidity; Cross-Sectional Studies; Disability Evaluation; Female; Heroin Dependence; HIV Seropositivity; Humans; Illicit Drugs; Male; Mental Disorders; Methadone; Middle Aged; Naloxone; Opioid-Related Disorders; Pain Measurement; Prescription Drugs; Young Adult

The objective was to estimate the annual interaction management cost of agonist opioid treatment (AOT) for opioid-dependent (OD) patients with buprenorphine-naloxone (Suboxone®) (B/N) or methadone associated with concomitant treatments for infectious (HIV) or psychiatric comorbidities. A costs analysis model was developed to calculate the associated cost of AOT and interaction management. The AOT cost included pharmaceutical costs, drug preparation, distribution and dispensing, based on intake regimen (healthcare center or take-home) and type and frequency of dispensing (healthcare center or pharmacy), and medical visits. The cost of methadone also included single-dose bottles, monthly costs of custody at pharmacy, urine toxicology drug screenings and nursing visits. Potential interactions between AOT and concomitant treatments (antivirals, antibacterials/antifungals, antipsychotics, anxiolytics, antidepressant and anticonvulsants), were identified to determine the additional use of healthcare resources for each interaction management. The annual cost per patient of AOT was €1,525.97 for B/N and €1,467.29 for methadone. The average annual cost per patient of interaction management was €257.07 (infectious comorbidities), €114.03 (psychiatric comorbidities) and €185.55 (double comorbidity) with methadone and €7.90 with B/N in psychiatric comorbidities. Total annual costs of B/N were €1,525.97, €1,533.87 and €1,533.87 compared to €1,724.35, €1,581.32 and €1,652.84 for methadone per patient with infectious, psychiatric or double comorbidity respectively.Compared to methadone, the total cost per patient with OD was lower with B/N (€47.45-€198.38 per year). This is due to the differences in interaction management costs associated with the concomitant treatment of infectious and/or psychiatric comorbidities.. El objetivo fue estimar en pacientes con dependencia a opiáceos (DO), el coste anual del manejo de interacciones del tratamiento sustitutivo con buprenorfina/naloxona (Suboxone®) (B/N) o metadona, asociado con tratamientos concomitantes por comorbilidades infecciosas (VIH) o psiquiátricas. Se realizó un análisis de costes (€, 2013), del tratamiento sustitutivo y del manejo de interacciones. El coste del tratamiento de B/N incluyó costes farmacológicos, elaboración, distribución y dispensación, en función del régimen de administración (centro asistencial o domiciliaria) y del tipo y frecuencia de dispensación (centro asistencial o farmacia), y visitas al especialista para prescripción. El coste de tratamiento con metadona incluyó, además, frascos monodosis, coste de custodia en farmacia, determinación en orina y visitas a enfermería. Se identificaron las interacciones para determinar los recursos sanitarios adicionales consumidos por la administración conjunta del tratamiento sustitutivo y concomitante (antirretrovirales, bactericidas/antifúngicos, antipsicóticos, ansiolíticos, antidepresivos y anticonvulsivos). El coste anual/paciente estimado del tratamiento sustitutivo fue de 1.525,97€ (B/N) y 1.467,29€ (metadona). El coste promedio anual/paciente estimado del manejo de interacciones fue de 257,07€ (infecciosas), 114,03€ (psiquiátricas) y 185,55€ (ambas) con metadona, y de 7,90€ con B/N por comorbilidades psiquiátricas. El coste total anual/paciente estimado de B/N fue 1.525,97€, 1.533,87€ y 1.533,87€ comparado con 1.724,35€, 1.581,32€ y 1.652,84€ de metadona, en pacientes que presentan comorbilidad infecciosa, psiquiátrica o ambas, respectivamente. Comparado con metadona, el coste total por paciente con DO de B/N fue menor (47,45€-198,38€ anuales) derivado de la diferencia del coste por manejo de interacciones del tratamiento concomitante de las comorbilidades infecciosas y/o psiquiátricas.

Topics: Analgesics, Opioid; Buprenorphine; Drug Interactions; Health Care Costs; Humans; Infections; Mental Disorders; Methadone; Naloxone; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders

We review clinical care issues that are related to illicit and therapeutic opioid use among pregnant women and women in the postpartum period and outline the major responsibilities of obstetrics providers who care for these patients during the antepartum, intrapartum, and postpartum periods. Selected patient treatment issues are highlighted, and case examples are provided. Securing a strong rapport and trust with these patients is crucial for success in delivering high-quality obstetric care and in coordinating services with other specialists as needed. Obstetrics providers have an ethical obligation to screen, assess, and provide brief interventions and referral to specialized treatment for patients with drug use disorders. Opioid-dependent pregnant women often can be treated effectively with methadone or buprenorphine. These medications are classified as pregnancy category C medications by the Food and Drug Administration, and their use in the treatment of opioid-dependent pregnant patients should not be considered "off-label." Except in rare special circumstances, medication-assisted withdrawal during pregnancy should be discouraged because of a high relapse rate. Acute pain management in this population deserves special consideration because patients who use opioids can be hypersensitive to pain and because the use of mixed opioid-agonist/antagonists can precipitate opioid withdrawal. In the absence of other indications, pregnant women who use opioids do not require more intense medical care than other pregnant patients to ensure adequate treatment and the best possible outcomes. Together with specialists in pain and addiction medicine, obstetricians can coordinate comprehensive care for pregnant women who use opioids and women who use opioids in the postpartum period.

Topics: Analgesics, Opioid; Buprenorphine; Confidentiality; Dose-Response Relationship, Drug; Emergency Service, Hospital; Female; Humans; Labor Pain; Labor, Obstetric; Mental Disorders; Methadone; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; Pain, Postoperative; Physician-Patient Relations; Postnatal Care; Pregnancy; Pregnancy Complications; Prenatal Care; Referral and Consultation; Triage

The buprenorphine/naloxone combination is used to treat the chronic relapsing disorder of opioid dependence. Adequate dosing levels are important to control cravings, prevent withdrawal syndrome, and maintain patients in treatment. The objective of this study was to estimate the impact of dosing on treatment persistence, resource utilization, and total direct health care costs.. A retrospective cohort analysis was performed using administrative claims extracted from the MarketScan and Clinformatics databases from January 2007 to June and November 2012. Patients initiating treatment with buprenorphine/naloxone were classified into 2 groups based on the prescribed average dose over the entire treatment period and matched by multiple criteria. The threshold for differentiating the dosing groups was set at 15 and 15.7 mg/day for publicly and privately insured patients, respectively. Resource utilization and related costs were calculated over the 12-month period after the treatment initiation.. Patient characteristics at baseline were considerably different between the privately and publicly insured patients. Publicly insured patients were slightly younger (33.1 vs 34.3 years old for privately insured) and had a higher prevalence of mental disorders (70.9% vs 64.9%). In both groups, patients treated with higher doses (> 15 mg and > 15.7 mg per day for publicly and privately insured patients, respectively) had lower risk of discontinuation (public: 11% lower; private: 9% lower) and lower probability of a psychiatric hospitalization than patients treated with lower doses (public: 17% lower; private: 41% lower). Total costs were comparable between the 2 groups (public: $14 600; private: $21 000) despite the expected higher cost of pharmacy in the higher-dose group.. Treatment with higher doses of buprenorphine/naloxone was associated with a longer time to treatment discontinuation, less resource use, and lower total medical costs despite higher pharmacy acquisition cost.

Topics: Adult; Age Factors; Buprenorphine; Buprenorphine, Naloxone Drug Combination; Comorbidity; Dose-Response Relationship, Drug; Female; Health Expenditures; Health Services; Humans; Insurance Claim Review; Insurance, Health; Kaplan-Meier Estimate; Male; Medication Adherence; Mental Disorders; Naloxone; Opiate Substitution Treatment; Opioid-Related Disorders; Recurrence; Retrospective Studies

Attitudes and beliefs towards psychotropic medication were evaluated among psychiatric outpatients, patients receiving buprenorphine treatment for substance abuse, and a group who reported never having used psychotropic medications (non-users). The Drug Attitude Inventory scale and the Beliefs about Medicines Questionnaire General were used to assess attitudes and beliefs of 49 participants. Non-users exhibited more negative attitudes and beliefs toward psychotropic medication than both psychiatric groups.

Topics: Adult; Aged; Aged, 80 and over; Attitude to Health; Buprenorphine; Culture; Female; Humans; Male; Mental Disorders; Middle Aged; Opiate Substitution Treatment; Psychotropic Drugs; Reference Values; Substance-Related Disorders; Surveys and Questionnaires

A national sample of addiction treatment Program Directors (N = 296) were assessed regarding their attitudes about pharmacological treatment for addiction disorders. Multivariable analyses indicate that directors who worked in organizations affiliated with research institutions and who had more professional experience had significantly more positive attitudes about a range of pharmacological therapies. Also, directors in organizations serving higher percentage homeless clients and clients with severe and persistent mental illness had more negative attitudes toward use of buprenorphine. Community-based organizations providing addiction treatment to specific vulnerable client groups exhibit more negative attitudes about pharmacological evidence-based practices and may underutilize those practices.

Topics: Attitude of Health Personnel; Buprenorphine; Evidence-Based Medicine; Female; Health Facility Administrators; Humans; Ill-Housed Persons; Male; Mental Disorders; Middle Aged; Residence Characteristics; Substance Abuse Treatment Centers; Substance-Related Disorders

To examine changes in behavioral and emotional problems among opioid-dependent adolescents during a 4-week combined behavioral and pharmacological treatment.. We examined scales of behavioral and emotional problems in youth using the Youth Self-Report measure at the time of substance abuse treatment intake and changes in scale scores during treatment participants were 36 adolescents (aged 13-18 years, eligible) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for opioid dependence. Participants received a 28-day outpatient, medication-assisted withdrawal with either buprenorphine, or clonidine, as part of a double-blind, double dummy comparison of these medications. All participants received a common behavioral intervention, composed of 3 individual counseling sessions per week, and incentives contingent on opioid-negative urine samples (collected 3 times/week) attendance and completion of weekly assessments.. Although a markedly greater number of youth who received buprenorphine remained in treatment relative to those who received clonidine, youth who remained in treatment showed significant reductions during treatment on 2 Youth Self-Report grouping scales (internalizing problems and total problems) and 4 of the empirically based syndrome scales (somatic, social, attention, and thought). On Youth Self-Report competence and adaptive scales, no significant changes were observed. There was no evidence that changes in any scales differed across medication condition.. Youth who were retained demonstrated substantive improvements in a number of clinically meaningful behavioral and emotional problems, irrespective of pharmacotherapy provided to them.

Topics: Adolescent; Affective Symptoms; Ambulatory Care; Behavior Therapy; Buprenorphine; Clonidine; Combined Modality Therapy; Comorbidity; Double-Blind Method; Drug Evaluation, Preclinical; Female; Humans; Internal-External Control; Male; Mental Disorders; Opiate Substitution Treatment; Opioid-Related Disorders; Personality Inventory; Token Economy

Heterogenic care of addicted detainees in the various prisons in The Netherlands triggered the National Agency of Correctional Institutions of the Ministry of Justice, to order the Dutch Institute for Health Care Improvement (CBO) to formulate the first national guideline titled 'Pharmacological care for detained addicts'. This article presents the content of this guideline, which mainly focuses on opioid-dependent addicts. In The Netherlands, approximately 50% of the detainees are problematic substance abusers, while again half of this group suffers from psychiatric co-morbidity. In addition, somatic co-morbidity, especially infectious diseases, is also common. Due to the moderate outcome seen with voluntary drug counselling regimes in prison, there is a policy shift to extent utilization of legally enforced approaches. Continuity of care is of great importance. In case of opioid addicts this, in general, means continuation of methadone maintenance treatment. Aftercare immediately after detention and optimalization of medical information transfer is crucial. This guideline aims to realize optimal and uniform management of addiction disorders in the Dutch prison system.

Topics: Buprenorphine; Communicable Diseases; Comorbidity; Continuity of Patient Care; Female; Health Policy; Health Services Accessibility; Humans; Male; Mental Disorders; Methadone; Netherlands; Opiate Substitution Treatment; Opioid-Related Disorders; Practice Guidelines as Topic; Pregnancy; Pregnancy Complications; Prisoners

This paper is adapted from the American Association of Psychiatric Administrators Annual Membership Luncheon Speech given at the meeting of the American Psychiatric Association in Toronto, Canada on May 23, 2006. The author discusses three experiences from his work for the New York City Department of Health and Mental Hygiene to illustrate how psychiatrists working as administrators are uniquely able to meet community mental health and substance misuse needs. The author describes public health interventions employed by psychiatric administrators to reduce morbidity and mortality from opioid and methamphetamine misuse.

Topics: Buprenorphine; Drug Overdose; Health Services Needs and Demand; Humans; Mental Disorders; Mental Health Services; Narcotic Antagonists; New York City; Physician Executives; Psychiatry; Public Health Administration; Substance-Related Disorders; United States; Workforce

The purpose of this study was to investigate the effects of methadone treatment and buprenorphine treatment on retention in treatment, urine drug testing results, psychiatric status, social adjustment, and quality of life among patients involved in long-term treatment with the cited medications. Two hundred thirteen patients (106 on buprenorphine treatment and 107 on methadone treatment) were enrolled in this open study at the 3rd month of their treatment and followed up until the 12th month; those who left the program before the end of the 3rd month of their treatment were not included in the study sample. The results of this study show statistically significant improvements in opioid use, psychiatric status, and quality of life between the 3rd and 12th months for both medications. This study suggests the long-term efficacy of methadone treatment and buprenorphine treatment on symptoms of opioid addiction and quality of life.

Topics: Adult; Buprenorphine; Cohort Studies; Comorbidity; Diagnosis, Dual (Psychiatry); Female; Follow-Up Studies; Heroin Dependence; Humans; Illicit Drugs; Italy; Male; Mental Disorders; Methadone; Narcotics; Patient Dropouts; Program Evaluation; Prospective Studies; Quality of Life; Substance Abuse Detection; Substance-Related Disorders

Buprenorphine is an efficacious treatment for opioid dependence recently approved for office-based medical practice. The purpose of the study was to describe the background characteristics, treatment process, outcomes and correlates of outcomes for patients receiving buprenorphine maintenance in "real world" office-based settings in New York City, without employing the many patient exclusion criteria characterizing clinical research studies of buprenorphine, including absence of co-occurring psychiatric and non-opioid substance use disorders. A convenience sample of six physicians completed anonymous chart abstraction forms for all patients who began buprenorphine induction or who transferred to these practices during 2003-2005 (N = 86). The endpoint was the patient's current status or status at discharge from the index practice, presented in an intent-to-treat analysis. The results were: male (74%); median age (38 yrs); White, non-Hispanic (82%); employed full-time, (58%); HCV+ (15%); substance use at intake: prescription opioids (50%), heroin (35%), non-opioids (49%); median length of treatment (8 months); median maintenance dose (15 mg/day); prescribed psychiatric medication (63%). The most frequent psychiatric disorders were: major depression, obsessive-compulsive and other anxiety, bipolar. At the endpoint: retained in the index practice (55%); transferred to other buprenorphine practice (6%); transferred to other treatment (7%); lost to contact or out of any treatment (32%). Outcomes were positive, in that 2/3 of patients remained in the index practice or transferred to other treatment. Patients living in their own home or misusing prescription opioids (rather than heroin) were more likely, and those employed part-time were less likely, to be retained in the index practice. At the endpoint, 24% of patients were misusing drugs or alcohol. Co-occurring psychiatric disorders and polysubstance abuse at intake were common, but received clinical attention, which may explain why their effect on outcomes was minimal.

Topics: Adolescent; Adult; Ambulatory Care; Buprenorphine; Comorbidity; Diagnosis, Dual (Psychiatry); Female; Humans; Male; Mental Disorders; Middle Aged; Narcotics; New York City; Opioid-Related Disorders; Private Practice

To determine 1 year outcomes for drug use, criminality, psychopathology and injection-related health problems in those entering treatment for heroin dependence in Australia.. Longitudinal prospective cohort study.. Seven hundred and forty five individuals entering treatment (methadone/buprenorphine maintenance therapy; detoxification; residential rehabilitation) and 80 heroin users not seeking treatment.. Sydney, Melbourne and Adelaide, Australia.. A total of 657 individuals were re-interviewed at 1 year, 80% of the original sample. There were substantial reductions in heroin and other drug use across all three treatment modalities. The majority of those who had entered treatment were heroin abstinent at 1 year (maintenance therapy 65%, detoxification 52%, residential rehabilitation 63%) compared to 25% of the non-treatment sample. The reduction in heroin use among the treatment samples was paralleled by reductions in poly drug use. There were also substantial reductions in risk-taking, crime and injection-related health problems across all treatment groups, and less marked reductions among the non-treatment group. Psychopathology was dramatically reduced among the treatment modalities, while remaining stable among the non-treatment group. Positive outcomes at 1 year were associated with a greater number of cumulative treatment days experienced over the 1 year follow-up period ('treatment dose') and fewer treatment episodes undertaken in that time ('treatment stability').. At 1 year, there were impressive reductions in drug use, criminality, psychopathology and injection-related health problems following treatment exposure. The positive findings were associated with a greater "dose" of treatment, and with more treatment stability over the follow-up period.

Topics: Adolescent; Adult; Australia; Buprenorphine; Crime; Female; Heroin Dependence; Humans; Inactivation, Metabolic; Interviews as Topic; Male; Mental Disorders; Middle Aged; Narcotics; Prevalence; Prospective Studies; Risk-Taking; Time Factors; Treatment Outcome

Present the evolution in the characteristics of drug addicts treated in the Addictions-Sud centre (Marseille) between 1996 and 2001, and compare the profile of patients according to the substitution therapy prescribed.. Descriptive analysis of the data collected from the inclusion questionnaire of patients seen during a hospital consultation in the centre and registered in a substitution program (n = 585 patients).. In our active file, the use of heroin and injections has decreased since 1996, whereas the consumption of cocaine and above all amphetamines and LSD has greatly increased. When treated, 60% of the patients were administered methadone and 40% BHD. (The patients included in the methadone program (n = 348) were considerably older and frequently HIV or hepatitis C-infected than those treated with BHD (n = 229)). The proportion of patients who had previously undertaken withdrawal or substitution measures, and who continued to inject drugs, was greater in the group of patients in the methadone program. The presence of depression, psychotic disorders and anxiety was noted respectively in 46, 30 and 24% of the patients treated.. Today, it is crucial that information on the treatment of drug addicts should be reinforced, so as to measure the progression of the problems encountered, specify the indications of the two substitution products currently prescribed and understand the impact they have on the psychiatric disorders and viral pathologies frequently noted in drug addicts.

Topics: Adult; Age Distribution; Buprenorphine; Cohort Studies; Drug Overdose; Female; France; Hallucinogens; Hepatitis C; HIV Infections; Hospitals, University; Humans; Lysergic Acid Diethylamide; Male; Mental Disorders; Methadone; Narcotic Antagonists; Narcotics; Public Assistance; Substance-Related Disorders; Suicide, Attempted; Surveys and Questionnaires

Topics: Buprenorphine; Clinical Trials as Topic; Comorbidity; Humans; Mental Disorders; Meta-Analysis as Topic; Methadone; Narcotics; Opioid-Related Disorders; Physicians, Family; Research Design; Treatment Outcome

Topics: Acquired Immunodeficiency Syndrome; Adult; Buprenorphine; France; HIV Infections; HIV Seropositivity; Humans; Mental Disorders; Methadone; Morphine; Paris; Substance-Related Disorders; Time Factors