Journal of opioid management最新文献

Background: Methadone is increasingly being used as a pharmacological agent in treating opioid use disorder (OUD). However, reports of illicit overuse of methadone have resulted in fatal consequences, mainly in those under methadone maintenance treatment (MMT). Considering the high prevalence of opioid addiction in Kerman, the present study was conducted to investigate methadone-related deaths in this province.

Methods: A descriptive cross-sectional study was performed on mortality cases caused by methadone use referred to the Forensic Medicine Organization of the Kerman Province in 2020 and 2021. The demographic data as well as concurrent abused substances were extracted from records.

Results: A total of 370 methadone-related deaths were registered, of which 45.7 percent were related to 2020, and 54.3 percent were related to 2021. Most cases had been referred to Kerman (65.9 percent), Sirjan (16.8 percent), Rafsanjan (6.2 percent), and Zarand (3.2 percent) forensic medicine centers. Of the deceased, 75.9 percent were men. The average age of the deceased was 33.37 ± 12.83 years, ranging from 6 days to 72 years. The majority of the cases had low levels of education. In 4.1 percent of the cases, simultaneous use of methadone and tramadol was reported, while 7.6 percent of the cases had simultaneous use of stimulants/hallucinogens, and 3.6 percent had simultaneous use of alcohol.

Conclusion: Taken together, considering the high frequency of methadone-related deaths in the Kerman Province as well as the low level of socio-economic status in the deceased, designing interventions to enhance the awareness of addicts, especially those who are undergoing MMT programs, could potentially reduce the incidence of methadone poisoning.

Objective: The Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care (6BBs) program provides a roadmap for improving the management of patients on opioid therapy for chronic pain. The goal of this project was to evaluate the How-to-Implement Toolkit (Toolkit) for clinics to independently implement the 6BBs without a practice facilitator.

Methods: Eight healthcare organizations with 62 clinics participated in the program. We conducted interviews and surveys with clinical staff. A mixed-methods synthesis was conducted, incorporating themes from qualitative data and descriptive analysis of survey data.

Results: We found that healthcare organizations appreciated the resources in the Toolkit but wanted the support of a practice facilitator. Organizations reported limited use of the Toolkit in its entirety but found individual tools useful.

Conclusions: The results point to the importance of support in implementing opioid quality improvement projects in primary care. The Toolkit and other 6BBs resources are available on the Agency for Healthcare Research and Quality website.

Objective: To investigate the potential impact of implementing alternatives to opioids (ALTOs) protocol in a community emergency department (ED) in North Texas. We hypothesize that the ALTO protocol is associated with decreased opioid utilization without affecting patient satisfaction to pain control and ED flow.

Design: A retrospective, single-center, cohort study.

Setting: An urban ED.

Participants: Adult patients (age >18 years old) who received pain medications in ED during the study timeframe were included. A total of 34,251 patients were included for final analysis.

Intervention: Patients receiving pain medication after the implementation of the ALTO protocol during March to August 2019 and patients during the same period from the prior year were identified as the post-protocol group and preprotocol group, respectively.

Main outcome measures: The primary outcome was the change in ED opioid administration. Secondary outcomes included patient satisfaction to pain control, left without being seen (LWOBS), door-to-doctor time, and turnaround time.

Results: The total opioid administration rate decreased by 59.6 percent after the implementation of the ALTO protocol. The percentage of patients that LWOBS (p = 0.003) and the average door-to-doctor time (p < 0.001) were significantly decreased in the post-protocol group. There was no significant difference in patient satisfaction to pain control (p = 0.192) and average turnaround time (p = 0.209).

Conclusions: Implementation of an ALTO protocol was associated with a significant reduction of opioid administration without a negative impact on patient satisfaction regarding pain control and ED flow.

We present data showing that the urinary metabolic ratio (MR) of metabolite to parent drug can be used to estimate the drug-drug interactions (DDIs) of pain management and substance abuse treatment medications with other coadministered drugs. We quantitatively measure 18 drugs and their phase I metabolites and monitor the effects of 14 interfering drugs on their MRs. The 18 drugs include dextromethorphan, oxycodone, hydrocodone, tramadol, morphine, buprenorphine, fentanyl, clonazepam, alprazolam, quetiapine, carisoprodol, tapentadol, ketamine, methadone, impramine, and amitriptyline. The 14 interfering drugs include fluoxetine, paroxetine, bupropion, citalopram, sertraline, venlafaxine, duloxetine, risperidone, trazodone, aripiprazole, cyclobenzaprine, amphetamine, and tetrahydrocannabinol. Some of these interfering drugs are inhibitors of either the CYP2D6, CYP3A4/5, or CYP2C19 pathways. By using the urinary MR of metabolite/parent drug, we observed patterns of inhibition and enhancement due to DDIs. Using the MR reference intervals of the 18 drug pairs established in an earlier study, and the current DDI system, we can alert providers of unusual metabolism caused by DDIs. This will help providers do better prescribing or review more closely all medications and supplements patients are taking, thus avoiding underdosing or potential medication adverse reactions.

We present data that show that quantitative urine drug concentrations obtained from individuals monitored for drug compliance as part of their participation in chronic opioid or substance abuse treatment can be used to quantify drug metabolism. We quantitatively monitor 18 drugs and their Phase 1 metabolite. These drugs were dextromethorphan, morphine, oxycodone, hydrocodone, quetiapine, tapentadol, tramadol, buprenorphine, clonazepam, fentanyl, imipramine, ketamine, carisoprodol, alprazolam, methadone, and amitriptyline. By using the ratio of metabolite/parent drug (prescribed medication), the expected or reference values for 18 drugs were obtained. Ratio values outside of this reference range could be considered to be caused by genetic metabolizing variants, drug-drug interactions, age, or deception. Alerting providers of the variance in metabolism from the expected norm might reduce overdosing or underdosing patients.

Objective: Methadone may cause detrimental side effects such as corrected QT (QTc) prolongation. However, methadone may be desirable in patients with advanced cancer and those with heart disease who have intractable pain. Therefore, we aimed to evaluate the safety and efficacy of initiating methadone for cancer pain in patients at high risk of methadone-induced QTc prolongation.

Design: A retrospective cohort study.

Setting: Single center.

Patients: Sixty-four patients with cancer who started oral methadone to relieve pain and underwent 12-lead electrocardiogram monitoring at baseline and 1-2 weeks after initiation of methadone therapy from January 1, 2013, to March 31, 2022, were enrolled.

Main outcome measures: The primary endpoints were the change in QTc from baseline after oral methadone therapy and the difference in methadone doses between the high- and low-risk groups for methadone-induced QTc prolongation.

Results: None of the patients developed clinically significant methadone-induced QTc prolongation or any adverse events attributable to cardiotoxicity, although 32 patients (50.0 percent) had heart disease or prolonged QTc before oral methadone initiation. Moreover, the high-risk group received a lower dose of opioid analgesics prior to methadone administration. For this reason, they started with a lower methadone dose than the low-risk group.

Conclusions: Even in patients with heart disease or prolonged QTc at baseline, methadone may be safely administered by initiating low-dose methadone when the dose of other opioids is low and by adjusting the concomitant medications that can interact with methadone.

Objective: Create a standardized protocol document on how to convert patients from full opioid agonist to buprenorphine. Providing patients with the best possible chance of a seamless conversion resulting in decreased risk of failure of therapy with buprenorphine.

Methods: A 10-question survey was distributed to better understand the different aspects the providers consider when converting a patient from full opioid agonist to buprenorphine. A medication use evaluation was completed utilizing a retrospective qualitative design to identify all patients who had a new prescription for any buprenorphine product from a chronic pain provider to establish patterns of current practice. This information, in conjunction with guidance from current literature and medication package inserts, was used to create a protocol for buprenorphine induction. Providers were educated on buprenorphine prior to guidance document implementation.

Results: A five-page guidance document on how to convert patients from full opioid agonist to buprenorphine was created for providers within the chronic pain clinic. The document includes recommendations on which patients are candidates for buprenorphine versus those who are not. The document also provides a three-step process to successfully perform a conversion including which buprenorphine product and induction technique to utilize. Definitions of each induction technique along with examples are provided within the document. Recommendation for converting between buprenorphine patch and films are also listed within the document.

Discussion: The five-page guidance document was successfully implemented in June 2024, supplying pain providers with all the knowledge necessary to convert patients comfortably, thus providing patients with the best possible chance of a seamless conversion and decreasing risk of failure of conversion to buprenorphine due to inadequate induction technique.

Opioid Use Disorder (OUD) poses a significant public health challenge globally, with an estimated 23 million opioid users in India. Opioid Agonist Therapy (OAT) stands as the cornerstone of treatment, offering potential reductions in morbidity, societal burdens, and improvements in patient quality of life. However, OAT coverage remains fairly low in India, with clinical guidelines lacking comprehensive information on implementation pragmatics. This viewpoint delves into the nuanced challenges faced by clinicians in the daily operations of OAT emphasizing disciplinary issues, practical responses, and the broader implications for treatment outcomes and public perception. The treatment provider's response is explored from different aspects like learning theory, attitude, psychodynamic interactions, and ethics. Understanding patient perspectives, including employment demands and perceptions of fairness, is crucial in tailoring responses and optimizing treatment engagement. While disciplinary measures are integral to maintaining treatment sanctity, their effectiveness must be balanced with patient autonomy and harm reduction goals. The discourse surrounding OAT disciplinary measures necessitates a multifaceted approach, integrating evidence-based practices, clinician experiences, patient rights, and administrative considerations to ensure equitable and effective treatment provision.

Introduction: Chronic pain is a leading cause of chronic disease in Australia, with a 2020 report indicating that one in five Australians aged over 45 experience chronic pain. The high prevalence of chronic pain accounts for significant healthcare utilization and associated costs, with the economic impact of chronic pain estimated to be AUD$139 billion in 2018.

Case presentations: This paper uses two exemplar cases to demonstrate inadequacies within the current systems supporting those with chronic pain and the associated impacts these inadequacies have on patient outcomes and healthcare costs.

Management and outcome: An analysis of these cases demonstrated a combined healthcare cost of AUD$312,705 throughout their inpatient admissions, with no apparent benefit to either patient's pain experience.

Discussion and conclusion: These cases highlight a multitude of opportunities to improve current pain management systems and their detrimental effects on patient well-being, healthcare utilization, and associated costs. Despite massive expenditures for the management of chronic pain, patients often continue to experience ongoing pain and reduced quality of life. This indicates that the available funds could be better utilized through reallocation to support a proactive, biopsychosocial model of care for the prevention and management of chronic pain.

Objective: To deploy an algorithm using medical and pharmacy claims data to identify members of a managed care organization at risk for opioid misuse and provide outreach.

Methods: A retrospective review of 2019 enrollment information and prescription and medical claims data identified members aged 18-64 years with medical and pharmacy benefits and at least one paid pharmacy claim for an opioid. The most recent paid prescription claim served as the index date for each patient. Members with cancer or sickle cell disorder, receiving palliative/hospice care, or nursing home residents were excluded. Diagnoses were obtained for 12 months prior to the index date, while medication use was assessed within 6 months prior to the index date. Clinical characteristics were used to stratify members by risk of opioid misuse into risk-based cohorts.

Results: There were 62,986 adult members with medical and pharmacy benefits receiving at least one scheduled (II, III, or IV) opioid during 2019. In this group, the average age was 43.3 years (±13.0), with 56 percent being female. More frequent diagnoses included low back pain (13.2 percent) and anxiety disorder (12.4 percent). About 10.3 percent of the group (n = 6,486 members) were assigned to one or more at-risk cohorts. Out of a total outreach attempt for 804 members, 45 percent had successful engagement. Of those members engaged, 39.8 percent declined any support services offered.

Conclusion: An evidence-based algorithm found 10.3 percent of members at higher risk of opioid misuse. Interventions for targeted members reached fewer than half, and many declined assistance. Health plans need more effective intervention strategies.