Addiction Science & Clinical Practice最新文献

Objectives: Among individuals with opioid use disorder using fentanyl, standard initial doses (2-4 mg) of buprenorphine may precipitate withdrawal, often preventing successful induction. Rapid low-dose induction is an emerging approach designed to mitigate this risk. This study describes a simplified rapid low-dose buprenorphine induction protocol in facilitating treatment initiation among patients presenting to an outpatient clinic.

Methods: This case series includes chart review data from nine patients with opioid use disorder treated at an outpatient substance use clinic who were initiated on buprenorphine-naloxone maintenance therapy. All had recent fentanyl use confirmed by UDS. Patients were instructed to follow a simplified induction protocol consisting of 1 mg of buprenorphine-naloxone, via 1/8th of an 8 - 2 mg sublingual film, administered at home hourly for 8 h, followed by maintenance dosing of 8 mg twice daily. Patients were advised to wait at least 24 h since last fentanyl use prior to initiating the induction protocol. Successful induction was defined as being on maintenance treatment at a follow-up appointment one week later.

Results: Of the nine patients who began the rapid low-dose induction protocol, seven successfully transitioned to buprenorphine-naloxone maintenance by the 7-day follow-up. Two patients did not return for follow-up.

Conclusion: In this case series, the simplified rapid low-dose buprenorphine induction protocol was well-tolerated and 77.8% of patients using fentanyl were able to successfully initiate buprenorphine-naloxone maintenance. Benefits of this protocol are use of a single, standard dose of buprenorphine-naloxone, rapid induction timeline over only 8 h, and simple patient instructions.

Background: Standard medications for opioid use disorder (MOUD) provide effective treatment pathways for recovery compared with no treatment or behavioral therapies alone. That said, people who continue to use non-prescribed opioids despite treatment with MOUD are at greater risk for high attrition and OUD-related harms. Novel, more effective approaches are needed for the treatment of OUD. To that end, glucagon-like peptide-1 receptor agonists (GLP-1RAs) provide a promising option as a non-opioid pharmacological intervention for OUD. Observational studies suggest that GLP-1RAs decrease craving measures in a residential OUD population but no controlled clinical trials have been conducted to determine if GLP-1RAs increase opioid abstinence and reduce craving in individuals with OUD in an outpatient population. The purpose of the current protocol is to evaluate the potential for the GLP-1RA, semaglutide, to increase abstinence and reduce craving in an outpatient population enrolled in a MOUD program and continue to use non-prescribed opioids.

Method: This protocol is a randomized, double-blind, placebo-controlled clinical trial designed to test the efficacy of the GLP-1RA, semaglutide, in 200 participants enrolled in an outpatient MOUD program (n = 100 buprenorphine; n = 100 methadone) for the treatment of OUD. Outcomes include the probability of participants being abstinent from illicit and nonprescribed opioids, as well as measures of craving and days of drug use. Measures will be evaluated using urine toxicology screens and self-report assessments across 19 weeks during a screening visit (Study Week 1), 12 treatment visits (Study Weeks 2-13), a washout visit (Study Week 14), and a final follow-up visit (Study Week 19).

Discussion: This manuscript describes a phase II clinical protocol to collect data on the efficacy of a GLP-1RA, semaglutide, in persons enrolled in an MOUD program and with ongoing non-prescribed opioid use despite treatment with methadone or buprenorphine. Completion of the current project will support the feasibility of phase III clinical trials for further evaluation in larger outpatient OUD populations that may lead to a new indication for GLP-1RA as a novel and effective treatment for OUD.

Trial registration: ClinicalTrials.gov: NCT06548490. Registered 12 August 2024, https://clinicaltrials.gov/study/NCT06548490 .

Context/background: The high prevalence of opioid use among jailed adults offers an unmatched opportunity to identify and treat those with opioid use disorder (OUD), a population that is at a substantial risk for post-release overdose. From a public health perspective, jails are critical touchpoints, as these facilities typically admit more than 7 million adults per year. One clinical consideration is whether pre-trial detainees with OUD would benefit from early induction onto extended-release buprenorphine (XRB).

Methods/study design: In this 3-year randomized controlled trial, we will identify and recruit 200 incarcerated adults with OUD who are receiving sublingual buprenorphine (SLB) or tolerate a SLB test dose and randomize them to receive extended release buprenorphine (XRB) (n = 100) or to remain on SLB (n = 100) while in custody. Study participation will continue through their pre-trial time in jail (up to 6 months) or until they are sentenced or released. Community treatment will then be tracked for 90 days following release. In addition to collecting data on XRB uptake in jail, we will assess (1) the percentage of XRB and SLB study participants leaving jail with a clinically active dose of buprenorphine in their system, (2) 90- day post-release MOUD continuation, (3) levels of buprenorphine diversion while in custody, and (4) recidivism and death (90 days). "Clinically active" is defined as receiving XRB within the past 28 days or SLB in the past 24 h.

Discussion: Findings from this study will demonstrate the feasibility and outcomes of inducting pre-trial adults with OUD onto XRB, as well as offer practical clinical and policy guidelines for best practices for treating this high risk and understudied population.

Background: Rural states have experienced increasing injection drug use (IDU)-associated infective endocarditis (IE). Inpatient addiction consult services can reduce morbidity associated with substance use and other infectious complications, such as IDU-IE. However data on the impact of such services on healthcare utilization are limited, particularly in rural communities.

Methods: This retrospective study assesses clinical and health service utilization data from index hospitalizations for IDU-IE before and after the implementation of the Integrated Medication for Addiction Treatment (IMAT) program at a tertiary care center in a rural state. We summarized data descriptively, stratified by both pre- and post-IMAT program implementation and IDU-IE and non-IDU IE. We also performed exploratory multivariable analyses assessing the association between IMAT program implementation and various outcomes. The primary outcomes were: 1) 90-day emergency department (ED) visits and 2) 30-day hospital readmissions post-discharge. Secondary outcomes included prescriptions at time of discharge for medication for opioid use disorder (MOUD), naloxone and key vaccinations.

Results: We identified n = 99 patients with IDU-IE. Comparing pre- and post-IMAT implementation, 30-day readmissions trended lower post-IMAT (18%) versus pre-IMAT (22%), although the difference was not significant (p = 0.7). 90-day ED visits remained stable (37%, p > 0.9). The proportion of MOUD prescribing (24% versus 80%), hepatitis B vaccination (29% versus 51%), and Tdap vaccination (7.3% versus 41%) increased significantly following IMAT implementation (p < 0.001, p = 0.037 and p < 0.001, respectively). In a regression analysis controlling for age, housing status, primary care provider, age, hepatitis C, cardiac device, Duke's criteria, valve affected, alcohol use disorder, payer, and vascular or infectious complications, the IMAT program was not significantly associated with the primary outcomes or with hepatitis B vaccination. However, the IMAT program was associated with increased MOUD prescribing (aOR: 110; CI:16-1500), naloxone prescribing (aOR 18; CI: 1.1-1600) hepatitis A vaccination (aOR: 5.3; CI: 1.2-32), and Tdap vaccination (aOR: 9.2; CI: 2.0-59).

Conclusions: Inpatient addiction services were associated with increased prescribing of MOUD, naloxone and key vaccinations, though the incidence of acute healthcare utilization did not change. These results highlight hospitalization as an opportunity to connect patients with IDU-IE to MOUD and preventative care, particularly in rural areas where access to such services may be limited.

Trial registration: Not applicable.

Introduction: American Indian and Alaska Native individuals are disproportionately impacted by the opioid epidemic, partially due to structural racism. Tribal nations and communities are finding innovative ways to provide opioid use disorder (OUD) treatment, but barriers to medications for opioid use disorder (MOUD) remain. This study surveyed Indigenous clients at a Syringe Services Program about barriers and facilitators to OUD treatment.

Methods: Interviews were conducted with 27 Indigenous individuals who had used opioids in the past month and were receiving opioid harm reduction services from a tribally-run Anishinaabe Syringe Services Program (rural Minnesota). Participants were asked five questions in interview style format about their experiences with opioid use disorder care with a focus on barriers and facilitators. The coding team analyzed interviews utilizing the Collaborative Story Analysis method to highlight overall impressions of participants' narratives.

Results: There were 27 participants: 48% male and 52% female. The main themes of barriers and facilitators were connection to others, flexibility of treatment services, and ensuring individual needs were met. Having a positive relationship with providers (e.g. non-judgmental), access to MOUD and Harm Reduction services, and minimizing assessment requirements prior to starting treatment were some of the most frequently identified facilitators to care. Lack of transportation, prioritizing care for others, and turbulent relationships with providers and certain aspects of care services were identified as barriers.

Conclusions: Study participants cited clear barriers and facilitators to accessing OUD treatment in a rural Anishinaabe Tribal Nation in Minnesota. The Tribal Nation has already implemented several strategies to improve access to MOUD care (e.g., hiring additional drivers to help with transportation, facilitating immediate MOUD care prior to an intake, if needed, and giving take home MOUD doses). Tailoring services to address identified barriers and leverage facilitators of connection and flexibility will enhance care.