text:
Entry into primary care-based buprenorphine treatment is associated with identification and treatment of other chronic medical problems
Background Buprenorphine is an effective treatment for opioid dependence that can be provided in a primary care setting. Offering this treatment may also facilitate the identification and treatment of other chronic medical conditions. Methods We retrospectively reviewed the medical records of 168 patients who presented to a primary care clinic for treatment of opioid dependence and who received a prescription for sublingual buprenorphine within a month of their initial visit. Results Of the 168 new patients, 122 (73%) did not report having an established primary care provider at the time of the initial visit. One hundred and twenty-five patients (74%) reported at least one established chronic condition at the initial visit. Of the 215 established diagnoses documented on the initial visit, 146 (68%) were not being actively treated; treatment was initiated for 70 (48%) of these within one year. At least one new chronic medical condition was identified in 47 patients (28%) during the first four months of their care. Treatment was initiated for 39 of the 54 new diagnoses (72%) within the first year. Conclusions Offering treatment for opioid dependence with buprenorphine in a primary care practice is associated with the identification and treatment of other chronic medical conditions.
Opioid Addiction and Abuse in Primary Care Practice: A Comparison of Methadone and Buprenorphine as Treatment Options
Opioid abuse and addiction have increased in frequency in the United States over the past 20 years. In 2009, an estimated 5.3 million persons used opioid medications nonmedically within the past month, 200 000 used heroin, and approximately 9.6% of African Americans used an illicit drug. Racial and ethnic minorities experience disparities in availability and access to mental health care, including substance use disorders. Primary care practitioners are often called upon to differentiate between appropriate, medically indicated opioid use in pain management vs inappropriate abuse or addiction. Racial and ethnic minority populations tend to favor primary care treatment settings over specialty mental health settings. Recent therapeutic advances allow patients requiring specialized treatment for opioid abuse and addiction to be managed in primary care settings. The Drug Addiction Treatment Act of 2000 enables qualified physicians with readily available short-term training to treat opioid-dependent patients with buprenorphine in an office-based setting, potentially making primary care physicians active partners in the diagnosis and treatment of opioid use disorders. Methadone and buprenorphine are effective opioid replacement agents for maintenance and/or detoxification of opioid-addicted individuals. However, restrictive federal regulations and stigmatization of opioid addiction and treatment have limited the availability of methadone. The opioid partial agonist-antagonist buprenorphine/naloxone combination has proven an effective alternative. This article reviews the literature on differences between buprenorphine and methadone regarding availability, efficacy, safety, side-effects, and dosing, identifying resources for enhancing the effectiveness of medication-assisted recovery through coordination with behavioral/psychological counseling, embedded in the context of recovery-oriented systems of care.
Bonhomme, Jean; Shim, Ruth S.; Gooden, Richard; Tyus, Dawn; Rust, George
Home Buprenorphine/Naloxone Induction in Primary Care
ABSTRACT BACKGROUND Buprenorphine can be used for the treatment of opioid dependence in primary care settings. National guidelines recommend directly observed initial dosing followed by multiple in-clinic visits during the induction week. We offered buprenorphine treatment at a public hospital primary care clinic using a home, unobserved induction protocol. METHODS Participants were opioid-dependent adults eligible for office-based buprenorphine treatment. The initial physician visit included assessment, education, induction telephone support instructions, an illustrated home induction pamphlet, and a 1-week buprenorphine/naloxone prescription. Patients initiated dosing off-site at a later time. Follow-up with urine toxicology testing occurred at day 7 and thereafter at varying intervals. Primary outcomes were treatment status at week 1 and induction-related events: severe precipitated withdrawal, other buprenorphine-prompted withdrawal symptoms, prolonged unrelieved withdrawal, and serious adverse events (SAEs). RESULTS Patients (N?=?103) were predominantly heroin users (68%), but also prescription opioid misusers (18%) and methadone maintenance patients (14%). At the end of week 1, 73% were retained, 17% provided induction data but did not return to the clinic, and 11% were lost to follow-up with no induction data available. No cases of severe precipitated withdrawal and no SAEs were observed. Five cases (5%) of mild-to-moderate buprenorphine-prompted withdrawal and eight cases of prolonged unrelieved withdrawal symptoms (8% overall, 21% of methadone-to-buprenorphine inductions) were reported. Buprenorphine-prompted withdrawal and prolonged unrelieved withdrawal symptoms were not associated with treatment status at week 1. CONCLUSIONS Home buprenorphine induction was feasible and appeared safe. Induction complications occurred at expected rates and were not associated with short-term treatment drop-out. Electronic supplementary material The online version of this article (doi:10.1007/s11606-008-0866-8) contains supplementary material, which is available to authorized users.
Grossman, Ellie; DiRocco, Danae; Gourevitch, Marc N.
A Urinalysis-based Comparative Study of Treatment Adherence on Buprenorphine and Buprenorphine/Naloxone Combination Used as Opioid Substitution Therapy
Objective: The objective of the current study was to explore the difference in treatment adherence to directly supervised buprenorphine and take-home buprenorphine/ naloxone combination for opioid substitution therapy. Urinalysis findings have been used to check treatment adherence on opioid substitution therapy agent. Additionally the study aimed to explore the misuse rate of buprenorphine/naloxone combination based on urinalysis findings. Design: Cross-sectional chart review Setting: Laboratory of a tertiary care drug dependence treatment center Participants: One-year laboratory urinalysis records of a tertiary care, drug-dependence treatment center in India were analyzed. All the urine samples of subjects on opioid substitution therapy with buprenorphine or buprenorphine/naloxone combination were included in the study. Measurements: Urinalysis using thin layer chromatography for buprenorphine and naloxone. In between group difference for treatment adherence on buprenorphine and buprenorphine/ naloxone combination was done using Mantel-Haenszel test. Results: A higher proportion of samples from subjects on buprenorphine/naloxone tested positive for buprenorphine as compared to subjects on buprenorphine. Twelve (7.6%) urine samples from patients on buprenorphine/naloxone tested positive for naloxone. Conclusions: The findings of the current study suggest that buprenorphine/naloxone combination has a higher adherence rate as compared to buprenorphine when used for opioid substitution therapy.
Jain, Raka
Buprenorphine in the Treatment of Opiate Dependence
Compelling clinical evidence establishes that buprenorphine is similar to methadone in efficacy for opiate detoxification and maintenance but safer than methadone in an overdose situation. The Drug Abuse Treatment Act of 2000 (DATA 2000) enabled US physicians with additional training to prescribe buprenorphine to a limited number of opiate-dependent patients. The sublingual tablets Subutex� (buprenorphine alone) and Suboxone� (a combination
Donald R. Wesson; David E. Smith
Emerging adult age status predicts poor buprenorphine treatment retention.
Emerging adults (18-25years old) are often poorly retained in substance use disorder treatment. Office-based buprenorphine often enhances treatment retention among people with opioid dependence. In this study, we examined the records of a collaborative care buprenorphine treatment program to compare the treatment retention rates of emerging adults versus older adults. Subjects were 294 adults, 71 (24%) aged 18-25, followed in treatment with buprenorphine, nurse care management, and an intensive outpatient program followed by weekly psychosocial treatment. Compared to older adults, emerging adults remained in treatment at a significantly lower rate at 3months (56% versus 78%) and 12months (17% versus 45%), and were significantly more likely to test positive for illicit opioids, relapse, or drop out of treatment. Further research into factors associated with buprenorphine treatment retention among emerging adults is needed to improve treatment and long-term outcomes in this group. PMID:24953168
Schuman-Olivier, Zev; Weiss, Roger D; Hoeppner, Bettina B; Borodovsky, Jacob; Albanese, Mark J
Buprenorphine: An Alternative Treatment for Opioid Dependence.
National Technical Information Service (NTIS)
The publication discusses the metabolism and kinetics, clinical efficacy and safety, behavioral pharmacology, and effects in animals and humans of buprenorphine, an alternative treatment for opioid dependence.
J. D. Blaine
Models for Integrating Buprenorphine Therapy into the Primary HIV Care Setting
Opiate dependence among human immunodeficiency virus (HIV)-infected patients has been associated with negative clinical outcomes, yet few affected patients receive appropriate and coordinated treatment for both conditions. The introduction of buprenorphine maintenance therapy into HIV care settings provides an opportunity for providers to integrate treatment for opiate dependence into their practices. Buprenorphine maintenance therapy has been associated with reductions in
Sanjay Basu; R. Douglas Bruce; Frederick L. Altice
Determinants of buprenorphine treatment for opioid dependence.
This study assessed the social, demographic and clinical determinants of whether an opioid-dependent patient received buprenorphine versus an alternative therapy. A retrospective cohort analysis of opioid-dependent adults enrolled in Group Health Cooperative between January 1, 2006 and December 1, 2010 was performed. Increasing the number of physicians with DATA waivers in a region and living in a relatively-populated area increased the likelihood of being treated with buprenorphine, indicating that lack of access is a potential barrier. Comorbidity also appeared to be a factor in receipt of treatment, with the effect varying by diagnosis. Finally, patients with an insurance plan allowing health services to be sought from any provider, with increased cost sharing, were significantly more likely to receive buprenorphine, implying that patient demand is a factor. Programs integrating patient education, physician training, and support from addiction specialists would be likely facilitators of increasing access to this cost-effective treatment. PMID:24209382
Murphy, Sean M; Fishman, Paul A; McPherson, Sterling; Dyck, Dennis G; Roll, John R
The Physician Clinical Support System-Buprenorphine (PCSS-B): a novel project to expand/improve buprenorphine treatment.
Opioid dependence is largely an undertreated medical condition in the United States. The introduction of buprenorphine has created the potential to expand access to and use of opioid agonist treatment in generalist settings. Physicians, however, often have limited training and experience providing this type of care. Some physicians believe having a mentoring relationship with an experienced provider during their initial introduction to the use of buprenorphine would ease implementation. Our goal was to describe the development, implementation, resources, and evaluation of the Physician Clinical Support System-Buprenorphine (PCSS-B), a federally funded program to improve access to and quality of treatment with buprenorphine. We provide a description of the PCSS-B, a national network of 88 trained physician mentors with expertise in buprenorphine treatment and skills in clinical education. We provide information regarding the use the PCSS-B core services including telephone, email and in-person support, a website, clinical guidances, a warmline and outreach to primary care and specialty organizations. Between July 2005 and July 2009, 67 mentors and 4 clinical experts reported providing mentoring services to 632 participants in 48 states, Washington DC and Puerto Rico. A total of 1,455 contacts were provided through email (45%), telephone (34%) and in-person visits (20%). Seventy-six percent of contacts addressed a clinical issue. Eighteen percent of contacts addressed a logistical issue. The number of contacts per participant ranged from 1-125. Between August 2005 and April 2009 there were 72,822 visits to the PCSS-B website with 179,678 pages viewed. Seven guidances were downloaded more than 1000 times. The warmline averaged more than 100 calls per month. The PCSS-B model provides support for a mentorship program to assist non-specialty physicians in the provision of buprenorphine and may serve as a model for dissemination of other types of care. PMID:20458550
Egan, James E; Casadonte, Paul; Gartenmann, Tracy; Martin, Judith; McCance-Katz, Elinore F; Netherland, Julie; Renner, John A; Weiss, Linda; Saxon, Andrew J; Fiellin, David A
Smoking cessation treatment among office-based buprenorphine treatment patients.
Opioid-dependent patients smoke at high rates, and office-based buprenorphine treatment provides an opportunity to offer cessation treatment. We examined tobacco use and smoking cessation treatment patterns among office-based buprenorphine treatment patients. We reviewed records of 319 patients treated with buprenorphine from 2005 to 2010. We examined smoking status, cessation medication prescriptions, and factors associated with receipt of cessation prescriptions. Mean age was 43.9years; most were men (74.2%) and Hispanic (70.9%). At buprenorphine initiation, 21.9% had no documentation of smoking status, while 67.4% were current, 10% former, and 0.9% never smokers. Of current smokers, 16.8% received smoking cessation prescriptions. Patients retained (vs. not retained) in buprenorphine treatment were more likely to receive smoking cessation medications (26.3% vs. 11.2%, p<0.005). We observed a high tobacco use prevalence among buprenorphine patients, and limited provision of cessation treatment. This is a missed opportunity to impact the high tobacco use burden in opioid-dependent persons. PMID:24912863
Nahvi, Shadi; Blackstock, Oni; Sohler, Nancy L; Thompson, Devin; Cunningham, Chinazo O
Medication-assisted treatment for opioid addiction: methadone and buprenorphine
Among agents for treatment of opioid addiction, methadone is a full mu-opioid receptor agonist, whereas buprenorphine is a partial agonist. Both are long-acting. Buprenorphine has a superior safety profile. Methadone is formulated for oral administration and buprenorphine for sublingual administration. A subdermal buprenorphine implant with a 6-month duration of action is being considered for approval by the U.S. Food and Drug Administration. Both medications reduce mortality rates and improve other outcomes. Data from a recent randomized controlled comparison of both medications (N = 1269) show better treatment retention with methadone but reduced illicit opioid use early in treatment with buprenorphine. Human immunodeficiency virus (HIV) risk behaviors were measured using the Risk Behavior Survey at baseline, 12 weeks, and 24 weeks for study completers. In the 30 days prior to treatment entry, 14.4% of the completers randomized to treatment with buprenorphine (n = 340) and 14.1% of the completers randomized to methadone treatment (n = 391) shared needles. The percent sharing needles decreased to 2.4% for buprenorphine and 4.8 for methadone in the 30 days prior to Week 24 (p < 0.0001). In the 30 days prior to treatment entry, 6.8% of the completers randomized to buprenorphine and 8.2% of the completers randomized to methadone had multiple sexual partners, with only 5.2% and 5.1%, respectively, reporting multiple partners at Week 24 (p < 0.04).
Saxon, Andrew J.; Hser, Yih-Ing; Woody, George; Ling, Walter
Urine naloxone concentration at different phases of buprenorphine maintenance treatment.
In spite of the benefits of buprenorphine-naloxone co-formulation (BNX) in opioid maintenance treatment, the naloxone component has not prevented parenteral use of BNX. Current laboratory methods are not sufficient to differentiate between therapeutic and illicit use of buprenorphine, and little is known about urine naloxone concentrations. Measurement of urine naloxone, together with buprenorphine and norbuprenorphine, might help to determine the naloxone source and administration route. A liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed and validated for this purpose. Naloxone, buprenorphine, and norbuprenorphine total concentrations were measured in urine samples from opioid-dependent patients before and during stable and unstable phases of maintenance treatment with BNX. The limit of quantification in urine was 1.0?�g/L for naloxone, buprenorphine and norbuprenorphine. Before treatment, all samples contained buprenorphine but the median naloxone concentration was 0?�g/L. During the maintenance treatment with BNX all urine samples were positive for naloxone, buprenorphine and norbuprenorphine. The naloxone concentration at a stable phase of treatment (median 60?�g/L, range 5-200?�g/L) was not different from the naloxone concentration at an unstable phase (70?�g/L, 10-1700?�g/L). Applying an upper limit of 200?�g/L to the sample, the median naloxone/buprenorphine ratio was higher in the high than in the low naloxone concentration group (0.9 vs 0.3, respectively). This study suggests that naloxone in urine can act as an indicator of compliance with BNX. Parenteral use of BNX was associated with a high naloxone/buprenorphine ratio. Negative naloxone with positive buprenorphine suggests the use/abuse of buprenorphine alone. PMID:23512803
Heikman, Pertti; H�kkinen, Margareeta; Gergov, Merja; Ojanper�, Ilkka
A randomized trial of buprenorphine maintenance for heroin dependence in a primary care clinic for substance users versus a methadone clinic
PURPOSE: Buprenorphine is an alternative to methadone for the maintenance treatment of heroine dependence and may be effective on a thrice weekly basis. Our objective was to evaluate the effect of thrice weekly buprenorphine maintenance for the treatment of heroin dependence in a primary care clinic on retention in treatment and illicit opioid use.SUBJECTS AND METHODS: Opioid-dependent patients were randomly
PatrickG O�Connor; AlisonH Oliveto; JuliaM Shi; ElisaG Triffleman; KathleenM Carroll; ThomasR Kosten; BruceJ Rounsaville; JulianaA Pakes; RichardS Schottenfeld
Impact of research network participation on the adoption of buprenorphine for substance abuse treatment.
There is a growing body of research supporting the use of buprenorphine and other medication assisted treatments (MATs) for the rapidly accelerating opioid epidemic in the United States. Despite numerous advantages of buprenorphine (accessible in primary care, no daily dosing required, minimal stigma), implementation has been slow. As the field progresses, there is a need to understand the impact of participation in practitioner-scientist research networks on acceptance and uptake of buprenorphine. This paper examines the impact of research network participation on counselor attitudes toward buprenorphine addressing both counselor-level characteristics and program-level variables using hierarchical linear modeling (HLM) to account for nesting of counselors within treatment programs. Using data from the National Treatment Center Study, this project compares privately funded treatment programs (N=345) versus programs affiliated with the National Institute on Drug Abuse Clinical Trials Network (CTN) (N=198). Models included 922 counselors in 172 CTN programs and 1203 counselors in 251 private programs. Results of two-level HLM logistic (Bernoulli) models revealed that counselors with higher levels of education, larger caseloads, more buprenorphine-specific training, and less preference for 12-step treatment models were more likely to perceive buprenorphine as acceptable and effective. Furthermore, buprenorphine was 50% more likely to be perceived as effective among counselors working in CTN-affiliated programs as compared to private programs. This study suggests that research network affiliation positively impacts counselors' acceptance and perceptions of buprenorphine. Thus, research network participation can be utilized as a means to promote positive attitudes toward the implementation of innovations including medication assisted treatment. PMID:24594902
Rieckmann, Traci R; Abraham, Amanda J; Kovas, Anne E; McFarland, Bentson H; Roman, Paul M
Short-term buprenorphine maintenance: treatment outcome.
Fifty-two heroin addicts were inducted onto buprenorphine under the care of psychiatric residents in a setting modeled on office practice. Subjects were maintained on a protocol of six weeks of 16 mg daily dosing, then tapered to zero dose up to week 16, and maintained on placebo through week 18. Of 44 subjects who continued after the first induction dose, 11 terminated during maintenance, 17 during taper; and 16 while on zero dose. Twice weekly urine toxicologies showed significant successive declines in samples positive for heroin use across these three periods: 70%, 41%, and 20%, respectively. Among historical variables, only prior AA attendance distinguished subjects who achieved zero dose from those who did not. A comparison with recent studies suggests that relatively inexperienced office-based physicians can maintain patients on buprenorphine at a level comparable to that reported for research clinic settings, but with comparable rates of heroin abstinence. These findings are discussed in light of potential options for office-based opioid maintenance. PMID:14621343
Galanter, Marc; Dermatis, Helen; Resnick, Richard; Maslansky, Robert; Neumann, Erna
Retention in methadone and buprenorphine treatment among African Americans.
Methadone has been the most commonly used pharmacotherapy for the treatment of opioid dependence in U.S. public sector treatment, but availability of buprenorphine as an alternative medication continues to increase. Drawing data from two community-based clinical trials that were conducted nearly contemporaneously, this study examined retention in methadone versus buprenorphine treatment over 6 months among urban African Americans receiving treatment in one of four publicly-funded programs (N=478; 178 methadone; 300 buprenorphine). Adjusting for confounds related to medication selection, survival analysis revealed that buprenorphine patients are at substantially higher risk of dropout compared to methadone patients (HR=2.43; p<.001). Buprenorphine's retention disadvantage appears to be concentrated in the earlier phases of treatment (approximately the first 50 days), after which risk of subsequent dropout becomes similar for the two medications. These findings confirm a retention disparity between methadone and buprenorphine in this population, and suggest potential avenues for future research to enhance retention in buprenorphine treatment. PMID:23566446
Gryczynski, Jan; Mitchell, Shannon Gwin; Jaffe, Jerome H; Kelly, Sharon M; Myers, C Patrick; O'Grady, Kevin E; Olsen, Yngvild K; Schwartz, Robert P
HIV Treatment Outcomes Among HIV-Infected, Opioid-Dependent Patients Receiving Buprenorphine/Naloxone Treatment within HIV Clinical Care Settings: Results From a Multisite Study
Background Having opioid dependence and HIV infection are associated with poor HIV-related treatment outcomes. Methods HIV-infected, opioid-dependent subjects (N = 295) recruited from 10 clinical sites initiated buprenorphine/naloxone (BUP/NX) and were assessed at baseline and quarterly for 12 months. Primary outcomes included receiving antiretroviral therapy (ART), HIV-1 RNA suppression, and mean changes in CD4 lymphocyte count. Analyses were stratified for the 119 subjects not on ART at baseline. Generalized estimating equations were deployed to examine time-dependent correlates for each outcome. Results At baseline, subjects on ART (N = 176) were more likely than those not on ART (N = 119) to be older, heterosexual, have lower alcohol addiction severity scores, and lower HIV-1 RNA levels; they were less likely to be homeless and report sexual risk behaviors. Subjects initiating BUP/NX (N = 295) were significantly more likely to initiate or remain on ART and improve CD4 counts over time compared with baseline; however, these improvements were not significantly improved by longer retention on BUP/NX. Retention on BUP/NX for three or more quarters was, however, significantly associated with increased likelihood of initiating ART (? = 1.34 [1.18, 1.53]) and achieve viral suppression (? = 1.25 [1.10, 1.42]) for the 64 of 119 (54%) subjects not on ART at baseline compared with the 55 subjects not retained on BUP/NX. In longitudinal analyses, being on ART was positively associated with increasing time of observation from baseline and higher mental health quality of life scores (? = 1.25 [1.06, 1.46]) and negatively associated with being homo- or bisexual (? = 0.55 [0.35, 0.97]), homeless (? = 0.58 [0.34, 0.98]), and increasing levels of alcohol addiction severity (? = 0.17 [0.03, 0.88]). The strongest correlate of achieving viral suppression was being on ART (? = 10.27 [5.79, 18.23]). Female gender (? = 1.91 [1.07, 3.41]), Hispanic ethnicity (? = 2.82 [1.44, 5.49]), and increased general health quality of life (? = 1.02 [1.00,1.04]) were also independently correlated with viral suppression. Improvements in CD4 lymphocyte count were significantly associated with being on ART and increased over time. Conclusions Initiating BUP/NX in HIV clinical care settings is feasible and correlated with initiation of ART and improved CD4 lymphocyte counts. Longer retention on BPN/NX was not associated with improved prescription of ART, viral suppression, or CD4 lymphocyte counts for the overall sample in which the majority was already prescribed ART at baseline. Among those retained on BUP/NX, HIV treatment outcomes did not worsen and were sustained. Increasing time on BUP/NX, however, was especially important for improving HIV treatment outcomes for those not on ART at baseline, the group at highest risk for clinical deterioration. Retaining subjects on BUP/NX is an important goal for sustaining HIV treatment outcomes for those on ART and improving them for those who are not. Comorbid substance use disorders (especially alcohol), mental health problems, and quality�of-life indicators independently contributed to HIV treatment outcomes among HIV-infected persons with opioid dependence, suggesting the need for multidisciplinary treatment strategies for this population.
Altice, Frederick L.; Bruce, R. Douglas; Lucas, Gregory M.; Lum, Paula J.; Korthuis, P. Todd; Flanigan, Timothy P.; Cunningham, Chinazo O.; Sullivan, Lynn E.; Vergara-Rodriguez, Pamela; Fiellin, David A.; Cajina, Adan; Botsko, Michael; Nandi, Vijay; Gourevitch, Marc N.; Finkelstein, Ruth
Factors that Affect the Efficacy of Buprenorphine and Naloxone as a Replacement Medication in Treating Opioid Dependence in the Primary Care Setting in Mendocino County, California
Introduction: Opioid dependence is a serious and growing public health issue. Treatment options have expanded since buprenorphine was approved for use as a maintenance medication by primary care providers in outpatient settings, but use of this medication is sti11limited. The safety and efficacy of buprenorphine have been well established, but very little is understood about what contributes to the success
Kelli Cole
In the crystal structure of a semi-synthetic opioid drug buprenorphine, C29H41NO4 {systematic name: (2S)-2-[(5R,6R,7R,14S)-9?-cyclo�propyl�methyl-3-hy�droxy-6-meth�oxy-4,5-ep�oxy-6,14-ethano�morphinan-7-yl]-3,3-di�methyl�butan-2-ol}, the cyclo�propyl�methyl group is disordered over two sites with an occupancy factor of 0.611?(3) for the major component. One of the hy�droxy groups is involved in intra�molecular O�H?O hydrogen bond. The other hy�droxy group acts as a proton donor in an inter�molecular O�H?O inter�action that connects mol�ecules into a zigzag chain along the b axis.
Mazurek, Jaroslaw; Hoffmann, Marcel; Fernandez Casares, Anna; Cox, Phillip D.; Minardi, Mathew D.
In the crystal structure of a semi-synthetic opioid drug buprenorphine, C29H41NO4 {systematic name: (2S)-2-[(5R,6R,7R,14S)-9?-cyclo-propyl-methyl-3-hy-droxy-6-meth-oxy-4,5-ep-oxy-6,14-ethano-morphinan-7-yl]-3,3-di-methyl-butan-2-ol}, the cyclo-propyl-methyl group is disordered over two sites with an occupancy factor of 0.611?(3) for the major component. One of the hy-droxy groups is involved in intra-molecular O-H?O hydrogen bond. The other hy-droxy group acts as a proton donor in an inter-molecular O-H?O inter-action that connects mol-ecules into a zigzag chain along the b axis. PMID:24940223
Mazurek, Jaroslaw; Hoffmann, Marcel; Fernandez Casares, Anna; Cox, Phillip D; Minardi, Mathew D
Hypogonadism in men receiving methadone and buprenorphine maintenance treatment.
The aim of this study was to determine the prevalence and investigate the aetiology of hypogonadism in men on methadone or buprenorphine maintenance treatment (MMT, BMT). 103 men (mean age 37.6 +/- 7.9) on MMT (n = 84) or BMT (n = 19) were evaluated using hormone assays, body mass index (BMI), serological, biochemical, demographic and substance use measures. Overall 54% of men (methadone 65%; buprenorphine 28%) had total testosterone (TT) <12.0 nm; 34% (methadone 39%; buprenorphine 11%) had TT <8.0 nm. Both methadone- and buprenorphine-treated men had lower free testosterone, luteinising hormone and estradiol than age-matched reference groups. Methadone-treated men had lower TT than buprenorphine-treated men and reference groups. Prolactin did not differ between methadone, buprenorphine groups, and reference groups. Primary testicular failure was an uncommon cause of hypogonadism. Yearly percentage fall in TT by age across the patient group was 2.3%, more than twice that expected normally. There were no associations between TT and opioid dose, cannabis, alcohol and tobacco consumption, or chronic hepatitis C viraemia. On multiple regression higher TT was associated with higher alanine aminotransferase and lower TT with higher BMI. Men on MMT have high prevalence of hypogonadotrophic hypogonadism. The extent of hormonal changes associated with buprenorphine needs to be explored further in larger studies. Men receiving long term opioid replacement treatment, especially methadone treatment, should be screened for hypogonadism. Wide interindividual differences in methadone metabolism and tolerance may in a cross-sectional study obscure a methadone dose relationship to testosterone in individuals. Future studies of hypogonadism in opioid-treated men should examine the potential benefits of dose reduction, choice of opioid medication, weight loss, and androgen replacement. PMID:17971165
Hallinan, R; Byrne, A; Agho, K; McMahon, C G; Tynan, P; Attia, J
Buprenorphine diffusion: the attitudes of substance abuse treatment counselors
In October 2002, the Food and Drug Administration approved buprenorphine for use in the treatment of opioid dependence. Successful diffusion, adoption, and implementation of this medication within the treatment field depend in part on substance abuse counselors. Using questionnaire data obtained from 2,298 counselors in community-based treatment programs in the private and public sectors between June 2002 and July 2004,
Hannah K. Knudsen; Lori J. Ducharme; Paul M. Roman; Tanja Link
Psychiatric and medical comorbidities, associated pain, and health care utilization of patients prescribed buprenorphine.
This study describes the comorbidities and health care utilization of individuals treated with buprenorphine using the 2007-2009 MarketScan Research Databases. Buprenorphine recipients had a high prevalence of comorbidities associated with chronic pain, including back problems (42%), connective tissue disease (24-27%), and nontraumatic joint disorders (20-23%). Approximately 69% of recipients filled prescriptions for opioid agonist medications in the 6 months before buprenorphine initiation. Buprenorphine recipients were frequently diagnosed with anxiety (23-42%) and mood disorders (39-51%) and filled prescriptions for antidepressants (47-56%) and benzodiazepines (47-56%) at high rates. Surprisingly, only 53-54% of patients filling a prescription for buprenorphine had a coded opioid abuse/dependence diagnosis. Research is needed to better understand buprenorphine's effectiveness in the context of prescription drug abuse and the best way to coordinate services to address the patient's comorbid addiction, pain, and psychiatric illnesses. PMID:23265445
Mark, Tami L; Dilonardo, Joan; Vandivort, Rita; Miller, Kay
Buprenorphine vs methadone maintenance treatment for concurrent opioid dependence and cocaine abuse
BACKGROUND: Buprenorphine, a partial mu-agonist and kappa-antagonist, has been proposed as an alternative to methadone for maintenance treatment of opioid dependence, especially for patients with concurrent cocaine dependence or abuse. This study evaluated whether higher maintenance doses of buprenorphine and methadone are superior to lower doses for reducing illicit opioid use and whether buprenorphine is superior to methadone for reducing
Richard S. Schottenfeld; Juliana Pakes; Alison Oliveto; Douglas M. Ziedonis; Thomas R. Kosten
Buprenorphine maintenance therapy hinders acute pain management in trauma.
Buprenorphine is a mixed opiate receptor agonist-antagonist growing in popularity as an office-based treatment for opioid-dependent patients. It has high affinity, but only partial agonism at the micro-opioid receptor resulting in a ceiling analgesic effect. At higher doses, buprenorphine potentiates antagonism at the kappa-opioid receptor. These properties make buprenorphine an effective maintenance treatment for opioid-dependent patients. These same properties, however, can interfere with the management of acute pain in patients on maintenance buprenorphine therapy. We present a case of a young multisystem trauma patient in whom adequate analgesia could not be achieved due to buprenorphine treatment before and through the early course of admission. Discontinuation of buprenorphine allowed for appropriate pain management and successful analgesia. Further education of acute care clinicians about buprenorphine pharmacology and careful selection of patients for buprenorphine maintenance therapy are needed to avoid delays of pain control in trauma patients. PMID:20420250
Harrington, Colin J; Zaydfudim, Victor
Criminal charges prior to and after initiation of office-based buprenorphine treatment
Background There is little data on the impact of office-based buprenorphine therapy on criminal activity. The goal of this study was to determine the impact of primary care clinic-based buprenorphine maintenance therapy on rates of criminal charges and the factors associated with criminal charges in the 2 years after initiation of treatment. Methods We collected demographic and outcome data on 252 patients who were given at least one prescription for buprenorphine. We searched a public database of criminal charges and recorded criminal charges prior to and after enrollment. We compared the total number of criminal cases and drug cases 2 years before versus 2 years after initiation of treatment. Results There was at least one criminal charge made against 38% of the subjects in the 2 years after initiation of treatment; these subjects were more likely to have used heroin, to have injected drugs, to have had any prior criminal charges, and recent criminal charges. There was no significant difference in the number of subjects with any criminal charge or a drug charge before and after initiation of treatment. Likewise, the mean number of all cases and drug cases was not significantly different between the two periods. However, among those who were opioid-negative for 6 or more months in the first year of treatment, there was a significant decline in criminal cases. On multivariable analysis, having recent criminal charges was significantly associated with criminal charges after initiation of treatment (adjusted odds ratio 3.92); subjects who were on opioid maintenance treatment prior to enrollment were significantly less likely to have subsequent criminal charges (adjusted odds ratio 0.52). Conclusions Among subjects with prior criminal charges, initiation of office-based buprenorphine treatment did not appear to have a significant impact on subsequent criminal charges.
A randomized trial of intensive outpatient (IOP) vs. standard outpatient (OP) buprenorphine treatment for African Americans
BACKGROUND Buprenorphine is increasingly being used in community-based treatment programs, but little is known about the optimal level of psychosocial counseling in these settings. The aim of this study was to compare the effectiveness of OP and IOP level counseling when provided as part of buprenorphine treatment for opioid-dependent African Americans. METHODS Participants were African American men and women starting buprenorphine treatment at one of two community-based clinics (N=300). Participants were randomly assigned to OP or IOP. Measures at baseline, 3- and 6-months included the primary outcome of DSM-IV opioid and cocaine dependence criteria, as well as additional outcomes of illicit opioid and cocaine use (urine test and self-report), criminal activity, retention in treatment, Quality of Life, Addiction Severity Index composite scores, and HIV risk behaviors. RESULTS Participants assigned to OP received, on average, 3.67 (SD=1.30) hours of counseling per active week in treatment. IOP participants received an average of 5.23 (SD=1.68) hours of counseling per active week (less than the anticipated 9 hours per week of counseling). Both groups showed substantial improvement over a 6-month period on nearly all measures considered. There were no significant differences between groups in meeting diagnostic criteria for opioid (p=.67) or cocaine dependence (p=.63). There were no significant between group differences on any of the other outcomes. A secondary analysis restricting the sample to participants meeting DSM-IV criteria for baseline cocaine dependence also revealed no significant between-group differences (all ps>.05). CONCLUSIONS Buprenorphine patients receiving OP and IOP levels of care both show short-term improvements.
Mitchell, Shannon Gwin; Gryczynski, Jan; Schwartz, Robert P.; O'Grady, Kevin E.; Olsen, Yngvild K.; Jaffe, Jerome H.
Early adoption of buprenorphine in substance abuse treatment centers: Data from the private and public sectors
The recent approval of buprenorphine for the treatment of opiate dependence offers an opportunity to analyze innovation adoption in community-based treatment. Using data collected from national samples of 299 privately funded and 277 publicly funded treatment centers, this research examines buprenorphine adoption using baseline data collected between 2002 and 2004 as well as follow-up data collected 12 months later. Private
Hannah K. Knudsen; Lori J. Ducharme; Paul M. Roman
Bringing Buprenorphine-Naloxone Detoxification to Community Treatment Providers: The NIDA Clinical Trials Network Field Experience
In October 2002, the U.S. Food and Drug Administration approved buprenorphine-naloxone (Suboxone�) sublingual tablets as an opioid dependence treatment available for use outside traditionally licensed opioid treatment programs. The NIDA Center for Clinical Trials Network (CTN) sponsored two clinical trials assessing buprenorphine-naloxone for short-term opioid detoxification. These trials provided an unprecedented field test of its use in twelve diverse community-based treatment programs. Opioid-dependent men and women were randomized to a thirteen-day buprenorphine-naloxone taper regimen for short-term opioid detoxification. The 234 buprenorphine-naloxone patients averaged 37 years old and used mostly intravenous heroin. Direct and rapid induction onto buprenorphine-naloxone was safe and well tolerated. Most patients (83%) received 8 mg buprenorphine-2 mg naloxone on the first day and 90% successfully completed induction and reached a target dose of 16mg buprenorphine-4 mg naloxone in three days. Medication compliance and treatment engagement was high. An average of 81% of available doses was ingested, and 68% of patients completed the detoxification. Most (80.3%) patients received some ancillary medications with an average of 2.3 withdrawal symptoms treated. The safety profile of buprenorphine-naloxone was excellent. Of eighteen serious adverse events reported, only one was possibly related to buprenorphine-naloxone. All providers successfully integrated buprenorphine-naloxone into their existing treatment milieus. Overall, data from the CTN field experience suggest that buprenorphine-naloxone is practical and safe for use in diverse community treatment settings, including those with minimal experience providing opioid-based pharmacotherapy and/or medical detoxification for opioid dependence.
Amass, Leslie; Ling, Walter; Freese, Thomas E.; Reiber, Chris; Annon, Jeffrey J.; Cohen, Allan J.; M.F.T.; McCarty, Dennis; Reid, Malcolm S.; Brown, Lawrence S.; Clark, Cynthia; Ziedonis, Douglas M.; Krejci, Jonathan; Stine, Susan; Winhusen, Theresa; Brigham, Greg; Babcock, Dean; L.C.S.W.; Muir, Joan A.; Buchan, Betty J.; Horton, Terry
Tetanus in an Injecting Buprenorphine Abuser
Introduction: Injecting drug abusers are vulnerable to many infectious complications. We describe a case of tetanus in a Singaporean who regularly abused buprenorphine. Clinical Picture: A 49-year-old male was hospitalised for progressive generalised spasms associated with dysarthria and opisthotonus. Tetanus was diagnosed clinically. Treatment: Supportive management was instituted in the intensive care unit (ICU). Toxicology samples tested positive for buprenorphine.
Felicia SW Teo; Yang Hsu; Khim Nian; Sin Fai Lam; A Johan
Buprenorphine-Naloxone Maintenance Following Release from Jail
Primary care is understudied as a re-entry drug and alcohol treatment setting. This study compared treatment retention and opioid misuse among opioid dependent adults seeking buprenorphine\\/naloxone maintenance in an urban primary care clinic following release from jail vs. community referrals. Post-release patients were either; a) induced to buprenorphine in-jail as part of a clinical trial, or, b) seeking buprenorphine induction
Joshua D. Lee; Ellie Grossman; Andrea Truncali; John Rotrosen; Andrew Rosenblum; Steven Magura; Marc N. Gourevitch
Using buprenorphine short-term taper to facilitate early treatment engagement
The U.S. Federal Food and Drug Administration approved buprenorphine for drug abuse treatment in 2002, and it became available for clinical use in early 2003. Maryhaven, a community treatment program, participated in a National Institute on Drug Abuse Clinical Trials Network trial evaluating buprenorphine�naloxone (BNX; Suboxone) short-term taper for medically managed opioid withdrawal and later adopted this treatment. In a
Gregory S. Brigham; Leslie Amass; Theresa Winhusen; Judy M. Harrer; Alvin Pelt
Buprenorphine versus methadone in the treatment of pregnant opioid-dependent patients: effects on the neonatal abstinence syndrome
This study was designed to compare the neonatal abstinence syndrome (NAS) in neonates of methadone and buprenorphine maintained pregnant opioid-dependent women and to provide preliminary safety and efficacy data for a larger multi-center trial. This randomized, double-blind, double-dummy, flexible dosing, parallel-group controlled trial was conducted in a comprehensive drug-treatment facility that included residential and ambulatory care. Participants were opioid-dependent pregnant
E. Jonesa; Rolley E. Johnsona; Donald R. Jasinskib; Kevin E. O'Gradyc; Christian A. Chisholmd; Robin E. Choof; Michael Crocettie; Robert Dudase; Cheryl Harrowe; Marilyn A. Huestisf; Lauren M. Janssone; Michael Lantzd; Barry M. Lesterg; Lorraine Miliod
Drug Treatment Outcomes among HIV-Infected Opioid Dependent Patients Receiving Buprenorphine/naloxone
Background Buprenorphine/naloxone allows the integration of opioid dependence and HIV treatment. Methods We conducted a prospective study in HIV-infected opioid dependent patients to investigate the impact of buprenorphine/naloxone treatment on drug use. Self-report and chart review assessments were conducted every 3 months (Quarters 1 through 4) for one year. Outcomes were buprenorphine/naloxone treatment retention, drug use, and addiction treatment processes. Results Among 303 patients enrolled between July 2005 and December 2007, retention in buprenorphine/naloxone treatment was 74%, 67%, 59% and 49% during Quarters 1,2 3, and 4, respectively. Past 30 day illicit opioid use decreased from 84% of patients at baseline to 42% in retained patients over the year. Patients were 52% less likely to use illicit opioids for each quarter in treatment (OR = .66; 95% CI 0.61�0.72). Buprenorphine/naloxone doses and office visits approximated guidelines published by the United States Department of Health and Human Services. Urine toxicology monitoring was less frequent than recommended. Conclusions Buprenorphine/naloxone provided in HIV treatment settings can decrease opioid use. Strategies are needed to improve retention and address ongoing drug use in this treatment population.
Fiellin, David A.; Weiss, Linda; Botsko, Michael; Egan, James E; Altice, Frederick L.; Bazerman, Lauri B.; Chaudhry, Amina; Cunningham, Chinazo O.; Gourevitch, Marc N.; Lum, Paula J.; Sullivan, Lynn E.; Schottenfeld, Richard S.; O'Connor, Patrick G.
Methadone versus buprenorphine maintenance for the treatment of heroin-dependent outpatients
The aim of this study was to assess the efficacy of methadone compared with buprenorphine maintenance therapy in heroin-dependent patients over a treatment period of 18 weeks. Subjects were randomized to receive either methadone or buprenorphine in a comparative double-blind study and consisted of 164 heroin-dependent male patients who met the DSM-IV criteria for heroin dependence and were seeking treatment.
Jamshid Ahmadi
Urinary Excretion of Buprenorphine, Norbuprenorphine, Buprenorphine-Glucuronide, and Norbuprenorphine-Glucuronide in Pregnant Women Receiving Buprenorphine Maintenance Treatment
BACKGROUND Buprenorphine (BUP) is under investigation as a medication therapy for opioid-dependent pregnant women. We investigated BUP and metabolite disposition in urine from women maintained on BUP during the second and third trimesters of pregnancy and postpartum. METHODS We measured BUP, norbuprenorphine (NBUP), buprenorphine glucuronide (BUP-Gluc), and NBUP-Gluc concentrations in 515 urine specimens collected thrice weekly from 9 women during pregnancy and postpartum. Specimens were analyzed using a fully validated liquid chromatography-mass spectrometry method with limits of quantification of 5 �g/L for BUP and BUP-Gluc and 25 �g/L for NBUP and its conjugated metabolite. We examined ratios of metabolites across trimesters and postpartum to identify possible changes in metabolism during pregnancy. RESULTS NBUP-Gluc was the primary metabolite identified in urine and exceeded BUP-Gluc concentrations in 99% of specimens. Whereas BUP-Gluc was identified in more specimens than NBUP, NBUP exceeded BUP-Gluc concentrations in 77.9% of specimens that contained both analytes. Among all participants, the mean BUP-Gluc:NBUP-Gluc ratio was significantly higher in the second trimester compared to the third trimester, and there were significant intrasubject differences between trimesters in 71% of participants. In 3 women, the percent daily dose excreted was higher during pregnancy than postpregnancy, consistent with other data indicating increased renal elimination of drugs during pregnancy. CONCLUSIONS These data are the first to evaluate urinary disposition of BUP and metabolites in a cohort of pregnant women. Variable BUP excretion during pregnancy may indicate metabolic changes requiring dose adjustment during later stages of gestation.
Kacinko, Sherri L.; Jones, Hendree E.; Johnson, Rolley E.; Choo, Robin E.; Concheiro-Guisan, Marta; Huestis, Marilyn A.
Preference for buprenorphine\\/naloxone and buprenorphine among patients receiving buprenorphine maintenance therapy in France: A prospective, multicenter study
Maintenance treatment with buprenorphine tablets (Subutex) has been associated with reductions in heroin use; however, concerns for intravenous misuse exist. A buprenorphine\\/naloxone formulation (Suboxone) was designed to reduce this misuse risk while retaining buprenorphine's efficacy and safety. This prospective, open-label, multicenter trial compared preferences for buprenorphine and buprenorphine\\/naloxone in 53 opioid-dependent patients stabilized on buprenorphine. Buprenorphine was first administered at
Jean-Pierre Daulou�de; Yves Caer; Pascal Galland; Pierre Villeger; Emmanuel Brunelle; J�r�me Bachellier; Jean-Michel Piquet; Jean Harbonnier; Yves Leglise; Pascal Courty
Training HIV Physicians to Prescribe Buprenorphine for Opioid Dependence
ERIC Educational Resources Information Center
Few HIV physicians are trained to provide buprenorphine treatment. We conducted a cross-sectional survey to assess the impact of an eight-hour course on the treatment of opioid dependence on HIV physicians' preparedness to prescribe buprenorphine. One hundred thirteen of 257 trained physicians (44%) provided HIV care. Post-course, the majority of�
Sullivan, Lynn E.; Tetrault, Jeanette; Bangalore, Deepa; Fiellin, David A.
Buprenorphine treatment outcome in dually diagnosed heroin dependent patients: A retrospective study
The present study compared retrospectively in a clinical non-experimental setting the efficacy of buprenorphine (BUP) in different subgroups of dually diagnosed and non-dually diagnosed opioid-dependent patients: all the subjects included in the study showed severe long-lasting heroin addiction and 68.4% were affected by psychiatric comorbidity. Participants (206) (mean age 32.2�8.9, 177 males�29 females) were applicants to a long-term buprenorphine treatment
Gilberto Gerra; Claudio Leonardi; Antonio D'Amore; Giovanni Strepparola; Roberto Fagetti; Cinzia Assi; Amir Zaimovic; Alfio Lucchini
Factors associated with the prescribing of buprenorphine or methadone for treatment of opiate dependence.
The study investigates patient preferences and beliefs and treatment program factors related to the decision to prescribe either buprenorphine or methadone to opiate-dependent patients. The sample (N = 192) was recruited from 10 addiction treatment services in London. Data were collected by means of a single structured interview conducted with patients commencing a treatment episode at the participating agencies. Data on patient demographics, beliefs, attitudes, and preferences were collected using a structured interview. Data regarding treatment goals and prescribed medication were collected from interviews with clinical staff. Oral methadone had a higher preference rating than buprenorphine. Clinical prescribing practices were influenced by patient preferences (both positive and negative), by prior treatment experiences, and by current treatment goals. Patient preferences and beliefs about opioid agonist medications served as an important influence upon clinical prescribing practices. The odds of being prescribed buprenorphine were three times greater among those patients who reported a preference for buprenorphine. The odds of receiving a prescription for methadone were about twice as great among those for whom methadone was the more preferred medication. Preferences were related to previous treatment experiences with these opioid agonists, and for patients in both groups, personal experience was the most important source of information about the treatment options. Buprenorphine was more likely to be prescribed for short-term detoxification and methadone for maintenance treatment. PMID:19004598
Ridge, Gayle; Gossop, Michael; Lintzeris, Nicholas; Witton, John; Strang, John
Counselor Attitudes toward the Use of Buprenorphine in Substance Abuse Treatment: A Multi-level Modeling Approach
In spite of evidence that buprenorphine is effective, safe, and offers greater access as compared with methadone, implementation for treatment of opiate dependence continues to be weak. Research indicates that legal and regulatory factors, state policies, and organizational and provider variables affect adoption of buprenorphine. This study uses hierarchical linear modeling (HLM) to examine National Treatment Center Study (NTCS) data to identify counselor characteristics (attitudes, training, beliefs) and organizational factors (accreditation, caseload, access to buprenorphine and other evidence-based practices) that influence implementation of buprenorphine for treatment of opiate dependence. Analyses showed that provider training about buprenorphine, higher prevalence of opiate dependent clients, and less treatment program emphasis on a 12-step model predicted greater counselor acceptance and perceived effectiveness of buprenorphine. Results also indicate that program use of buprenorphine for any treatment purpose (detoxification, maintenance, and/or pain management) and time (calendar year in data collection) were associated with increased diffusion of knowledge about buprenorphine among counselors and with more favorable counselor attitudes toward buprenorphine.
Kovas, Anne E.; McFarland, Bentson H.; Abraham, Amanda J.
Extended vs Short-term Buprenorphine-Naloxone for Treatment of Opioid-Addicted Youth
Context The usual treatment for opioid-addicted youth is detoxification and counseling. Extended medication-assisted therapy may be more helpful. Objective To evaluate the efficacy of continuing buprenorphine-naloxone for 12 weeks vs detoxification for opioid-addicted youth. Design, Setting, and Patients Clinical trial at 6 community programs from July 2003 to December 2006 including 152 patients aged 15 to 21 years who were randomized to 12 weeks of buprenorphine-naloxone or a 14-day taper (detox). Interventions Patients in the 12-week buprenorphine-naloxone group were prescribed up to 24 mg per day for 9 weeks and then tapered to week 12; patients in the detox group were prescribed up to 14 mg per day and then tapered to day 14. All were offered weekly individual and group counseling. Main Outcome Measure Opioid-positive urine test result at weeks 4, 8, and 12. Results The number of patients younger than 18 years was too small to analyze separately, but overall, patients in the detox group had higher proportions of opioid-positive urine test results at weeks 4 and 8 but not at week 12 ( ?22 = 4.93, P = .09). At week 4, 59 detox patients had positive results (61%; 95% confidence interval [CI] = 47%-75%) vs 58 12-week buprenorphine-naloxone patients (26%; 95% CI = 14%-38%). At week 8, 53 detox patients had positive results (54%; 95% CI = 38%-70%) vs 52 12-week buprenorphine-naloxone patients (23%; 95% CI = 11%-35%). At week 12, 53 detox patients had positive results (51%; 95% CI = 35%-67%) vs 49 12-week buprenorphine-naloxone patients (43%; 95% CI = 29%-57%). By week 12, 16 of 78 detox patients (20.5%) remained in treatment vs 52 of 74 12-week buprenorphine-naloxone patients (70%; ?12 = 32.90, P < .001). During weeks 1 through 12, patients in the 12-week buprenorphine-naloxone group reported less opioid use ( ?12 = 18.45, P < .001), less injecting ( ?12 = 6.00, P = .01), and less nonstudy addiction treatment ( ?12 = 25.82, P < .001). High levels of opioid use occurred in both groups at follow-up. Four of 83 patients who tested negative for hepatitis C at baseline were positive for hepatitis C at week 12. Conclusions Continuing treatment with buprenorphine-naloxone improved outcome compared with short-term detoxification. Further research is necessary to assess the efficacy and safety of longer-term treatment with buprenorphine for young individuals with opioid dependence.
Woody, George E.; Poole, Sabrina A.; Subramaniam, Geetha; Dugosh, Karen; Bogenschutz, Michael; Abbott, Patrick; Patkar, Ashwin; Publicker, Mark; McCain, Karen; Potter, Jennifer Sharpe; Forman, Robert; Vetter, Victoria; McNicholas, Laura; Blaine, Jack; Lynch, Kevin G.; Fudala, Paul
State policy influence on the early diffusion of buprenorphine in community treatment programs
Background Buprenorphine was approved for use in the treatment of opioid dependence in 2002, but its diffusion into everyday clinical practice in community-based treatment programs has been slow. This study examines the net impact of efforts by state agencies, including provision of Medicaid coverage, on program-level adoption of buprenorphine as of 2006. Methods Interviews were conducted with key informants in 49 of the 50 state agencies with oversight responsibility for addiction treatment services. Information from these interviews was integrated with organizational data from the 2006 National Survey of Substance Abuse Treatment Services. A multivariate logistic regression model was estimated to identify the effects of state efforts to promote the use of this medication, net of a host of organizational characteristics. Results The availability of Medicaid coverage for buprenorphine was a significant predictor of its adoption by treatment organizations. Conclusion Inclusion of buprenorphine on state Medicaid formularies appears to be a key element in ensuring that patients have access to this state-of-the-art treatment option. Other potential barriers to the diffusion of buprenorphine require identification, and the value of additional state-level policies to promote its use should be evaluated.
Ducharme, Lori J; Abraham, Amanda J
Transdermal buprenorphine in the treatment of cancer and non-cancer pain - the results of multicenter studies in Poland.
This was a multicenter, non-interventional, post-marketing study that aimed to evaluate the analgesic activity, safety of use, safety profile and adverse drug reactions of transdermal buprenorphine (Transtec 35, 52.5 and 70 ?g/h) during the treatment of moderate to severe chronic cancer and non-cancer pain. The study was performed in Poland by 339 doctors. The study involved 4,030 general practice outpatients (managed by primary care physicians), pain therapy center patients, specialist outpatient clinic patients as well as patients treated in inpatients units. The recruitment process began in September of 2007, and the study was completed in October of 2008. The study has been reported to the Central Register of Clinical Trials in Poland; it was also in accordance with the requirements of the Polish Pharmaceutical Law in force. The objective of the study was to evaluate the efficacy, safety of use and application of transdermal buprenorphine in patients with moderate to severe cancer pain and in patients with severe, non-malignant pain in the course of other diseases. Patients were enrolled if their pain was not well-controlled after using non-opioid analgesics. Another objective of the study was to monitor adverse drug reactions of transdermal buprenorphine reported by patients or noted by the doctors during the study visits. This first such multicenter study in Poland has confirmed high efficacy and good tolerability of buprenorphine and, therefore, confirmed its usefulness in the treatment of moderate to severe cancer pain as well as in the treatment of severe pain in patients with non-cancer pain that cannot be effectively treated with non-opioid analgesics. PMID:22001981
Przeklasa-Muszy?ska, Anna; Dobrogowski, Jan
A multi-level analysis of counselor attitudes toward the use of buprenorphine in substance abuse treatment
Despite evidence that buprenorphine is effective and safe and offers greater access as compared with methadone, implementation for treatment of opiate dependence continues to be weak. Research indicates that legal and regulatory factors, state policies, and organizational and provider variables affect adoption of buprenorphine. This study uses hierarchical linear modeling to examine National Treatment Center Study data to identify counselor
Traci R. Rieckmann; Anne E. Kovas; Bentson H. McFarland; Amanda J. Abraham
Improving Adherence to HIV Quality of Care Indicators in Persons With Opioid Dependence: The Role of Buprenorphine
Background Opioid-dependent HIV-infected patients are less likely to receive HIV quality of care indicators (QIs) compared with nondependent patients. Buprenorphine/naloxone maintenance therapy (bup/nx) could affect the quality of HIV care for opioid-dependent patients. Methods We abstracted 16 QIs from medical records at nine HIV clinics 12 months before and after initiation of bup/nx versus other treatment for opioid dependence. Summary quality scores (number of QIs received/number eligible � 100) were calculated. We compared change in QIs and summary quality scores in patients receiving bup/nx versus other participants. Results One hundred ninety-four of 268 participants (72%) received bup/nx and 74 (28%) received other treatment. Mean summary quality scores increased over 12 months for participants receiving bup/nx (45.6% to 51.6%, P < 0.001) but not other treatment (48.6% to 47.8%, P = 0.788). Bup/nx participants experienced improvements in six of 16 HIV QIs versus three of 16 QIs in other participants. Improvements were mostly in preventive and monitoring care domains. In multivariable analysis, bup/nx was associated with improved summary quality score (? 8.55; 95% confidence interval, 2.06�15.0). Conclusions In this observational cohort study, HIV-infected patients with opioid dependence received approximately half of HIV QIs at baseline. Buprenorphine treatment was associated with improvement in HIV QIs at 12 months. Integration of bup/nx into HIV clinics may increase receipt of high-quality HIV care. Further research is required to assess the effect of improved quality of HIV care on clinical outcomes.
Korthuis, P. Todd; Fiellin, David A.; Fu, Rongwei; Lum, Paula J.; Altice, Frederick L.; Sohler, Nancy; Tozzi, Mary J.; Asch, Steven M.; Botsko, Michael; Fishl, Margaret; Flanigan, Timothy P.; Boverman, Joshua; McCarty, Dennis
Improved Buprenorphine Immunoassay Performance After Urine Treatment with ?-Glucuronidase.
Buprenorphine (BUP), a semi-synthetic opioid analgesic, is increasingly prescribed for the treatment of chronic pain and opioid dependence. Urine immunoassay screening methods are available for monitoring BUP compliance and misuse; however, these screens may have poor sensitivity or specificity. We evaluated whether the pretreatment of urine with ?-glucuronidase (BG) improves the sensitivity and overall accuracy of three BUP enzyme immunoassays when compared with liquid chromatography-tandem mass spectrometry (LC-MS-MS). Urine samples sent to our laboratories for BUP testing (n = 114) were analyzed before and after BG pretreatment by cloned enzyme donor immunoassay (CEDIA), enzyme immunoassay (EIA) and homogenous EIA (HEIA) immunoassays using a common 5 ng/mL cutoff. Total BUP and norbuprenorphine (NBUP) concentrations were measured by LC-MS-MS as the reference method. Urine BG pretreatment improved EIA, HEIA and CEDIA sensitivities from 70, 82 and 94%, respectively, to 97% for each of the three methods, when compared with LC-MS-MS. While the specificity of the EIA and HEIA remained 100% after BG pretreatment, the specificity of the CEDIA decreased from 74 to 67%. Urine pretreatment with BG is recommended to improve sensitivity of the EIA and HEIA BUP screening methods. PMID:24802159
Snyder, Marion L; Darragh, Alicia; Flood, James G; Jones, Jenny; Ropar, Kaitlin; Jarolim, Petr; Melanson, Stacy E F
Comment on "a comparison of buprenorphine + naloxone to buprenorphine and methadone in the treatment of opioid dependence during pregnancy: maternal and neonatal outcomes".
In a recent article, Lund et al sought to compare maternal and neonatal outcomes of various treatment regimens for opioid dependence during pregnancy.1 In their background, discussion the authors state that "In the United States buprenorphine plus naloxone [Suboxone(�)] � has been the preferred form of prescribed buprenorphine due to its reduced abuse liability relative to buprenorphine alone [Subutex(�)]." This claim is certainly consistent with the view of the firm that has manufactured and sold both products, Reckitt Benckiser. In September of 2011, the company announced that it was "� discontinuing distribution and sale of Subutex(�) tablets as we believe that mono product (product containing buprenorphine alone with no naloxone) creates a greater risk of misuse, abuse and diversion �".2 Supporting evidence for the alleged "reduced abuse liability" appears to be lacking, however, and evidence cannot be located in the two references cited by Dr. Lund and his co-authors, which in fact are silent on the subject of abuse potential.3,4 In contrast, it has been reported that the transition to buprenorphine/naloxone from the mono formulation has been associated with "� no reduction in injection risk behaviors among IDUs."5. PMID:23772177
Newman, Robert G; Gevertz, Susan G
Cost-effectiveness of Extended Buprenorphine-Naloxone Treatment for Opioid-Dependent Youth: Data from a Randomized Trial
Introduction The objective is to estimate cost, net social cost, and cost-effectiveness in a clinical trial of extended buprenorphine-naloxone treatment versus brief detoxification treatment in opioid-dependent youth. Methods Economic evaluation of a clinical trial conducted at 6 community outpatient treatment programs from July 2003 to December 2006 including 152 patients aged 15 to 21 years who were randomized to 12 weeks of buprenorphine-naloxone (BUP) or a 14-day taper (DETOX). BUP patients were prescribed up to 24 mg per day for 9 weeks and then tapered to zero at the end of week 12. DETOX patients were prescribed up to 14 mg per day and then tapered to zero on day 14. All were offered twice weekly drug counseling. Data were collected prospectively during the 12-week treatment and at follow-up interviews at months 6, 9, and 12. Results The 12-week outpatient study treatment cost was $1514 (p<0.001) higher for BUP relative to DETOX. One-year total direct medical cost was only $83 higher for BUP (p=0.97). The cost-effectiveness ratio of BUP relative to DETOX was $1,376 in terms of 1-year direct medical cost per quality-adjusted life year (QALY) and $25,049 in terms of outpatient treatment program cost per QALY. The acceptability curve suggests that the cost-effectiveness ratio of BUP relative to DETOX has an 86% chance of being accepted as cost-effective for a threshold of $100,000 per QALY. Conclusions Extended buprenorphine-naloxone treatment relative to brief detoxification is cost effective in the U.S. health care system for the outpatient treatment of opioid-dependent youth.
Polsky, Daniel; Glick, Henry A.; Yang, Jianing; Subramaniam, Geetha A.; Poole, Sabrina A.; Woody, George E.
Developing and Implementing a New Prison-Based Buprenorphine Treatment Program
ERIC Educational Resources Information Center
Research suggests that buprenorphine treatment may be a promising intervention for incarcerated individuals with heroin addiction histories. However, its implementation varies from corrections-based methadone because of unique challenges regarding dosing, administration, and regulation. Describing the first randomized clinical trial of�
Kinlock, Timothy W.; Gordon, Michael S.; Schwartz, Robert P.; Fitzgerald, Terrence T.
Compliance with buprenorphine medication-assisted treatment and relapse to opioid use.
Opioid dependence (OD), often characterized as a chronic relapsing disorder, affects millions of people worldwide. The purpose of this study was to examine the effect of compliance with buprenorphine on reducing relapse among a sample of patients in treatment for OD. Patients new to buprenorphine (N?= 703) completed the Addiction Severity Index (ASI) at baseline, and at 1, 2, and 3 months postbaseline. The ASI is a semistructured interview designed to measure problem severity in seven functional areas known to be affected by alcohol and drug dependence. Compliance was defined as taking buprenorphine medication on at least 22 of the past 28 days (80%), while relapse classification was based on resumed use of opioids during the follow-up period (months 2 and 3). Relapse was regressed onto demographic indicators, baseline ASI composite scores, and compliance with buprenorphine. Noncompliant patients were over 10 times more likely to relapse than those who were compliant (exp ?= 10.55;?p?< .001). Neither demographics nor baseline ASI composite scores were predictive of relapse (p's > .05). Compliance with medication-assisted treatment supports abstinence, essential for patient recovery. Understanding the factors that drive treatment compliance and noncompliance may assist providers in supporting patient compliance and recovery.? PMID:22211347
Tkacz, Joseph; Severt, Jamie; Cacciola, John; Ruetsch, Charles
Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40
ERIC Educational Resources Information Center
This Treatment Improvement Protocol (TIP) addresses the clinical use of buprenorphine in the treatment of opioid addiction. TIPs are best-practice guidelines for the treatment of substance use disorders that make the latest research in substance abuse treatment available to counselors and educators. The content was generated by a panel of experts�
Boone, Margaret; Brown, Nancy J.; Moon, Mary A.; Schuman, Deborah J.; Thomas, Josephine; Wright, Denise L.
Abuse liability of intravenous buprenorphine/naloxone and buprenorphine alone in buprenorphine-maintained intravenous heroin abusers
BACKGROUND Sublingual buprenorphine is an effective maintenance treatment for opioid dependence, yet intravenous buprenorphine misuse occurs. A buprenorphine/naloxone formulation was developed to mitigate this misuse risk. This randomized, double-blind, crossover study was conducted to assess the intravenous abuse potential of buprenorphine/naloxone compared with buprenorphine in buprenorphine-maintained injection drug users (IDUs). METHODS Intravenous heroin users (n=12) lived in the hospital for 8�9 weeks and were maintained on each of 3 different sublingual buprenorphine doses (2 mg, 8 mg, 24 mg). Under each maintenance dose, participants completed laboratory sessions during which the reinforcing and subjective effects of intravenous placebo, naloxone, heroin, and low and high doses of buprenorphine and buprenorphine/naloxone were examined. Every participant received each test dose under the 3 buprenorphine maintenance dose conditions. RESULTS Intravenous buprenorphine/naloxone was self-administered less frequently than buprenorphine or heroin (P < 0.0005). Participants were most likely to self-administer drug intravenously when maintained on the lowest sublingual buprenorphine dose. Subjective ratings of �drug liking� and �desire to take the drug again� were lower for buprenorphine/naloxone than for buprenorphine or heroin (P = 0.0001). Participants reported that they would pay significantly less money for buprenorphine/naloxone than for buprenorphine or heroin (P < 0.05). Seven adverse events were reported; most were mild and transient. CONCLUSIONS These data suggest that although the buprenorphine/naloxone combination has intravenous abuse potential, it is lower than for buprenorphine alone, particularly when participants received higher maintenance dosages and lower buprenorphine/naloxone challenge doses. Buprenorphine/naloxone may be a reasonable option for managing the risk for buprenorphine misuse during opioid dependence treatment.
Comer, Sandra D.; Sullivan, Maria A.; Vosburg, Suzanne K.; Manubay, Jeanne; Amass, Leslie; Cooper, Ziva D.; Saccone, Phillip; Kleber, Herbert D.
Top Manager Effects on Buprenorphine Adoption in Outpatient Substance Abuse Treatment Programs
To examine the influence of top managers� characteristics on the adoption of buprenorphine for opioid dependence among U.S.\\u000a outpatient substance abuse treatment units, this investigation analyzed a cross-sectional national study of 547 such units\\u000a in the 2004�2005 wave of the Drug Abuse Treatment System Survey. Administrators reported their demographics, training, and\\u000a treatment orientation, as well as features of the unit
Peter D. Friedmann; Lan Jiang; Jeffrey A. Alexander
Buprenorphine adoption in the National Drug Abuse Treatment Clinical Trials Network
The National Drug Abuse Treatment Clinical Trials Network (CTN), a collaborative federal research initiative that brings together universities and community-based treatment programs (CTPs), has conducted multiple clinical trials of buprenorphine for opioid dependence. Part of the CTN's mission is to promote the adoption of evidence-based treatment technologies. Drawing on a data collected during face-to-face interviews with administrators from a panel
Hannah K. Knudsen; Amanda J. Abraham; J. Aaron Johnson; Paul M. Roman
Buprenorphine and nor-buprenorphine levels in head hair samples from former heroin users under Suboxone� treatment.
In the current study, buprenorphine (BUP) and its major metabolite, nor-buprenorphine (NBUP), were determined in hair samples from former heroin users following Suboxone� treatment. Hair samples from 36 subjects were analyzed. The drugs of interest were isolated from hair by solid-liquid extraction with methanol and were determined by liquid chromatography-mass spectrometry, using an electrospray ionization interface. The analytical parameters of the method (such as linearity, limits of quantification, recovery, accuracy, and precision) were determined. The inter-quartile range of BUP levels was from 11.4 to 37.4?pg/mg (mean value 56.6?pg/mg) for the proximal hair segment, from 5.8 to 43.3?pg/mg for the middle hair segment (mean value 25.3?pg/mg), while a range from 4.3 to 33.9?pg/mg (mean value 105.2?pg/mg) for the distant to the root hair segment was determined. For NBUP the corresponding inter-quartile range was from 27.0 to 147.6 for the proximal segment (mean value 95.4?pg/mg), from 21.5 to 164.7?pg/mg for the middle segment (mean value 102.0?pg/mg) and from 20.4 to 103.6?pg/mg for the distant segment (mean value 156.8?pg/mg). The mean BUP/NBUP concentration ratio was 0.5. The daily dose of Suboxone� correlated significantly with BUP and NBUP levels in hair (p?=?0.001 and p?=?0.023) as well as with the BUP/NBUP ratio (p?=?0.010). No significant correlation was found between the levels of BUP and NBUP and the duration of Suboxone� administration. The developed and validated method was successfully used for the determination of BUP and NBUP in hair samples collected from former heroin users under Suboxone� treatment. Copyright � 2014 John Wiley & Sons, Ltd. PMID:24817054
Belivanis, Stamatis; Tzatzarakis, Manolis N; Vakonaki, Elena; Kovatsi, Leda; Mantsi, Mary; Alegakis, Athanasios; Kavvalakis, Matthaios P; Vynias, Dionisios; Tsatsakis, Aristidis M
Buprenorphine versus methadone for opioid dependence: predictor variables for treatment outcome
The present study compared in a clinical non-experimental setting the efficacy of buprenorphine (BUP) and methadone (METH) in the treatment of opioid dependence: all the subjects included in the study showed severe long-lasting heroin addiction. Participants (154) were applicants to a 12 weeks treatment program, who were assigned to either METH (78) (mean doses 81.5�36.4mg) or BUP (76) (mean doses
G Gerra; F Borella; A Zaimovic; G Moi; M Bussandri; C Bubici; S Bertacca
Suboxone� (Buprenorphine\\/Naloxone) as an Agonist Opioid Treatment in Spain: A Budgetary Impact Analysis
Objective: To evaluate the economic impact of buprenorphine\\/naloxone (B\\/N) as an agonist opioid treatment for opiate dependence. Methods: A budgetary impact analysis model was designed to calculate the annual costs (drugs and associated costs) to the Spanish National Healthcare System of methadone versus B\\/N. Data for the model were obtained from official databases and expert panel opinion. Results: It was
Jos� Mart�nez-Raga; Francisco Gonz�lez Saiz; C�sar Pascual; Miguel A. Casado; Francisco J. Sabater Torres
A placebo controlled clinical trial of buprenorphine as a treatment for opioid dependence
Large-scale placebo controlled clinical trials assessing the efficacy of medications for the treatment of drug dependence have generally been limited to alcohol, cocaine and nicotine dependent populations. The purpose of the present study was to assess the early (1�2 week) clinical effectiveness of buprenorphine versus placebo in an opioid dependent population. The study used a parallel-group design with a behavioral
Rolley E. Johnson; Thomas Eissenberg; Maxine L. Stitzer; Eric C. Strain; Ira A. Liebson; George E. Bigelow
Reversal of Sleep Disturbances in Cocaine-and Heroin-Dependent Men During Chronic Buprenorphine Treatment
Changes in sleep architecture and continuity are frequent side effects of drugs of abuse, and complaints of poor sleep are often reported by recovering drug abusers. As part of a Phase 1 assessment of the safety and efficacy of 4 and 8 mg\\/day of buprenorphine treatment, the sleep patterns of 20 male opiate-and cocaine-dependent patients were quantified by using standard
Scott E. Lukas; Cynthia M. Dorsey; Nancy K. Mello; Jack H. Mendelson; Leslie H. Lundahl; Michelle Sholar; Steven L. Cunningham
Buprenorphine and methadone maintenance in jail and post-release: a randomized clinical trial.
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. PMID:18930603
Magura, Stephen; Lee, Joshua D; Hershberger, Jason; Joseph, Herman; Marsch, Lisa; Shropshire, Carol; Rosenblum, Andrew
Patterns of non-compliant buprenorphine, levomethadone, and methadone use among opioid dependent persons in treatment
Background The non-compliant use of opioid substitution treatment (OST) medicines is widespread and well-documented. However, less is known about characteristics of non-compliant OST medicine use and the factors that predict it. The two main goals of this study are to compare characteristics of non-compliant levomethadone, methadone, and buprenorphine use and to explore factors that may differentially predict it among opioid dependent persons in treatment. Methods Data from 595 opioid dependent patients with non-compliant OST medicine use were analyzed. Characteristics of use between substances were compared using chi-squared tests and predictive factors were explored through multinomial logistic regressions. Results Non-compliant levomethadone and methadone use was characterized by more frequent parallel consumption of other psychoactive substances and intravenous use, whereas buprenorphine was more often procured without a prescription. Regarding predictive factors, methadone was perceived to relieve withdrawal symptoms better than buprenorphine and levomethadone was perceived as being better at modulating the effects of other substances and worst at enhancing mood. Conclusions Patterns of non-compliant use differ according to OST medicine. These patterns are considered with the reduction of non-compliant use and the improvement of treatment in mind.
Effects of buprenorphine versus buprenorphine\\/naloxone tablets in non-dependent opioid abusers
Rationale: Buprenorphine is an opioid agonist-antagonist under development in the United States as a sublingual medication for treatment\\u000a of opioid dependence. Buprenorphine may be abused; therefore, tablets combining buprenorphine with naloxone have been developed\\u000a with the intent of reducing the abuse risk in people physically dependent upon opioids. The characteristics and abuse potential\\u000a of buprenorphine and buprenorphine\\/naloxone tablets in non-dependent
Eric C. Strain; Kenneth Stoller; Sharon L. Walsh; George E. Bigelow
Heroin Dependence Treatment in Malaysia: A randomized, double-blind placebo-controlled comparison of buprenorphine and naltrexone maintenance treatment
Background Expanding access to effective treatments for heroin dependence is a global health priority that will also reduce HIV transmission. This study compares the efficacy for maintaining heroin abstinence, preventing relapse, and reducing HIV risk behaviors of three common treatments: detoxification followed by drug counseling only or drug counseling combined with opioid antagonist (naltrexone) or agonist (buprenorphine) maintenance treatment. Methods 126 detoxified heroin dependent patients in Malaysia were randomly assigned to 24 weeks of medication maintenance with naltrexone, buprenorphine, or placebo, provided double-blind and double-dummy. All patients received manual-guided drug counseling. Primary outcomes, assessed by three times per week urine testing, were days to first heroin use, days to heroin relapse (3 consecutive opioid-positive urine tests), maximum consecutive days heroin abstinence, and, assessed by self-report at baseline, 3- and 6-months, reductions in HIV risk behaviors. The study was terminated after 22 months of enrolment, based on findings of superior buprenorphine efficacy in an interim safety analysis and the recommendation of the Data and Safety Monitoring Board. This study is registered with ClinicalTrials.gov, with the number NCT00383045. Findings We observed consistent, significant linear contrasts in days to first heroin use (p<0.001), days to heroin relapse (p<0.001), maximum consecutive days heroin abstinence (p<0.01), and retention (p<0.001), with all results best for buprenorphine, intermediate for naltrexone, and worst for placebo. Buprenorphine was associated with significantly greater time to first heroin use and retention compared to naltrexone (p<0.01 for both measures) or placebo (p<0.001 for both measures) and also significantly greater time to heroin relapse (p<0.01) and maximum consecutive weeks abstinent (p<0.01) compared to placebo. There were no significant differences between naltrexone and placebo on these measures. HIV risk behaviors were significantly reduced from baseline across all 3 treatments (p<0.001), but the reductions did not differ significantly among the 3 treatments. Interpretation The effectiveness of buprenorphine for maintaining prolonged periods of abstinence, delaying the time to resumption of heroin use or relapse, and retaining patients in treatment supports widespread dissemination of opioid agonist maintenance treatment.
Schottenfeld, Richard S.; Chawarski, Marek C.; Mazlan, Mahmud
Improved Quality of Life for Opioid Dependent Patients Receiving Buprenorphine Treatment in HIV Clinics
Background Opioid dependence and HIV infection are associated with poor health-related quality of life (HRQOL). Buprenorphine/naloxone (bup/nx) provided in HIV care settings may improve HRQOL. Methods We surveyed 289 HIV-infected opioid-dependent persons treated with clinic-based bup/nx about HRQOL using the Short Form Health Survey (SF-12) administered at baseline, 3, 6, 9, and 12 months. We used normalized SF-12 scores which correspond to a mean HRQOL of 50 for the general U.S. population (SD 10, possible range 0�100). We compared mean normalized mental and physical composite and component scores in quarters 1, 2, 3, and 4 with baseline scores using GEE models. We assessed the effect of clinic-based bup/nx prescription on HRQOL composite scores using mixed effects regression with site as random effect and time as repeated effect. Results Baseline normalized SF-12 scores were lower than the general U.S. population for all HRQOL domains. Average composite mental HRQOL improved from 38.3 (SE 12.5) to 43.4 (SE 13.2) (? 1.13 [95% CI 0.72, 1.54]) and composite physical HRQOL remained unchanged (? 0.21 [95% CI ?0.16, 0.57]) over 12 months follow-up. Continued bup/nx treatment across all four quarters was associated with improvements in both physical (? 2.38 [95% CI 0.63, 4.12]) and mental (? 2.51 [95% CI 0.42, 4.60]) HRQOL after adjusting for other contributors to HRQOL. Conclusions Clinic-based bup/nx maintenance therapy is potentially effective in ameliorating some of the adverse effects of opioid dependence on HRQOL for HIV-infected populations.
Korthuis, P. Todd; Tozzi, Mary Jo; Nandi, Vijay; Fiellin, David A.; Weiss, Linda; Egan, James E.; Botsko, Michael; Acosta, Angela; Gourevitch, Marc N.; Hersh, David; Hsu, Jeffrey; Boverman, Joshua; Altice, Frederick L.
A retrospective evaluation of patients switched from buprenorphine (subutex) to the buprenorphine/naloxone combination (suboxone)
Background In Finland, buprenorphine (Subutex) is the most abused opioid. In order to curb this problem, many treatment centres transferred ("forced transfer") their buprenorphine patients to the buprenorphine plus naloxone (Suboxone) combination product in late 2003. Methods Data from a retrospective study involving five different treatment centers, examining the effects of switching patients to Suboxone, were gathered from 64 opioid-dependent patients who had undergone the medication transfer. Results Most patients (90.6%) switched to Suboxone at the same dose of buprenorphine that they had been receiving as Subutex (average 22 mg). The majority of these patients (71.9%) were maintained at the same dose of Suboxone throughout the 4-week study period. During the first 4 weeks, 50% of the patients reported adverse events and at the four month time point, 26.6% reported adverse events. However, due to adverse events one patient only discontinued treatment with Suboxone during the 4-week study period, and five during the four month follow-up period. Of the 26 patients in the follow-up period, Suboxone was misused intravenously once each by 4 patients and twice by 1 patient. These 5 patients all reported that injecting Suboxone was like injecting "nothing" with any euphoria, or that it was a bad experience. Conclusion We conclude that when patients are transferred from high doses (> 22 mg) of buprenorphine to the combination product, dose adjustments may be necessary especially in the later phase of the treatment. We recommend that a transfer from Subutex to Suboxone should be carefully discussed and planned in advance with the patients and after the transfer adverse events should be regularly monitored. With regard of buprenorphine IV abuse, the combination product seems to have a less abuse potential than buprenorphine alone.
Simojoki, Kaarlo; Vorma, Helena; Alho, Hannu
[Buprenorphine transdermal patch (Norspan tape)].
Buprenorphine is a chemically synthesized opioid characterized as the partial mu agonist and kappa antagonist, and transdermal buprenorphine patch will be considered useful as a strong analgesic with fewer psychological side effects in the treatment of chronic non-cancer pain. Use of transdermal buprenorphine should be limited for pain relief of intractable muscle skeletal pain that cannot be alleviated with other analgesics. To avoid severe complication and drug abuse or addiction, assessment of pain and medical history including drug dependence by medical team are important before administration of transdermal buprenorphine. Moreover, side effects such as nausea, vomiting, constipation, erythema and itching, loss of appetite should be treated appropriately. When transdermal buprenorphine is administered to chronic pain patients, physicians must examine the condition of patients regularly at an outpatient clinic. Moreover, decreasing and discontinuation of opioid including transdermal buprenorphine should always be considered during the treatment. Most important objective of chronic pain treatment is to improve QOL and ADL of patients. PMID:23905402
Hamaguchi, Shinsuke; Ikeda, Tomohito
Infant neurobehavior following prenatal exposure to methadone or buprenorphine: results from the neonatal intensive care unit network neurobehavioral scale.
This study examined the neurobehavioral functioning of neonates prenatally exposed to methadone (n = 11) or buprenorphine (n = 10), who underwent the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) examinations on days 3, 5, 7, 10, and 14 post-delivery. Linear mixed model analyses revealed that NNNS scores of arousal and excitability showed significant differences between medications over time. Compared to neonates who did not require medication to treat neonatal abstinence syndrome (NAS), neonates receiving pharmacotherapy for NAS showed differences over time in quality of movement, excitability, and lethargy. Results suggest the NNNS may detect subtle differences over time between both neonates prenatally exposed to methadone or buprenorphine and neonates pharmacologically treated or untreated for NAS. PMID:20482340
Jones, Hendr�e E; O'Grady, Kevin E; Johnson, Rolley E; Velez, Martha; Jansson, Lauren M
Buprenorphine-Naloxone Maintenance Following Release from Jail
Primary care is understudied as a re-entry drug and alcohol treatment setting. This study compared treatment retention and opioid misuse among opioid dependent adults seeking buprenorphine/naloxone maintenance in an urban primary care clinic following release from jail vs. community referrals. Post-release patients were either; a) induced to buprenorphine in-jail as part of a clinical trial, or, b) seeking buprenorphine induction post-release. From 2007�2008, N=142 patients were new to primary care buprenorphine: n=32 post-release; n=110 induced after community referral and without recent incarceration. Jail-released patients were more likely African American or Hispanic and uninsured. Treatment retention rates for post-release (37%) vs. community (30%) referrals were similar at 48 weeks. Rates of opioid positive urines and self-reported opioid misuse were also similar between groups. Post-release patients in primary care buprenorphine treatment had equal treatment retention and rates of opioid abstinence vs. community-referred patients.
Lee, Joshua D.; Grossman, Ellie; Truncali, Andrea; Rotrosen, John; Rosenblum, Andrew; Magura, Steven; Gourevitch, Marc N.
The effects of buprenorphine in buprenorphine-maintained volunteers
Buprenorphine is a mu opioid partial agonist currently used as an analgesic, and being developed for the treatment of opioid\\u000a dependence. The purpose of this study was to determine the abuse liability of parenteral buprenorphine in volunteers maintained\\u000a on daily sublingual (SL) buprenorphine (8?mg). In a residential laboratory, eight volunteers underwent pharmacologic challenges\\u000a two times per week. Medication challenges were
Eric C. Strain; Sharon L. Walsh; Kenzie L. Preston; Ira A. Liebson; George E. Bigelow
Initiation of buprenorphine during incarceration and retention in treatment upon release.
We report here on a feasibility study of initiating buprenorphine/naloxone prior to release from incarceration and linking participants to community treatment providers upon release. The study consisted of a small number of Rhode Island (RI) prisoners (N = 44) diagnosed with opioid dependence. The study design is a single arm, open-label pilot study with a 6-month follow up interview conducted in the community. However, a natural experiment arose during the study comparing pre-release initiation of buprenorphone/naloxone to initiation post-release. Time to post-release prescriber appointment (mean days) for initiation of treatment outside Rhode Island Department of Corrections (RIDOC) versus inside RIDOC was 8.8 and 3.9, respectively (p = .1). Median post release treatment duration (weeks) for outside RIDOC versus inside RIDOC was 9 and 24, respectively (p = .007). We conclude that initiating buprenorphine/naloxone prior to release from incarceration may increase engagement and retention in community-based treatment. PMID:23541303
Zaller, Nickolas; McKenzie, Michelle; Friedmann, Peter D; Green, Traci C; McGowan, Samuel; Rich, Josiah D
Facts about Buprenorphine for Treatment of Opioid Addiction
... in treatment. Through counseling, you learn about the motivations and behaviors that led to your opioid addiction. ... Counseling can provide you with encouragement and with motivation to stick to treatment. It can help you ...
Similarities and Differences in Opiod Treatment Programs that Provide Methadone Maintenance or Buprenorphine Maintenance. The N-SSATS Report.
National Technical Information Service (NTIS)
The National Survey of Substance Abuse Treatment Services (N-SSATS) asks OTPs about their services. This report includes information about OTPs that responded to N-SSATS; it does not include data from private physicians who prescribe buprenorphine. This r...
Buprenorphine: how to use it right
The unique pharmacology of buprenorphine at the mu-opioid receptor (i.e. high affinity, low intrinsic activity and slow dissociation) results in buprenorphine having: (1) a good safety profile, (2) low physical dependence, and (3) flexibility in dose scheduling. Early studies assessed the effectiveness of buprenorphine for the treatment of opioid dependence using a sublingual solution formulation. More recently, a combination tablet
Rolley E. Johnson; Eric C. Strain; Leslie Amass
A novel community-based buprenorphine program: client description and initial outcomes.
The aims of this retrospective, descriptive study were to describe clients served by a buprenorphine program in a community-based recovery center and to present initial treatment outcomes. A record review was conducted for clients treated from July 2010 to August 2011. Client demographic, health, substance use, and treatment history data were abstracted from the records of the first 78 clients served. Buprenorphine and opiate use data were collected via urine toxicology reports, collected weekly among clients who remained enrolled in treatment. The average percentages of weeks spent opiate free and buprenorphine compliant were 83% (SD = 26%) and 95% (SD = 13%), respectively. When positive heroin toxicology and negative buprenorphine toxicology were replaced for the missing/unknown data, the average percentages of opiate-abstinent weeks and buprenorphine compliance were 60% (SD = 34%) and 74% (SD = 28%), respectively. Roughly half of all clients (49%) were successfully transitioned to continue treatment with buprenorphine in a primary care setting. Findings from this study demonstrate that buprenorphine treatment for opiate dependence can be incorporated into a community-based recovery center with high rates of opiate abstinence and treatment adherence. PMID:24394496
Daniels, Amy M; Salisbury-Afshar, Elizabeth; Hoffberg, Adam; Agus, Deborah; Fingerhood, Michael I
Transdermal buprenorphine for the treatment of cancer pain: results from a multicenter, observational, post-marketing study in Spain (RELIEF study).
SUMMARY�Aim:This study evaluated health outcomes in patients with cancer pain during treatment with transdermal buprenorphine, including quality of life, effectiveness, tolerability, and functional consequences for patients and their carers. Methods: In this 3-month, noncomparative, multicenter, observational study performed in a normal clinical practice setting in Spain, patients received transdermal buprenorphine 37, 52.5 or 70 �g/h, with patches changed every 96 h. The effect of transdermal buprenorphine on quality of life (primary study focus) was assessed using the Visual Analog Scale (VAS) component of the EuroQol 5 Dimensions� (EQ-5D). In addition, pain (assessed using the Brief Pain Inventory - Short Form [BPI-SF] and VAS-pain), the impact of pain on patients and carers (assessed using the Beck Depression Inventory, sleep quality analysis, VAS-patient limitation, VAS-carer limitation and the Palliative Care Scale), patient's use of health resources, patient satisfaction, and tolerability, were evaluated. Results: Of 116 patients entering the study, 42 completed the 3-month study period. Five patients withdrew due to adverse events. The two main reasons for study discontinuation were nontreatment-related death (27.1%) and lost to follow-up (18.8%). The mean age was 62.9 years and the mean baseline duration of pain was 7.78 weeks. In the month prior to starting transdermal buprenorphine, 80% of patients had received at least one nonopioid analgesic medication; 21% had received an opioid analgesic (most commonly tramadol). The most common dose of transdermal buprenorphine used was 35 �g/h. The mean improvement from baseline in the EQ-5D VAS score among 65 patients with data was 15.20 � 24.96 (p < 0.0001). EQ-5D descriptive parameters also improved during the study (not statistically significant). Mean improvements in BPI scores for worst pain (3.76) and average pain (3.03) were significant (p < 0.0001). The other measures of pain relief also supported transdermal buprenorphine as an effective analgesic. Sleep quality improved during the study. VAS scores (100 mm scale) for patient limitation and caregiver burden due to pain improved, with a significant mean change in VAS-carer limitation score (30.34; p < 0.0001). Adverse events were reported by ten (8.6%) patients, most commonly affecting the gastrointestinal system (vomiting [4.3% of patients], nausea [2.6%] and constipation [0.9%]). The majority of patients reported satisfaction with their analgesic treatment. Conclusions: In this observational study in normal clinical practice, transdermal buprenorphine provided effective pain relief and was generally well tolerated by patients with cancer pain. It also improved quality of life for patients and reduced caregiver burden. Considering the high number of study discontinuations (mainly due to nontreatment-related death and lost to follow-up), the results of this study need to be evaluated with caution. PMID:24645762
Camps, Carlos; Casinello, Javier; Virizuela, J Antonio; Escobar, Yolanda; Sanchez-Magro, Isabel; Stern, Andres
Characteristics of U.S. substance abuse treatment facilities adopting buprenorphine in its initial stage of availability
This study examined the adoption of buprenorphine for the treatment of opiate dependence among U.S. substance abuse treatment facilities and their characteristics at the time of the initial availability of the medication. Data come from a 2003 national survey of all substance abuse treatment facilities in the U.S. Out of our sample of 13,060 facilities, 5.5% of facilities reported they
Alison L. Koch; Cynthia L. Arfken; Charles R. Schuster
Genetic variation in OPRD1 and the response to treatment for opioid dependence with buprenorphine in European-American females.
Two commonly prescribed treatments for opioid addiction are methadone and buprenorphine. Although these drugs show some efficacy in treating opioid dependence, treatment response varies among individuals. It is likely that genetic factors have a role in determining treatment outcome. This study analyses the pharmacogenetic association of six polymorphisms in OPRD1, the gene encoding the delta-opioid receptor, on treatment outcome in 582 opioid addicted European Americans randomized to either methadone or buprenorphine/naloxone (Suboxone) over the course of a 24-week open-label clinical trial. Treatment outcome was assessed as the number of missed or opioid-positive urine drug screens over the 24 weeks. In the total sample, no single-nucleotide polymorphisms (SNPs) in OPRD1 were significantly associated with treatment outcome in either treatment arm. However, sex-specific analyses revealed two intronic SNPs (rs581111 and rs529520) that predicted treatment outcome in females treated with buprenorphine. Females with the AA or AG genotypes at rs581111 had significantly worse outcomes than those with the GG genotype when treated with buprenorphine (P=0.03, relative risk (RR)=1.67, 95% confidence interval (CI) 1.06-2.1). For rs529520, females with the AA genotype had a significantly worse outcome than those with the CC genotype when (P=0.006, RR=2.15, 95% CI 1.3-2.29). No significant associations were detected in males. These findings suggest that rs581111 and rs52920 may be useful when considering treatment options for female opioid addicts, however, confirmation in an independent sample is warranted. PMID:24126707
Clarke, T-K; Crist, R C; Ang, A; Ambrose-Lanci, L M; Lohoff, F W; Saxon, A J; Ling, W; Hillhouse, M P; Bruce, R D; Woody, G; Berrettini, W H
The cost-effectiveness of buprenorphine maintenance therapy for opiate addiction in the United States
Aims. To determine the cost-effectiveness of buprenorphine maintenance therapy for opiate addiction in the United States, particularly its effect on the HIV epidemic. Design. We developed a dynamic model to capture the effects of adding buprenorphine maintenance to the current opiate dependence treatment system. We evaluated incremental costs, including all health-care costs, and incremental effectiveness, measured as quality-adjusted life years
Paul G. Barnett; Gregory S. Zaric; Margaret L. Brandeau
Timing of buprenorphine adoption by privately funded substance abuse treatment programs: The role of institutional and resource-based interorganizational linkages
Identifying facilitators of more rapid buprenorphine adoption may increase access to this effective treatment for opioid dependence. Using a diffusion of innovations theoretical framework, we examine the extent to which programs' interorganizational institutional and resource-based linkages predict the likelihood of being an earlier adopter, later adopter, or nonadopter of buprenorphine. Data were derived from face-to-face interviews with administrators of 345
Sarah A. Savage; Amanda J. Abraham; Hannah K. Knudsen; Tanja C. Rothrauff; Paul M. Roman
Methadone vs. buprenorphine\\/naloxone during early opioid substitution treatment: a naturalistic comparison of cognitive performance relative to healthy controls
BACKGROUND: Both methadone- and buprenorphine-treated opioid-dependent patients frequently show cognitive deficits in attention, working memory, and verbal memory. However, no study has compared these patient groups with each other during early opioid substitution treatment (OST). Therefore, we investigated attention, working memory, and verbal memory of opioid-dependent patients within six weeks after the introduction of OST in a naturalistic setting and
Pekka Rapeli; Carola Fabritius; Hannu Alho; Mikko Salaspuro; Kristian Wahlbeck; Hely Kalska
Predictors of attrition with buprenorphine/naloxone treatment in opioid dependent youth?
Background In opioid dependent youth there is substantial attrition from medication-assisted treatment. If youth at risk for attrition can be identified at treatment entry or early in treatment, they can be targeted for interventions to help retain them in treatment. Methods Opioid dependent adolescents and young adults (n=152), aged 15�21, were randomized to 12 weeks (BUP, n=74) or 2 weeks of detoxification (DETOX, n=78) with buprenorphine/naloxone (Bup/Nal), both in combination with 12 weeks of psychosocial treatment. Baseline and early treatment related predictors of treatment attrition were identified in each group using bivariate and multivariate logistic regression. Results In the DETOX group 36% left between weeks 2 and 4, at the end of the dose taper, while in the BUP group only 8% left by week 4. In the BUP group, early adherence to Bup/Nal, early opioid negative urines, use of any medications in the month prior to treatment entry, and lifetime non-heroin opioid use were associated with retention while prior 30-day hallucinogen use was associated with attrition. In the DETOX group, only use of sleep medications was associated with retention although not an independent predictor. A broad range of other pre-treatment characteristics was unrelated to attrition. Conclusions Prompt attention to those with early non-adherence to medication or an early opioid positive urine, markers available in the first 2 weeks of treatment, may improve treatment retention. Extended Bup/ Nal treatment appeared effective in improving treatment retention for youth with opioid dependence across a wide range of demographics, and pre-treatment clinical characteristics.
Warden, Diane; Subramaniam, Geetha A.; Carmody, Thomas; Woody, George E.; Minhajuddin, Abu; Poole, Sabrina A.; Potter, Jennifer; Fishman, Marc; Bogenschutz, Michael; Patkar, Ashwin; Trivedi, Madhukar H.
Patient Characteristics Associated with Buprenorphine/Naloxone Treatment Outcome for Prescription Opioid Dependence: Results from a Multisite Study
Background Prescription opioid dependence is a growing problem, but little research exists on its treatment, including patient characteristics that predict treatment outcome. Methods A secondary analysis of data from a large multisite, randomized clinical trial, the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study (POATS) was undertaken to examine baseline patient characteristics (N=360) associated with success during 12-week buprenorphine/naloxone treatment for prescription opioid dependence. Baseline predictor variables included self-reported demographic and opioid use history information, diagnoses assessed via the Composite International Diagnostic Interview, and historical opioid use and related information from the Pain And Opiate Analgesic Use History. Results In bivariate analyses, pre-treatment characteristics associated with successful opioid use outcome included older age, past-year or lifetime diagnosis of major depressive disorder, initially obtaining opioids with a medical prescription to relieve pain, having only used opioids by swallowing or sublingual administration, never having used heroin, using an opioid other than extended-release oxycodone most frequently, and no prior opioid dependence treatment. In multivariate analysis, age, lifetime major depressive disorder, having only used opioids by swallowing or sublingual administration, and receiving no prior opioid dependence treatment remained as significant predictors of successful outcome. Conclusions This is the first study to examine characteristics associated with treatment outcome in patients dependent exclusively on prescription opioids. Characteristics associated with successful outcome after 12 weeks of buprenorphine/naloxone treatment include some that have previously been found to predict heroin-dependent patients� response to methadone treatment and some specific to prescription opioid-dependent patients receiving buprenorphine/naloxone.
Dreifuss, Jessica A.; Griffin, Margaret L.; Frost, Katherine; Fitzmaurice, Garrett M.; Potter, Jennifer Sharpe; Fiellin, David A.; Selzer, Jeffrey; Hatch-Maillette, Mary; Sonne, Susan C.; Weiss, Roger D.
Cognitive functioning during methadone and buprenorphine treatment: results of a randomized clinical trial.
Cognitive impairment in drug-dependent patients receiving methadone (MMP) maintenance treatment has been reported previously. We assessed cognitive functioning after at least 14 days of stable substitution treatment with buprenorphine (BUP) or MMP and after 8 to 10 weeks. We performed a randomized, nonblinded clinical trial in 59 drug-dependent patients receiving either BUP or MMP maintenance treatment and healthy normal controls (n = 24) matched for sex, age, and educational level. Thirteen patients dropped out of the study before the second testing was performed (BUP, n = 22; MMP, n = 24). A neuropsychological test battery was used to measure selective attention, verbal memory, motor/cognitive speed, and cognitive flexibility. In addition, subjective perceived stress was assessed with a questionnaire. Patients in both treatment groups performed equally well in all of the cognitive domains tested. Both BUP and MMP patients showed significantly improved concentration and executive functions after 8 to 10 weeks of stable substitution treatment. The control group achieved better results than the BUP and MMP groups in most cognitive domains, indicating cognitive impairment in the patients. Perceived stress did not show any significant change after 8 to 10 weeks of treatment, and no major differences were detected between the 3 groups. No effects of perceived stress on cognitive function were found. Our results indicate a cognitive impairment in patients receiving maintenance treatment with BUP or MMP compared with healthy controls. Selective attention improved in both patient groups during treatment. We propose that the improvement of attention may facilitate rehabilitation of drug-dependent patients. PMID:19011441
Soyka, Michael; Lieb, Martin; Kagerer, Sabine; Zingg, Christina; Koller, Gabriele; Lehnert, Peter; Limmer, Claudia; Kuefner, Heinrich; Hennig-Fast, Kristina
Effects of buprenorphine and methadone in methadone-maintained subjects
Buprenorphine, a partial mu opioid agonist, is an experimental medication under development for the treatment of opioid dependence as an alternative to methadone maintenance. The present study examined the relationship between level of opioid physical dependence and response to buprenorphine administration as part of a program to develop procedures for transferring patients from methadone to buprenorphine treatment. This laboratory study
S. L. Walsh; H. L. June; K. J. Schuh; K. L. Preston; G. E. Bigelow; M. L. Stitzer
Clinical and pharmacological evaluation of buprenorphine and naloxone combinations: why the 4:1 ratio for treatment?
Although only a partial ?-opiate agonist, buprenorphine can be abused and diverted from medical therapy to the illicit drug market. A combination of buprenorphine and naloxone for sublingual administration may discourage diversion and abuse by precipitating opiate withdrawal when taken parenterally. Because opiate-abusing populations are not homogeneous and have varying levels of opiate dependence, the efficacy of buprenorphine and naloxone
John Mendelson; Reese T. Jones
Timing of buprenorphine adoption by privately funded substance abuse treatment programs: The role of institutional and resource-based inter-organizational linkages
Identifying facilitators of more rapid buprenorphine adoption may increase access to this effective treatment for opioid dependence. Using a diffusion of innovations theoretical framework, we examine the extent to which programs� inter-organizational institutional and resource-based linkages predict the likelihood of being an earlier, later, or non-adopter of buprenorphine. Data were derived from face-to-face interviews with administrators of 345 privately funded substance abuse treatment programs in 2007�2008. Results of multinomial logistic regression models show that inter-organizational and resource linkages were associated with timing of adoption. Programs reporting membership in provider associations were more likely to be earlier adopters of buprenorphine. Programs that relied more on resources linkages, such as the detailing activities by pharmaceutical companies and the NIDA website, were more likely to be earlier adopters of buprenorphine. These findings suggest that institutional and resource-based inter-organizational linkages may expose programs to effective treatments, thereby facilitating more rapid and sustained adoption of innovative treatment techniques.
Savage, Sarah A.; Abraham, Amanda J.; Knudsen, Hannah K.; Rothrauff, Tanja C.; Roman, Paul M.
Short-Term Buprenorphine Maintenance
Fifty-two heroin addicts were inducted onto buprenorphine under the care of psychiatric residents in a setting modeled on office practice. Subjects were maintained on a protocol of six weeks of 16 mg daily dosing, then tapered to zero dose up to week 16, and maintained on placebo through week 18. Of 44 subjects who continued after the first induction dose,
Marc Galanter; Helen Dermatis; Richard Resnick; Robert Maslansky; Erna Neumann
Gender Differences Among Prisoners With Pre-Incarceration Heroin Dependence Participating in a Randomized Clinical Trial of Buprenorphine Treatment
The primary focus of the current study is to examine whether gender and other baseline characteristics were significantly associated with more severe patterns of drug use. It involves data from 260 male and female pre-release prison inmates with pre-incarceration heroin dependence who enrolled in a randomized clinical trial of prison-initiated buprenorphine. Three outcomes are examined: 1) Lifetime Intravenous drug use; 2) Lifetime number of drugs used; and 3) Heroin use in prison. Regarding lifetime intravenous drug use; race (p = .0001), education (p = .009), age (p = .0001), and psychological treatment (p = .028) were significant. Concerning lifetime number of drugs used; race (p =.0001) and age of first crime (p = .001) were significant. Finally, gender (p = .004), was the only significant variable in terms of using heroin while in prison. All of these differences may have important clinical, treatment, and research implications, which are discussed.
Gordon, Michael S.; Kinlock, Timothy W.; Couvillion, Kathryn A.; Wilson, Monique E.; Schwartz, Robert P.; O'Grady, Kevin E.
Bioavailability of Buprenorphine from Crushed and Whole Buprenorphine (Subutex) Tablets
Background: Buprenorphine (Subutex) is the most abused opioid in Finland. In order to curb the abuse potential of this drug, many treatment centers and prisons crush Subutex tablets before administering them to patients. To date, there are no published studies comparing the efficacy and bioavailability of crushed and whole Subutex tablets. Methods: A total of 16 opioid-dependent patients stabilized on
Kaarlo Simojoki; Pirjo Lillsunde; Nicholas Lintzeris; Hannu Alho
Buprenorphine use in pregnant opioid users: a critical review.
Pregnancy in opioid users poses a number of problems to treating physicians. Most guidelines recommend maintenance treatment to manage opioid addiction in pregnancy, with methadone being the gold standard. More recently, buprenorphine has been discussed as an alternate medication. The use and efficacy of buprenorphine in pregnancy is still controversial. This article reviews the current database on the basis of a detailed and critical literature search performed in MEDLINE (206 counts). Most of the relevant studies (randomised clinical trials and one national cohort sample) were published in the last 2 years and mainly compared buprenorphine with methadone. Some studies are related to maternal outcomes, others to foetal, neonatal or older child outcomes. With respect to maternal outcomes, most studies suggest that buprenorphine has similar effects to methadone. Very few data from small studies discuss an effect of buprenorphine on neurodevelopment of the foetus. Neonatal abstinence syndrome is common in infants of both buprenorphine- and methadone-maintained mothers. As regards neonatal outcomes, buprenorphine has the same clinical outcome as methadone, although some newer studies suggest that it causes fewer withdrawal symptoms. Since hardly any studies have investigated the combination of buprenorphine with naloxone (which has been suggested to possibly have teratogenic effects) in pregnant women, a switch to buprenorphine monotherapy is recommended in women who become pregnant while receiving the combination product. These novel findings indicate that buprenorphine is emerging as a first-line treatment for pregnant opioid users. PMID:23775478
Soyka, Michael
Emergency department visits and hospitalizations for buprenorphine ingestion by children--United States, 2010-2011.
Buprenorphine (Subutex) and buprenorphine/naloxone (Suboxone) received Food and Drug Administration approval in 2002 for the treatment of opioid dependence. Introduction of these drugs expanded the availability of opioid-dependence treatment options to reduce the morbidity and mortality associated with opioid abuse, and buprenorphine has become an increasingly prescribed component of office-based treatment. However, unsupervised ingestion of buprenorphine-containing products by children is a growing concern. PMID:23344700
Emergency Department Visits Involving Buprenorphine.
National Technical Information Service (NTIS)
Buprenorphine is a medication used to treat opioid addiction. A properly prescribed dose of buprenorphine can help opioid-addicted individuals to stop misusing opioids without experiencing withdrawal symptoms. Although buprenorphine is itself an opioid, a...
Buprenorphine and naloxone interactions in opiate-dependent volunteers
Objective: Sublingual buprenorphine appears useful in the treatment of opiate dependence. A combination sublingual dose of buprenorphine and naloxone could have less potential for parenteral use by opiate-dependent individuals. To estimate the abuse potential of a combination formulation, we assessed the parenteral effects of a buprenorphine and naloxone combination in untreated heroin addicts.Methods: Eight healthy, opiate-dependent daily users of heroin
John Mendelson; Reese T. Jones; Isabella Fernandez; Susette Welm; Ann K. Melby; Matthew J. Baggott
Comparative Effects of Vasectomy Surgery and Buprenorphine Treatment on Faecal Corticosterone Concentrations and Behaviour Assessed by Manual and Automated Analysis Methods in C57 and C3H Mice
Establishing effective cage-side pain assessment methods is essential if post-surgical pain is to be controlled effectively in laboratory animals. Changes to overall activity levels are the most common methods of assessment, but may not be the most appropriate for establishing the analgesic properties of drugs, especially in mice, due their high activity levels. Use of drugs that can affect activity (e.g. opioids) is also a problem. The relative merits of both manual and automated behaviour data collection methods was determined in two inbred mouse strains undergoing vasectomy following treatment with one of 2 buprenorphine dose rates. Body weights and the effects of surgery and buprenorphine on faecal corticosterone were also measured. Surgery caused abnormal behaviour and reduced activity levels, but high dose buprenorphine caused such large-scale increases in activity in controls that we could not establish analgesic effects in surgery groups. Only pain-specific behaviour scoring using the manual approach was effective in showing 0.05 mg/kg buprenorphine alleviated post-vasectomy pain. The C57 mice also responded better to buprenorphine than C3H mice, indicating they were either less painful, or more responsive to its analgesic effects. C3H mice were more susceptible to the confounding effects of buprenorphine irrespective of whether data were collected manually or via the automated approach. Faecal corticosterone levels, although variable, were higher in untreated surgery mice than in control groups, also indicating the presence of pain or distress. Pain-specific scoring was superior to activity monitoring for assessing the analgesic properties of buprenorphine in vasectomised mice. Buprenorphine (0.01 mg/kg), in these strains of male mice, for this procedure, provided inadequate analgesia and although 0.05 mg/kg was more effective, not completely so. The findings support the recommendation that analgesic dose rates should be adjusted in relation to the potential severity of the surgical procedure, the mouse strain, and the individual animals' response.
Wright-Williams, Sian; Flecknell, Paul A.; Roughan, Johnny V.
Transdermal buprenorphine - a critical appraisal of its role in pain management
This paper reviews the current clinical data for the role of transdermal buprenorphine (BUP TDS) in the treatment of diverse acute and chronic pain syndromes. Literature searches were carried out using PubMed (1988 to June 2009). The published findings seem to support hypotheses regarding the rather unique analgesic mechanisms of buprenorphine as compared with pure ?-opioids like morphine and fentanyl. However, the exact mechanism of this analgesic efficacy still remains largely unknown despite recent advances in preclinical pharmacological studies. Such assessments have demonstrated the sustained antihyperalgesic effect of buprenorphine in diverse animal pain models. These findings are supported in a growing number of clinical studies of oral, intrathecal, intravenous, and Bup TDS. This review paper focuses almost entirely on the clinical experience concerning the transdermal administration of buprenorphine, although preclinical aspects are also addressed in order to provide a complete picture of the unique pharmacological properties of this analgesic drug. Mounting evidence indicates the appropriateness of Bup TDS in the treatment of diverse acute and chronic pain syndromes which have been less or not responsive to other opioids. Additionally, BUP TDS seems to hold great promise for other difficult-to-treat (pain) conditions, such as patients in the intensive care setting. However, its use is somewhat tempered by the occurrence of local skin reactions which have been shown to be often therapy resistant. Further studies are certainly warranted to identify even more precisely the clinical syndromes that are most sensitive to buprenorphine treatment, and to compare buprenorphine to other opioids in head-to-head trials of acute and chronic pain conditions.
Hans, Guy; Robert, Dominique
[Primary health care and family medicine--possibilities for treatment of opiate addicts].
The global trend of promoting management and treatment of drug addicts in family physician offices is the result of the success of opioid agonist therapy. Studies have shown favorable results by shifting treatment into the hands of family physician. This process contributes to general health care of drug addicts and their health by linking different areas of health care, thereby providing comprehensive protection. Shifting treatment of addiction to family physician offices contributes to the elimination of treatment isolation and stigmatization, while further benefits are lower barriers to employment, increase in patient privacy and opportunity to provide health care. The aim of this study was to provide a concise overview of the knowledge from new clinical research over the past ten years on heroin addiction treatment in primary care. New research dealing with the approach to treating addicts indicates a direct link between receiving primary health care with a reduced likelihood of using heroin; furthermore, the main concerns of drug addicts for treatment are availability of more therapeutic programs, better functioning of existing programs, and improved staff relations towards them; final results and outcomes achieved by office and hospital treatment of drug addicts are similar and confirm the positive linear relationship between treatment duration and outcome. Studies comparing therapies show a positive effect of the adaptive methadone treatment maintenance model on the psychosocial factors; equal efficiency of treatment regardless of initiation with buprenorphine or with methadone; and equal effectiveness of levo-alpha-acetylmethadol treatment compared with methadone and diacetylmorphine as a good alternative for addiction therapy with previously unsatisfactory results. New studies on buprenorphine show equal effectiveness and cost of detoxification whether guided by a family physician or at the hospital; non-supervised therapy does not significantly influence the outcome, but is significantly cheaper; long-term therapy with buprenorphine in the doctor's office shows mild retention. PMID:23814972
Tiljak, Hrvoje; Nerali?, Ivana; Cerovecki, Venija; Kastelic, Andrej; Adzi?, Zlata Ozvaci?; Tiljak, Anja
Attitudes toward buprenorphine and methadone among opioid-dependent individuals
Attitudes and beliefs about drug abuse treatment have long been known to shape response to that treatment. Two major pharmacological alternatives are available for opioid dependence: methadone, which has been available for the past 40 years, and buprenorphine, a recently-introduced medication. This mixed methods study examined the attitudes of opioid-dependent individuals toward methadone and buprenorphine. A total of 195 participants (n = 140 who were enrolling in one of 6 Baltimore area methadone programs and n = 55 who were out-of-treatment) were administered the Attitudes toward Methadone and toward Buprenorphine Scales and a subset (n = 46) received an ethnographic interview. In-treatment group had significantly more positive attitudes toward methadone than did the out-of-treatment group (p < .001), while they did not differ in their attitudes toward buprenorphine. Both groups had significantly more positive attitudes toward buprenorphine than methadone. Addressing these attitudes may increase treatment entry and retention.
Schwartz, Robert P.; Kelly, Sharon M.; O'Grady, Kevin E.; Mitchell, Shannon Gwin; Peterson, James A.; Reisinger, Heather Schacht; Agar, Michael H.; Brown, Barry S.
Socio-demographic Profile and Help-seeking Behaviour of Buprenorphine Abusers in Singapore
Introduction: The US Food and Drug Administration (FDA) approved buprenorphine or Subutex for the treatment of opiate dependence in October 2002. Buprenorphine is a partial agonist of the mu-opioid receptor; although initial animal research suggested a low abuse potential for buprenorphine, it was subsequently shown to have an abuse potential similar to that of morphine or hydromorphone. The objectives of
Munidasa Winslow; Wei-Ling Ng; Subramaniam Mythily
Rifampin, but not Rifabutin, May Produce Opiate Withdrawal in Buprenorphine-Maintained Patients*
Background This series of studies examines the pharmacokinetic/pharmacodynamic interactions between buprenorphine, an opioid partial agonist increasingly used in treatment of opioid dependence, and rifampin, a medication used as a first line treatment for tuberculosis; or rifabutin, an alternative antituberculosis medication. Methods Opioid-dependent individuals on stable doses of buprenorphine/naloxone underwent two, 24-hour blood sampling studies: 1. for buprenorphine pharmacokinetics and 2. following 15 days of rifampin 600 mg daily or rifabutin 300 mg daily for buprenorphine and rifampin or rifabutin pharmacokinetics. Results Rifampin administration produced significant reduction in plasma buprenorphine concentrations (70% reduction in mean area under the curve (AUC); p=<0�001) and onset of opiate withdrawal symptoms in 50% of participants (p=0�02). While rifabutin administration to buprenorphine-maintained subjects resulted in a significant decrease in buprenorphine plasma concentrations (35% decrease in AUC; p<0�001) no opiate withdrawal was seen. Compared with historical control data, buprenorphine had no significant effect on rifampin pharmacokinetics, but was associated with 22% lower rifabutin mean AUC (p=0�009), although rifabutin and its active metabolite concentrations remained in the therapeutic range. Conclusions Rifampin is a more potent inducer of buprenorphine metabolism than rifabutin with pharmacokinetic and pharmacodynamic adverse consequences. Those patients requiring rifampin treatment for tuberculosis and receiving buprenorphine therapy are likely to require an increase in buprenorphine dose to prevent withdrawal symptoms. Rifabutin administration was associated with decreases in buprenorphine plasma concentrations, but no clinically significant adverse events were observed.
McCance-Katz, Elinore F.; Moody, David E.; Prathikanti, Sudha; Friedland, Gerald; Rainey, Petrie M.
Clinical efficacy of buprenorphine: comparisons to methadone and placebo
Buprenorphine has been studied extensively since 1978 when it was initially proposed as an alternative to methadone for treatment of opioid dependence. Early work by Jasinski, Mello, Mendelson and their colleagues demonstrated buprenorphine's low physical abuse potential and its ability to substitute for heroin and reduce heroin self-administration in opiate-dependent humans. The subsequent early clinical studies suggested that, in clinical
Walter Ling; Donald R Wesson
Deaths involving buprenorphine: a compendium of French cases
Buprenorphine at high dosage became available in France in 1996, as a substitution treatment for heroin addicts. Since this date, numerous deaths were attributed to this drug. This paper reports two original series of 39 and 78 fatalities involving buprenorphine observed at the Institute of Legal Medicine of Strasbourg and at 13 other French forensic centers, respectively. The files were
P. Kintz
Cost analysis of clinic and office-based treatment of opioid dependence: results with methadone and buprenorphine in clinically stable patients.
The cost of providing and receiving treatment for opioid dependence can determine its adoption. To compare the cost of clinic-based methadone (MC, n=23), office-based methadone (MO, n=21), and office-based buprenorphine (BO, n=34) we performed an analysis of treatment and patient costs over 6 months of maintenance in patients who had previously been stabilized for at least 1 year. We performed statistical comparisons using ANOVA and chi-square tests and performed a sensitivity analysis varying cost estimates and intensity of clinical contact. The cost of providing 1 month of treatment per patient was $147 (MC), $220 (MO) and $336 (BO) (p<0.001). Mean monthly medication cost was $93 (MC), $86 (MO) and $257 (BO) (p<0.001). The cost to patients was $92 (MC), $63 (MO) and $38 (BO) (p=0.102). Sensitivity analyses, varying cost estimates and clinical contact, result in total monthly costs of $117 to $183 (MC), $149 to $279 (MO), $292 to $499 (BO). Monthly patient costs were $84 to $133 (MC), $55 to $105 (MO) and $34 to $65 (BO). We conclude that providing clinic-based methadone is least expensive. The price of buprenorphine accounts for a major portion of the difference in costs. For patients, office-based treatment may be less expensive. PMID:18804923
Jones, Emlyn S; Moore, Brent A; Sindelar, Jody L; O'Connor, Patrick G; Schottenfeld, Richard S; Fiellin, David A
Pain and Associated Substance Use among Opioid Dependent Individuals Seeking Office-Based Treatment with Buprenorphine-Naloxone: A Needs Assessment Study
Background and Objectives A paucity of studies has examined the pain experiences of opioid dependent individuals seeking office-based buprenorphine-naloxone treatment (BNT). We set out to examine, among those seeking BNT: (a) the prevalence of pain types (i.e., recent pain, chronic pain), (b) the characteristics of pain (intensity, frequency, duration, interference, location, and genesis), and (c) substance use to alleviate pain. Methods We surveyed 244 consecutive individuals seeking office-based buprenorphine-naloxone treatment (BNT) for opioid dependence about physical pain and associated substance use. Results Thirty-six percent of respondents reported chronic pain (CP) (i.e., pain lasting at least 3 months) and 36% reported �some pain� (SP) (i.e., past week pain not meeting the threshold for CP). In comparison to SP respondents, those with CP were, on average, older; reported greater current pain intensity, pain frequency, typical pain duration, typical pain intensity, and typical pain interference; were more likely to report shoulder or pelvis and less likely to report stomach or arms as their most bothersome pain location; and were more likely to report accident or nerve damage and less likely to report opioid withdrawal as the genesis of their pain. Both pain subgroups reported similarly high rates of past-week substance use to alleviate pain. Conclusions and Scientific Significance The high rates of pain and self-reported substance use to manage pain suggest the importance of assessing and addressing pain in BNT patients.
Barry, Declan T.; Savant, Jonathan D.; Beitel, Mark; Cutter, Christopher J.; Moore, Brent A.; Schottenfeld, Richard S.; Fiellin, David A.
Rewarding or aversive effects of buprenorphine/naloxone combination (Suboxone) depend on conditioning trial duration.
Buprenorphine is used as a sublingual medication in the treatment of opioid dependence. However, its misuse by i.v. injection may limit its acceptability and dissemination. A buprenorphine/naloxone (ratio 4:1) combination has been developed to reduce diversion and abuse. So far, the relevance of this combination has not been investigated in the animal models traditionally used to study the reinforcing effects of drugs of abuse. The aim of this study was to compare the rewarding effects, assessed by conditioned place preference (CPP), of buprenorphine and buprenorphine/naloxone combination following i.v. administration in mice. Animals were treated with different doses of buprenorphine or buprenorphine/naloxone combination (ratio 4:1), and CPP conditioning trial duration was 5 or 30�min. At the longest trial duration, a bell-shaped dose-response curve was obtained with buprenorphine, which was shifted significantly to the right with naloxone combination. At the shortest trial duration, an aversive effect was observed with the buprenorphine/naloxone combination in animals, involving opioid receptor-like 1 (ORL1). These findings may explain the discrepancies reported in the literature as some authors have shown a reduced buprenorphine/naloxone misuse compared to buprenorphine in opioid abusers, while others have not. PMID:24606726
Canestrelli, Corinne; Marie, Nicolas; Noble, Florence
From research to the real world: Buprenorphine in the decade of the Clinical Trials Network
The National Institute on Drug Abuse (NIDA) established the National Drug Abuse Treatment Clinical Trials Network (CTN) in 1999 to bring researchers and treatment providers together to develop a clinically relevant research agenda. Initial CTN efforts addressed the use of buprenorphine, a mu-opioid partial agonist, as treatment for opioid dependence. Strong evidence of buprenorphine's therapeutic efficacy was demonstrated in clinical
Walter Ling; Petra Jacobs; Maureen Hillhouse; Albert Hasson; Christie Thomas; Thomas Freese; Steven Sparenborg; Dennis McCarty; Roger Weiss; Andrew Saxon; Allan Cohen; Michele Straus; Gregory Brigham; David Liu; Paul McLaughlin; Betty Tai
Buprenorphine and naloxone co-administration in opiate-dependent patients stabilized on sublingual buprenorphine
Buprenorphine and naloxone sublingual (s.l.) dose formulations may decrease parenteral buprenorphine abuse. We evaluated pharmacologic interactions between 8 mg s.l. buprenorphine combined with 0, 4, or 8 mg of naloxone in nine opiate-dependent volunteers stabilized on 8 mg s.l. buprenorphine for 7 days. Combined naloxone and buprenorphine did not diminish buprenorphine's effects on opiate withdrawal nor alter buprenorphine bioavailability. Opiate
Debra S Harris; Reese T Jones; Susette Welm; Robert A Upton; Emil Lin; John Mendelson
Interactions Between Buprenorphine and the Protease Inhibitors Darunavir-Ritonavir and Fosamprenavir-Ritonavir
Background.?This study examined drug interactions between buprenorphine, a partial opioid agonist used for opioid dependence treatment and pain management, and the protease inhibitors (PIs) darunavir-ritonavir and fosamprenavir-ritonavir. Methods.?The pharmacokinetics of buprenorphine and its metabolites and symptoms of opioid withdrawal or excess were compared in opioid-dependent, buprenorphine-naloxone�maintained, human immunodeficiency virus (HIV)�negative volunteers (11 for darunavir-ritonavir and 10 for fosamprenavir-ritonavir) before and after 15 days of PI administration. PI pharmacokinetics and adverse effects were compared between the buprenorphine-maintained participants and an equal number of sex-, age-, race-, and weight-matched, healthy, non�opioid-dependent volunteers who received darunavir-ritonavir or fosamprenavir-ritonavir but not buprenorphine. Results.?There were no significant changes in buprenorphine or PI plasma levels and no significant changes in medication adverse effects or opioid withdrawal. Increased concentrations of the inactive metabolite buprenorphine-3-glucuronide suggested that darunavir-ritonavir and fosamprenavir-ritonavir induced glucuronidation of buprenorphine. Conclusions.?Dose adjustments are not likely to be necessary when buprenorphine and darunavir-ritonavir or fosamprenavir-ritonavir are coadministered for the treatment of opioid dependence and HIV disease.
Rainey, Petrie M.; Moody, David E.; Morse, Gene D.; Ma, Qing; Prathikanti, Sudha; Pade, Patricia A.; Alvanzo, Anika A. H.; McCance-Katz, Elinore F.
A review of the studies using buprenorphine in cats.
Pain management is a crucial component of feline medicine and surgery. This review critically evaluates studies using buprenorphine in cats and highlights the clinical application of the opioid in this species. The pharmacokinetic-pharmacodynamic (PK-PD) modeling of IV buprenorphine has been best described by a combined effect compartmental/receptor association-dissociation model with negative hysteresis. Therefore, plasma concentrations of the drug are not correlated with analgesia, and clinicians should not expect to observe pain relief immediately after drug administration. In addition, a ceiling effect has not been demonstrated after administration of clinical doses of buprenorphine in cats; dosages of up to 0.04�mg/kg have been reported. The route of administration influences the onset, duration, and magnitude of antinociception and analgesia when using this drug in cats. At clinical dosages, the SC route of administration does not appear to provide adequate antinociception and analgesia whereas the buccal route has produced inconsistent results. Intravenous or IM administration at a dosage of 0.02-0.04�mg/kg is the preferred for treatment of pain in the acute setting. A literature search found 14 clinical trials evaluating buprenorphine sedation, analgesia, or both in cats. There were 22 original research studies reporting the antinociceptive effects of buprenorphine by means of thermal threshold, mechanical threshold, or both, minimal alveolar concentration, or PK-PD. Individual variability in response to buprenorphine administration has been reported, indicating that buprenorphine may not provide sufficient analgesia in some cats. Pain assessment is important when evaluating the efficacy of buprenorphine and determining whether additional analgesic treatment is needed. PMID:24655078
Steagall, P V M; Monteiro-Steagall, B P; Taylor, P M
Managing Opioid Addiction with Buprenorphine
Legislation has enabled physicians to treat opioid-dependent patients with an office-based main- tenance program using buprenorphine, a partial mu-opioid receptor agonist. Clinical studies indicate buprenorphine effectively manages opioid addiction. Buprenorphine is more effective than placebo for managing opioid addiction but may not be superior to methadone if high doses are needed. It is comparable to lower doses of methadone, however.
Effectiveness of buprenorphine in double diagnosed patients. Buprenorphine as psychothropic drug
Summary Opiate drugs were first proposed for the treatment of dysphoric syndromes, depression and psychoses many years ago. Even so, the usefulness of these compounds in psychiatry is supported by only a small corpus of data. The reasons given for the restrictions placed on opiate use are based on prejudice rather than scientific evidence. Buprenorphine, with its unique pharmacological profile,
Icro Maremmani; Matteo Pacini; Pier Paolo Pani
Buprenorphine and Norbuprenorphine in Hair of Pregnant Women and Their Infants after Controlled Buprenorphine Administration
Background: Buprenorphine is under investigation as a pharmacotherapeutic agent for treating opioid depen- dence in pregnant women. We hypothesized that there would be a relationship between the cumulative mater- nal dose of buprenorphine during pregnancy and the concentration of buprenorphine and norbuprenorphine in maternal and infant hair. Methods: This study examined buprenorphine and nor- buprenorphine concentrations in hair obtained from
Robert S. Goodwin; Diana G. Wilkins; Olga Averin; Robin E. Choo; Jennifer R. Schroeder; Donald R. Jasinski; Rolley E. Johnson; Hendree E. Jones; Marilyn A. Huestis
National Technical Information Service (NTIS)
The major goals of this continuing project are the establishment of a telemedicine system for comprehensive diabetes management and the assessment of diabetic retinopathy that provides increased access for diabetic patients to appropriate care, that centr...
D. Birkmire-Peters D. S. Vincent J. Humphry K. Parisi
From Research to the Real World: Buprenorphine in the Decade of the Clinical Trials Network
The National Institute on Drug Abuse (NIDA) established the National Drug Abuse Treatment Clinical Trials Network (CTN) in 1999 to bring researchers and treatment providers together to develop a clinically relevant research agenda. Initial CTN efforts addressed the use of buprenorphine, a mu-opioid partial agonist, as treatment for opioid dependence. Strong evidence of buprenorphine's therapeutic efficacy was demonstrated in clinical trials involving several thousand opioid-dependent participants, and in 2002, the FDA approved buprenorphine for the treatment of opioid dependence. With the advent of a sublingual tablet containing both buprenorphine and naloxone to mitigate abuse and diversion (Suboxone�), buprenorphine appeared poised to be the first-line treatment for opioid addiction. Notwithstanding its many attributes, certain implementation barriers remained to be addressed in CTN studies, and these efforts have brought a body of knowledge on buprenorphine to front-line clinicians. The purpose of this article is to review CTN-based buprenorphine research and related efforts to overcome challenges to the implementation of buprenorphine therapy in mainstream practice. Furthermore, this paper explores current issues and future challenges that may require additional CTN efforts.
Ling, Walter; Jacobs, Petra; Hillhouse, Maureen; Hasson, Albert; Thomas, Christie; Freese, Thomas; Sparenborg, Steven; McCarty, Dennis; Weiss, Roger; Saxon, Andrew; Cohen, Allan; Straus, Michele; Brigham, Gregory; Liu, David; McLaughlin, Paul; Tai, Betty
Effect of telaprevir on the pharmacokinetics of buprenorphine in volunteers on stable buprenorphine/naloxone maintenance therapy.
This was an open-label, single-sequence trial in hepatitis C virus-negative volunteers on stable, individualized, buprenorphine maintenance therapy. Telaprevir at 750 mg every 8 h was coadministered with buprenorphine/naloxone (4:1 ratio as sublingual tablets) for 7 days with food. Pharmacokinetic profiles of buprenorphine, norbuprenorphine, and naloxone were measured over the 24-hour dosing interval on day -1 (buprenorphine/naloxone alone, reference) and day 7 of telaprevir coadministration (test). Geometric least-squares mean ratios and associated 90% confidence intervals of treatment ratios (test/reference) were calculated using log-transformed pharmacokinetic parameters. Opioid withdrawal symptoms were evaluated throughout the study (via questionnaires and pupillometry). Pharmacokinetic data were available for 14 and 13 volunteers on day -1 and day 7, respectively. The area under the concentration-time curve (AUC) for buprenorphine was unchanged and the maximum concentration of drug in serum (C(max)) for buprenorphine, C(max) and AUC for norbuprenorphine, and C(max) naxolone were modestly decreased during coadministration with telaprevir. Geometric least-squares mean ratios (90% confidence intervals) for buprenorphine were 0.80 (0.69, 0.93) for the C(max) and 0.96 (0.84, 1.10) for the AUC from 0 to 24 h (AUC(0-24)); for norbuprenorphine, values were 0.85 (0.66, 1.09) for C(max) and 0.91 (0.71, 1.16) for AUC(0-24); for naloxone, the C(max) was 0.84 (0.62, 1.13). Coadministration of telaprevir did not increase withdrawal symptom frequency, and there were no serious adverse events reported during or after completion of telaprevir coadministration. Results suggest dose adjustment may not be necessary when telaprevir and buprenorphine/naloxone are coadministered. PMID:22564847
Luo, Xia; Trevejo, Jose; van Heeswijk, Rolf P G; Smith, Frances; Garg, Varun
Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. A Treatment Improvement Protocol TIP 40.
National Technical Information Service (NTIS)
This Treatment Improvement Protocol (TIP) is composed of 6 chapters and 10 appendices, including a complete list of references (Appendix A, Bibliography). Chapter 1, Introduction, describes the basic facts regarding opioid addiction, the traditional appro...
The development of more efficient and effective cancer treatments�treatments that destroy cancer cells while leaving surrounding healthy tissue unharmed�is a critical element of NCI�s research agenda, particularly the development of therapies tailored to the cancers of individual patients. Our understanding of the molecular changes in cancer is leading to the dawn of an age of genetically informed cancer medicine for both treatment and cancer prevention.
Network therapy: decreased secondary opioid use during buprenorphine maintenance.
Network therapy (NT) employs family members and/or friends to support compliance with an addiction treatment carried out in office practice. This study was designed to ascertain whether NT is a useful psychosocial adjunct, relative to a control treatment, for achieving diminished illicit heroin use for patients on buprenorphine maintenance. Patients agreeing to randomization to either NT (N = 33) or medication management (MM, N = 33) were inducted onto short-term buprenorphine maintenance and then tapered to zero dose. NT resulted in significantly more urine toxicologies negative for opioids than MM (65% vs. 45%) and more NT than MM patients (50% vs. 23%) experienced a positive outcome relative to secondary heroin use by the end of treatment. The use of NT in office practice may therefore improve the effectiveness of eliminating secondary heroin use during buprenorphine maintenance. It may also be useful in enhancing compliance with an addiction treatment regimen in other contexts. PMID:15182896
Galanter, Marc; Dermatis, Helen; Glickman, Linda; Maslansky, Robert; Sellers, M Brealyn; Neumann, Erna; Rahman-Dujarric, Claudia
Patient perspectives of an integrated program of medical care and substance use treatment.
The benefits of integrating primary care and substance use disorder treatment are well known, yet true integration is difficult. We developed and evaluated a team-based model of integrated care within the primary care setting for HIV-infected substance users and substance users at risk for contracting HIV. Qualitative data were gathered via focus groups and satisfaction surveys to assess patients' views of the program, evaluate key elements for success, and provide recommendations for other programs. Key themes related to preferences for the convenience and efficiency of integrated care; support for a team-based model of care; a feeling that the program requirements offered needed structure; the importance of counseling and education; and how provision of concrete services improved overall well-being and quality of life. For patients who received buprenorphine/naloxone for opioid dependence, this was viewed as a major benefit. Our results support other studies that theorize integrated care could be of significant value for hard-to-reach populations and indicate that having a clinical team dedicated to providing substance use disorder treatment, HIV risk reduction, and case management services integrated into primary care clinics has the potential to greatly enhance the ability to serve a challenging population with unmet treatment needs. PMID:24428768
Drainoni, Mari-Lynn; Farrell, Caitlin; Sorensen-Alawad, Amy; Palmisano, Joseph N; Chaisson, Christine; Walley, Alexander Y
Buprenorphine and naloxone combinations: the effects of three dose ratios in morphine-stabilized, opiate-dependent volunteers
Sublingual buprenorphine is a promising new treatment for opiate dependence, but its opioid agonist effects pose a risk for\\u000a parenteral abuse. A formulation combining buprenorphine with the opiate antagonist naloxone could discourage such abuse. The\\u000a effects of three intravenous (IV) buprenorphine and naloxone combinations on agonist effects and withdrawal signs and symptoms\\u000a were examined in 12 opiate-dependent subjects. Following stabilization
J. Mendelson; Reese T. Jones; Susette Welm; Matthew Baggott; Isabella Fernandez; Ann K. Melby; Rajneesh P. Nath
The effect of buprenorphine and benzodiazepines on respiration in the rat.
Methadone and buprenorphine are the two main opioid substitution treatments for heroin dependence currently offered in Australia. A number of publications have implicated buprenorphine as being potentially dangerous in combination with benzodiazepines but no comparison has been made to the relative dangers of benzodiazepines combined with buprenorphine or methadone. The effect of i.v. methadone and buprenorphine on respiration was investigated by evaluating arterial blood pCO2, pO2 and pH, and measuring respiratory rate in rats. Measurements were taken at 0, 15, 30, 60, 120, 180 and 240 min after i.v. administration of methadone or buprenorphine. Effects on respiration were greatest 15 min after i.v. drug administration. The effect of methadone and buprenorphine on respiration was compared with and without diazepam pretreatment (20 mg/kg). Buprenorphine alone exhibited a bell shaped dose response inhibition of respiration; however the plateau of the dose response inhibition on respiration was lost when administered in combination with diazepam. Methadone showed a dose-dependent inhibitory effect on respiration, which was potentiated with diazepam pretreatment. While the effect of diazepam pretreatment was the abolishment of the protective bell shaped dose response effect on respiration, the effect of buprenorphine and diazepam was not greater than methadone and diazepam. PMID:15943948
Nielsen, Suzanne; Taylor, David A
Network therapy: Decreased secondary opioid use during buprenorphine maintenance
Network therapy (NT) employs family members and\\/or friends to support compliance with an addiction treatment carried out in office practice. This study was designed to ascertain whether NT is a useful psychosocial adjunct, relative to a control treatment, for achieving diminished illicit heroin use for patients on buprenorphine maintenance. Patients agreeing to randomization to either NT (N = 33) or
Marc Galanter; Helen Dermatis; Linda Glickman; Robert Maslansky; M. Brealyn Sellers; Erna Neumann; Claudia Rahman-Dujarric
The Implementation of Buprenorphine/Naloxone in College Health Practice
ERIC Educational Resources Information Center
Opiate abuse and dependence have become important concerns for college healthcare providers. The passage of the Drug Addiction Treatment Act of 2000 and the approval of the combination buprenorphine/naloxone for office-based treatment of opiate dependence have increased the options available for college students and their healthcare providers. The�
DeMaria, Peter A., Jr.; Patkar, Ashwin A.
Sublingual versus subcutaneous buprenorphine in opiate abusers
To compare the pharmacologic profiles of sublingually and subcutaneously administered buprenorphine, 10 healthy male subjects with histories of opiate abuse were given sublingually administered buprenorphine (1, 2, and 4 mg), subcutaneously administered buprenorphine (1 and 2 mg), and placebo in a double-blind, double-dummy, placebo-controlled study. All active buprenorphine dosages produced a significant degree of miosis but no significant changes in
Donald R Jasinski; Paul J Fudala; Rolley E Johnson; R E Johnson NIDA
Buprenorphine as a Pharmacotherapy for Cocaine Abuse
The partial �-opiate agonist, buprenorphine, is the subject of recent evaluation as a potential pharmacotherapy for cocaine dependence. This paper reviews the extant preclinical and clinical evidence of buprenorphine effectiveness in treating cocaine abuse, including data from our large methadone comparison trial and a smaller buprenorphine dose ranging study. Although buprenorphine appears to reduce cocaine self-administration in studies of non-opiate
Peggy A. Compton; Walter Ling; V. Charles Charuvastra; Donald R. Wesson
Evaluation on drug dependence of buprenorphine 1
AIM: To survey and assess the drug dependence and abuse potential liability of buprenorphine among opiate abusers. METHODS: Subjects of opiate dependence with history of buprenorphine use for 3 d at least were surveyed by interview. Physical dependence of buprenorphine was assessed using 30 items opiate withdrawal scale (OWS), which composed of 30 symptoms\\/signs. A 4-point scale was used to
LIU Zhi-Min; L� Xian-Xiang; LIAN Zhi; GUO Ping; AN Xin
Buprenorphine TDS: use in daily practice, benefits for patients.
In Germany and many other countries, buprenorphine has been used for a long time for the management of pain in both cancer and non-cancer patients. Although a transdermal delivery system for buprenorphine (Transtec) has recently been introduced, the clinical experience in daily practice with this drug, delivered in a matrix patch, is only now being evaluated. In preliminary data from a survey of 3,255 patients with chronic pain, 26% had cancer pain, while the most common diagnoses of the other respondents included back pain (33%), osteoarthritis (22%), osteoporosis (17%), and neuropathic pain (10%, multiple entries). Before being switched to the buprenorphine patch, most patients had been pretreated with World Health Organization (WHO) Step II opioids (47%) or WHO Step III opioids (18%), including tramadol (in 35% of patients) and a tilidin/naloxone combination (15%); 9% had not been prescribed any opioids in advance of receiving transdermal buprenorphine. Most patients (77%) in the survey had been started on the lowest dose of the buprenorphine patch (35 microg/h), and nearly half (49%) were placed on adjuvant analgesics, including tramadol or tilidin/naloxone. Pain relief was rated as good or very good by 81% of the respondents. Adverse effects were similar to those seen on other opioids, although their intensity was mild in most cases. Local side effects, including erythema (4% of cases) and pruritus (1%), were transitory. Based on the survey results, transdermal buprenorphine is considered an effective opioid treatment for patients with stable cancer and non-cancer pain; it may prove particularly useful in patients who have experienced side effects taking oral analgesic preparations, as well as in those who are taking extensive co-medications. PMID:12665120
Radbruch, Lukas
Buprenorphine Suppresses Cocaine Self-Administration by Rhesus Monkeys
Cocaine abuse has reached epidemic proportions in the United States, and the search for an effective pharmacotherapy continues. Because primates self-administer most of the drugs abused by humans, they can be used to predict the abuse liability of new drugs and for preclinical evaluation of new pharmacotherapies for drug abuse treatment. Daily administration of buprenorphine (an opioid mixed agonist-antagonist) significantly
Nancy K. Mello; Jack H. Mendelson; Mark P. Bree; Scott E. Lukas
Opioid Abstinence Reinforcement Delays Heroin Lapse during Buprenorphine Dose Tapering
ERIC Educational Resources Information Center
A positive reinforcement contingency increased opioid abstinence during outpatient dose tapering (4, 2, then 0 mg/day during Weeks 1 through 3) in non-treatment-seeking heroin-dependent volunteers who had been maintained on buprenorphine (8 mg/day) during an inpatient research protocol. The control group (n = 12) received $4.00 for completing�
Greenwald, Mark K.
Open-label trial of an injection depot formulation of buprenorphine in opioid detoxification
Buprenorphine, a partial mu-opioid agonist, has been shown effective for treatment of opioid dependence but also has some abuse potential. A novel formulation of buprenorphine, using a polymer microcapsule depot sustained-release technology, has been developed which may offer effective treatment of opioid dependence while also minimizing risks of patient noncompliance and illicit diversion. This open-label, first-in-human study evaluated the safety
Bai-Fang X. Sobel; Stacey C. Sigmon; Sharon L. Walsh; Rolley E. Johnson; Ira A. Liebson; Elie S. Nuwayser; James H. Kerrigan; George E. Bigelow
Opioid Addiction and Pregnancy: Perinatal Exposure to Buprenorphine Affects Myelination in the Developing Brain
Buprenorphine is a ?-opioid receptor partial agonist and ?-opioid receptor antagonist currently on trials for the management of pregnant opioid-dependent addicts. However, little is known about the effects of buprenorphine on brain development. Oligodendrocytes express opioid receptors in a developmentally regulated manner and thus, it is logical to hypothesize that perinatal exposure to buprenorphine could affect myelination. To investigate this possibility, pregnant rats were implanted with minipumps to deliver buprenorphine at 0.3 or 1 mg/kg/day. Analysis of their pups at different postnatal ages indicated that exposure to 0.3 mg/kg/day buprenorphine caused an accelerated and significant increase in the brain expression of all myelin basic protein (MBP) splicing isoforms. In contrast, treatment with the higher dose caused a developmental delay in MBP expression. Examination of corpus callosum at 26-days of age indicated that both buprenorphine doses cause a significant increase in the caliber of the myelinated axons. Surprisingly, these axons have a disproportionately thinner myelin sheath, suggesting alterations at the level of axon-glial interactions. Analysis of myelin associated glycoprotein (MAG) expression and glycosylation indicated that this molecule may play a crucial role in mediating these effects. Co-immunoprecipitation studies also suggested a mechanism involving a MAG-dependent activation of the Src-family tyrosine kinase Fyn. These results support the idea that opioid signaling plays an important role in regulating myelination in vivo and stress the need for further studies investigating potential effects of perinatal buprenorphine exposure on brain development.
Urine specimen detection of concurrent nonprescribed medicinal and illicit drug use in patients prescribed buprenorphine.
Patients being treated with buprenorphine usually have a history of opioid dependence and may be predisposed to misuse of drugs. Concurrent drug misuse increases the risk of life-threatening drug interactions. This retrospective data analysis observed which nonprescribed and illicit drugs were most commonly detected in the urine of patients from pain management clinics taking buprenorphine with or without a prescription. GC, LC/MS and LC-MS-MS were used to quantify 20,929 urine specimens. The most prevalent illicit drug used in both the groups (prescribed and nonprescribed buprenorphine) was marijuana, followed by cocaine. The most prevalent nonprescribed medications abused by both the groups were benzodiazepines, followed by oxycodone and hydrocodone. The overall prevalence of illicit and nonprescribed drug use was significantly higher in subjects who used buprenorphine without a prescription versus prescribed use. Of the concurrent use of marijuana and cocaine with buprenorphine, cocaine is most concerning since it decreases exposure to buprenorphine (lower area under the concentration-time curve and maximum concentration). The concurrent use of nonprescribed benzodiazepines with buprenorphine can cause excess sedation leading to respiratory depression and even death. These findings highlight the importance of educating patients about these potential toxicities. Furthermore, pain providers should consider expanding the spectrum of drugs that they monitor in patients under treatment. PMID:24080973
Guo, Alexander Y; Ma, Joseph D; Best, Brookie M; Atayee, Rabia S
Benzodiazepine use among opiate-dependent subjects in buprenorphine maintenance treatment: Correlates of use, abuse and dependence
BackgroundPrevious studies from North America, Europe and Australia have reported high levels of benzodiazepine use among opiate-dependent patients in opiate maintenance treatment. However, to date, there are no available data on patterns of abuse and dependence on benzodiazepines according to DSM criteria among these patients.
Estelle Lavie; M�lina Fats�as; C�cile Denis; Marc Auriacombe
Electrically-assisted transdermal delivery of buprenorphine
The objective of this study was to explore the electrically assisted transdermal delivery of buprenorphine. Oral delivery of buprenorphine, a synthetic opiate analgesic, is less efficient due to low absorption and large first-pass metabolism. While transdermal delivery of buprenorphine is expected to avoid the first-pass effect and thereby be more bioavailable, use of electrical enhancement techniques (iontophoresis and\\/or electroporation) could
Sagarika Bose; William R. Ravis; Yuh-Jing Lin; Lei Zhang; G�nter A. Hofmann; Ajay K. Banga
The Wellbeing of Infants Exposed to Buprenorphine via Breast Milk at 4 Weeks of Age.
Background: Buprenorphine has been available in Australia since 2000 as an alternative pharmacotherapy to methadone for the treatment of opioid dependence. However, there is little information in the literature regarding the effect of buprenorphine on the wellbeing of infants exposed to buprenorphine via breast milk, following discharge from hospital. Objective: The aim of the present study was to examine the wellbeing of infants exposed to buprenorphine via breast milk up to 4 weeks postnatally. Methods: Approximately 4 weeks after birth, information on the feeding and sleeping patterns, skin color, infant elimination patterns and hydration, and Neonatal Abstinence Scores of infants (n = 7) exposed to buprenorphine via breast milk was collected via both observation and documentation. Results: Infants were progressing well, with normal sleep patterns and skin color, and 2 mothers had minor concerns regarding infant elimination patterns. Four infants were exclusively breastfed and 3 were receiving a supplement, with a range of 260 to 700 mL of formula over 24 hours. The sleep patterns following feeding ranged from 1.55 to 3.33 hours, with a median of 2.12 hours. Conclusion: No adverse effects were detected in infants exposed to buprenorphine via breast milk up to 4 weeks postnatally. Further research using larger samples to assess possible developmental effects over longer periods of time is required. PMID:24399105
Gower, Shelley; Bartu, Anne; Ilett, Kenneth F; Doherty, Dorota; McLaurin, Renate; Hamilton, Dale
Randomized, placebo-controlled pilot trial of gabapentin during an outpatient, buprenorphine-assisted detoxification procedure.
This pilot study examined the efficacy of the N-type calcium channel blocker gabapentin to improve outcomes during a brief detoxification protocol with buprenorphine. Treatment-seeking opioid-dependent individuals were enrolled in a 5-week, double-blind, placebo-controlled trial examining the effects of gabapentin during a 10-day outpatient detoxification from buprenorphine. Participants were inducted onto buprenorphine sublingual tablets during Week 1, were randomized and inducted onto gabapentin or placebo during Week 2, underwent a 10-day buprenorphine taper during Weeks 3 and 4, and then were tapered off gabapentin/placebo during Week 5. Assessments included thrice-weekly opioid withdrawal scales, vitals, and urine drug screens. Twenty-four individuals (13 male; 17 Caucasian, 3 African American, 4 Latino; mean age 29.7 years) participated in the detoxification portion of the study (gabapentin, n = 11; placebo, n = 13). Baseline characteristics did not differ significantly between groups. Self-reported and observer-rated opioid withdrawal ratings were relatively low and did not differ between groups during the buprenorphine taper. Urine results showed a Drug � Time interaction, such that the probability of opioid-positive urines significantly decreased over time in the gabapentin versus placebo groups during Weeks 3 and 4 (OR = 0.73, p = .004). These results suggest that gabapentin reduces opioid use during a 10-day buprenorphine detoxification procedure. PMID:23855333
Sanders, Nichole C; Mancino, Michael J; Gentry, W Brooks; Guise, J Benjamin; Bickel, Warren K; Thostenson, Jeff; Oliveto, Alison H
Buprenorphine detection in hair samples by immunometric screening test: preliminary experience.
The recent introduction of buprenorphine use by the Drug Addiction Services has induced toxicology laboratories to develop new qualitative or semiquantitative screening assay for its determination in hair samples. The aim of this preliminary study was to verify the correlation between the buprenorphine intake and the immunometric screening test results (VMA-T Comedical and buprenorphine CEDIA/Thermo-Fisher/Microgenics reagents) and therefore their comparison with the liquid chromatography coupled with mass spectrometry (LC/MS) results. Hair samples were obtained from 32 subjects without buprenorphine-therapy reported and 17 in treatment. In glass test tube with hermetic cap were weighed 33 mg of 49 finely cut hair samples, washed with 1 mL of SLV-VMA-T washing solution, which is then completely sucked and eliminated. The samples were extracted with 400 microL of VMA-T reagent for an hour at 100 degrees C. The extracts were analysed by immunometric screening test on ILab 650 chemistry analyser, using buprenorphine CEDIA reagent assay. From the 32 non-takers of drug, 30 semiquantitative results were less than 10 pg/mg and 2 were over 10 pg/mg; from the 17 subjects with therapy, all were over 10 pg/mg (range 13-50 pg/mg); no samples were false-negative. Results suggest that exist a good relationship between the administration of buprenorphine and its concentration in hair, detectable through this method and reagents line. PMID:20080369
Svaizer, Fiorenza; Lotti, Andrea; Gottardi, Massimo; Miozzo, Maria Pia
Oligodendrocyte Responses to Buprenorphine Uncover Novel and Opposing Roles of ?-Opioid- and Nociceptin/Orphanin FQ Receptors in Cell Development: Implications for Drug Addiction Treatment During Pregnancy
While the classical function of myelin is the facilitation of saltatory conduction, this membrane and the oligodendrocytes, the cells that make myelin in the central nervous system (CNS), are now recognized as important regulators of plasticity and remodeling in the developing brain. As such, oligodendrocyte maturation and myelination are among the most vulnerable processes along CNS development. We have shown previously that rat brain myelination is significantly altered by buprenorphine, an opioid analogue currently used in clinical trials for managing pregnant opioid addicts. Perinatal exposure to low levels of this drug induced accelerated and increased expression of myelin basic proteins (MBPs), cellular and myelin components that are markers of mature oligodendrocytes. In contrast, supra-therapeutic drug doses delayed MBP brain expression and resulted in a decreased number of myelinated axons. We have now found that this biphasic-dose response to buprenorphine can be attributed to the participation of both the ?-opioid receptor (MOR) and the nociceptin/orphanin FQ receptor (NOP receptor) in the oligodendrocytes. This is particularly intriguing because the NOP receptor/nociceptin system has been primarily linked to behavior and pain regulation, but a role in CNS development or myelination has not been described before. Our findings suggest that balance between signaling mediated by (a) MOR activation and (b) a novel, yet unidentified pathway that includes the NOP receptor, plays a crucial role in the timing of oligodendrocyte maturation and myelin synthesis. Moreover, exposure to opioids could disrupt the normal interplay between these two systems altering the developmental pattern of brain myelination.
Eschenroeder, Andrew C.; Vestal-Laborde, Allison A.; Sanchez, Emilse S.; Robinson, Susan E.; Sato-Bigbee, Carmen
Buprenorphine and methadone for opioid addiction during pregnancy.
Buprenorphine and methadone are opioid-receptor agonists used as opioid substitution therapy during pregnancy to limit exposure of the fetus to cycles of opioid withdrawal and reduce the risk of infectious comorbidities of illicit opioid use. As part of a comprehensive care plan, such therapy may result in improved access to prenatal care, reduced illicit drug use, reduced exposure to infections associated with intravenous drug use, and improved maternal nutrition and infant birth weight. This article describes differences in patient selection between the two drugs, their relative safety during pregnancy, and changes in daily doses as a guide for prescribing clinicians. PMID:24845488
Mozurkewich, Ellen L; Rayburn, William F
Correlations of maternal buprenorphine dose, buprenorphine, and metabolite concentrations in meconium with neonatal outcomes.
For the first time, relationships among maternal buprenorphine dose, meconium buprenorphine and metabolite concentrations, and neonatal outcomes are reported. Free and total buprenorphine and norbuprenorphine, nicotine, opiates, cocaine, benzodiazepines, and metabolites were quantified in meconium from 10 infants born to women who had received buprenorphine during pregnancy. Neither cumulative nor total third-trimester maternal buprenorphine dose predicted meconium concentrations or neonatal outcomes. Total buprenorphine meconium concentrations and buprenorphine/norbuprenorphine ratios were significantly related to neonatal abstinence syndrome (NAS) scores >4. As free buprenorphine concentration and percentage free buprenorphine increased, head circumference decreased. Thrice-weekly urine tests for opiates, cocaine, and benzodiazepines and self-reported smoking data from the mother were compared with data from analysis of the meconium to estimate in utero exposure. Time of last drug use and frequency of use during the third trimester were important factors associated with drug-positive meconium specimens. The results suggest that buprenorphine and metabolite concentrations in the meconium may predict the onset and frequency of NAS. PMID:18701886
Kacinko, S L; Jones, H E; Johnson, R E; Choo, R E; Huestis, M A
Abuse and diversion of buprenorphine sublingual tablets and film.
Buprenorphine abuse is common worldwide. Rates of abuse and diversion of three sublingual buprenorphine formulations (single ingredient tablets; naloxone combination tablets and film) were compared. Data were obtained from the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS(�)) System Poison Center, Drug Diversion, Opioid Treatment (OTP), Survey of Key Informants' Patients (SKIP), and College Survey Programs through December 2012. To control for drug availability, event ratios (rates) were calculated quarterly, based on the number of patients filling prescriptions for each formulation ("unique recipients of a dispensed drug," URDD) and averaged and compared using negative binomial regression. Abuse rates in the OTP, SKIP, and College Survey Programs were greatest for single ingredient tablets, and abuse rates in the Poison Center Program and illicit diversion rates were greatest for the combination tablets. Combination film rates were significantly less than rates for either tablet formulation in all programs. No geographic pattern could be discerned. PMID:24680219
Lavonas, Eric J; Severtson, S Geoffrey; Martinez, Erin M; Bucher-Bartelson, Becki; Le Lait, Marie-Claire; Green, Jody L; Murrelle, Lenn E; Cicero, Theodore J; Kurtz, Steven P; Rosenblum, Andrew; Surratt, Hilary L; Dart, Richard C
Care and Treatment for Congenital Heart Defects
... can also learn about: Surgical procedures Cardiac catheterizations Heart transplants Preparing children for surgery Feeding Tips Children's special ... Symptoms & Diagnosis � Care & Treatment Introduction Surgery Cardiac ... Transplants Preparing Children for Surgery - Feeding Tips - Children's Special ...
Integrating Primary Medical Care With Addiction Treatment
Context The prevalence of medical disorders is high among substance abuse patients, yet medical services are seldom provided in coordination with substance abuse treatment. Objective To examine differences in treatment outcomes and costs between integrated and independent models of medical and substance abuse care as well as the effect of integrated care in a subgroup of patients with substance abuse�related medical conditions (SAMCs). Design Randomized controlled trial conducted between April 1997 and December 1998. Setting and Patients Adult men and women (n=592) who were admitted to a large health maintenance organization chemical dependency program in Sacramento, Calif. Interventions Patients were randomly assigned to receive treatment through an integrated model, in which primary health care was included within the addiction treatment program (n=285), or an independent treatment-as-usual model, in which primary care and substance abuse treatment were provided separately (n=307). Both programs were group based and lasted 8 weeks, with 10 months of aftercare available. Main Outcome Measures Abstinence outcomes, treatment utilization, and costs 6 months after randomization. Results Both groups showed improvement on all drug and alcohol measures. Overall, there were no differences in total abstinence rates between the integrated care and independent care groups (68% vs 63%, P=.18). For patients without SAMCs, there were also no differences in abstinence rates (integrated care, 66% vs independent care, 73%; P=.23) and there was a slight but nonsignificant trend of higher costs for the integrated care group ($367.96 vs $324.09, P=.19). However, patients with SAMCs (n=341) were more likely to be abstinent in the integrated care group than the independent care group (69% vs 55%, P=.006; odds ratio [OR], 1.90; 95% confidence interval [CI], 1.22-2.97). This was true for both those with medical (OR, 3.38; 95% CI, 1.68-6.80) and psychiatric (OR, 2.10; 95% CI, 1.04-4.25) SAMCs. Patients with SAMCs had a slight but nonsignificant trend of higher costs in the integrated care group ($470.81 vs $427.95, P=.14). The incremental cost-effectiveness ratio per additional abstinent patient with an SAMC in the integrated care group was $1581. Conclusions Individuals with SAMCs benefit from integrated medical and substance abuse treatment, and such an approach can be cost-effective. These findings are relevant given the high prevalence and cost of medical conditions among substance abuse patients, new developments in medications for addiction, and recent legislation on parity of substance abuse with other medical benefits.
Weisner, Constance; Mertens, Jennifer; Parthasarathy, Sujaya; Moore, Charles; Lu, Yun
Preliminary Study of Buprenorphine and Bupropion for Opioid Dependent Smokers
In this double-blind, placebo-controlled trial, bupropion (BUPRO, 300 mg/day) was compared to placebo (PBO) for concurrent treatment of opioid and tobacco addiction in 40 opioid-dependent smokers stabilized on buprenorphine (BUPRE, 24 mg/day). Participants received contingent, monetary reinforcement for abstinence from smoking, illicit opioids, and cocaine. Significant differences in treatment retention were observed (BUPRE+BUPRO, 58%; BUPRE+PBO, 90%). BUPRO treatment was not more effective than placebo for abstinence from tobacco, opioids, or cocaine in BUPRE stabilized patients. These preliminary findings do not support the efficacy of BUPRO, in combination with BUPRE, for concurrent treatment of opioid and tobacco addiction.
Mooney, Marc E.; Poling, James; Gonzalez, Gerardo; Gonsai, Kishor; Kosten, Thomas; Sofuoglu, Mehmet
Comparing Outcomes for Youth Served in Treatment Foster Care and Treatment Group Care
ERIC Educational Resources Information Center
This study compared youth in the Florida Medicaid system prior to entry into treatment foster care or treatment group care, and compared outcomes in the 6 months after treatment. Florida Medicaid data from FY2003/04 through 2006/2007 along with Department of Juvenile Justice, Department of Law Enforcement, and involuntary examination data were�
Robst, John; Armstrong, Mary; Dollard, Norin
A preliminary study comparing methadone and buprenorphine in patients with chronic pain and coexistent opioid addiction.
Patients with opioid addiction who receive prescription opioids for treatment of nonmalignant chronic pain present a therapeutic challenge. Fifty-four participants with chronic pain and opioid addiction were randomized to receive methadone or buprenorphine/naloxone. At the 6-month follow-up examination, 26 (48.1%) participants who remained in the study noted a 12.75% reduction in pain (P = 0.043), and no participants in the methadone group compared to 5 in the buprenorphine group reported illicit opioid use (P = 0.039). Other differences between the two conditions were not found. Long-term, low-dose methadone or buprenorphine/naloxone treatment produced analgesia in participants with chronic pain and opioid addiction. PMID:23480249
Neumann, Anne M; Blondell, Richard D; Jaanim�gi, Urmo; Giambrone, Amanda K; Homish, Gregory G; Lozano, Jacqueline R; Kowalik, Urszula; Azadfard, Mohammadreza
Self-management of buprenorphine/naloxone among online discussion board users.
Background: Buprenorphine/naloxone is an effective medication used to treat opioid dependence. Patients in treatment and those using it illegally without prescriptions have discussed using buprenorphine/naloxone anonymously on Internet discussion boards. Their beliefs about self-treatment and efforts to self-treat are not well known. Objectives: To identify facilitators of self-treatment by online buprenorphine/naloxone users. Methods: A qualitative, retrospective study of discussion board postings from September 2010 to November 2012 analyzed 121 threads from 13 discussion boards using grounded theory. Results: Facilitators of self-management themes that emerged included: (1) a ready supply of buprenorphine/naloxone from a variety of sources; (2) distrust of buprenorphine prescribers and pharmaceutical companies; (3) the declaration that buprenorphine/naloxone is a "bad-tasting" medicine; (4) the desire to adopt a different delivery method other than sublingually; and (5) a desire to become completely "substance-free." The sublingual film formulation appears to be an important facilitator in self-treatment because it can more easily be apportioned to extend the medication because of limited supply, cost, or to taper. Conclusions/Importance: The findings indicate a range of self-management activities ranging from altering the amount taken to modifying the physical medication composition or changing the administration route; some of these behaviors constitute problematic extra-medical use. Contributors to discussion boards seem to trust each other more than they trust pharmacists and prescribing physicians. The shared knowledge and behaviors of this understudied online community are important to healthcare providers because of the previously unknown precautions and risks taken to self-treat. PMID:24779501
Brown, Shan-Estelle; Altice, Frederick L
Assessment of differential doses of buprenorphine for long term pharmacotherapy among opiate dependent subjects.
The aim of the present study was to evaluate, two different doses of sublingual buprenorphine (2 mg and 4 mg) among patients on maintenance treatment and to assess the relationship of steady state plasma level with craving. Twenty three male opioid dependent (ICD-10 DCR) subjects, were assigned to double blind randomized controlled trial of 2 and 4 mg/day doses of buprenorphine in an inpatient setting. They were evaluated thrice (2nd, 7th and 14th day) in 2 weeks for withdrawal symptoms (acute and protracted), sedation, euphoria, craving, side effects, global rating of well being and for measurement of plasma levels of buprenorphine. The data showed that there were no significant difference in scores of euphoria and sedation, protracted withdrawal symptoms and side effects, craving and overall well being and plasma level of buprenorphine among the subjects. However, both the groups had significant difference in score on almost all the measurements on final observation in comparison to initial observation. Both 2 mg/day and 4 mg/day dose of buprenorphine were effective in long term pharmacotherapy of opioid dependence without significant difference as compared by different measures used in the study. PMID:18831352
De, Shantanu; Jain, Raka; Ray, Rajat; Dhawan, Anju; Varghese, Sunny T
Respiratory Rates and Arterial Blood-Gas Tensions in Healthy Rabbits Given Buprenorphine, Butorphanol, Midazolam, or Their Combinations
The objective of this study was to evaluate the respiratory effects of buprenorphine, butorphanol, midazolam, and their combinations in healthy conscious rabbits. Six adult female New Zealand white rabbits were anesthetized briefly with isoflurane by mask to allow placement of a catheter into the central ear artery. After a 60-min recovery period, a baseline arterial sample was obtained. Animals then were injected intramuscularly with either 0.9% NaCl (1 mL), buprenorphine (0.03 mg/kg), butorphanol (0.3 mg/kg), midazolam (2 mg/kg), buprenorphine + midazolam (0.03 mg/kg, 2 mg/kg), or butorphanol + midazolam (0.3 mg/kg, 2 mg/kg). Arterial blood gases were evaluated at 30, 60, 90, 120, 180, 240, and 360 min after drug administration. All drug treatments caused significant decreases in respiratory rate, compared with saline. Buprenorphine and the combinations of midazolam�butorphanol and midazolam�buprenorphine resulted in statistically significant decreases in pO2. No significant changes in pCO2 pressure were recorded for any treatment. Increases in blood pH were associated with administration of butorphanol, midazolam, and the combinations of midazolam�butorphanol and midazolam�buprenorphine. In light of these results, buprenorphine and the combinations of midazolam�buprenorphine and midazolam�butorphanol result in statistically significant hypoxemia in rabbits that breathe room air. The degree of hypoxemia is of questionable clinical importance in these healthy subjects. Hypoxemia resulting from these drug combinations may be amplified in rabbits with underlying pulmonary or systemic disease.
Schroeder, Carrie A; Smith, Lesley J
Buprenorphine/Naloxone Reduces the Reinforcing and Subjective Effects of Heroin in Heroin-Dependent Volunteers
Rationale Although buprenorphine is effective in treating opioid dependence, optimal maintenance doses of buprenorphine or the buprenorphine/naloxone combination have not yet been established. Objective The present study was designed to evaluate the effects of buprenorphine/naloxone maintenance (2/0.5, 8/2, 32/8 mg sublingual) on the reinforcing and subjective effects of heroin (0, 12.5, 25, 50, and 100 mg intranasal) in heroin-dependent individuals. Methods During test weeks, participants (N=7) first sampled a dose of heroin and $20. During subsequent choice sessions, participants could choose to self administer heroin and/or money. Participants responded under a modified progressive-ratio schedule (PR 50, �, 2800) during a 10-trial self-administration task. Results Heroin break point values and subjective responses were significantly lower under 8/2 and 32/8 mg buprenorphine/naloxone compared to 2/0.5 mg. The self-administration and subjective effects data for heroin in the presence of buprenorphine/naloxone were compared to a separate control group of recently detoxified participants (N=8) in order to obtain estimates for the apparent in vivo dissociation constant (KA), the efficacy estimate (tau), and the estimated fraction of receptors remaining after buprenorphine/naloxone treatment (q). The apparent in vivo dissociation constant for heroin ranged from 50�126 mg (KA) and the efficacy estimate ranged from 13�20 (tau). In addition, 2/0.5, 8/2 and 32/8 mg buprenorphine/naloxone dose-dependently reduced the receptor population by 74%, 83%, and 91%, respectively. Conclusions These data demonstrate that both 8/2 and 32/8 mg buprenorphine/naloxone were well tolerated and effective in reducing the reinforcing and subjective effects of heroin, relative to the 2/0.5 mg dose. The data also show for the first time in humans that it is possible to quantify the efficacy and affinity of heroin for mu opioid receptors and that 80�90% of mu receptors need to be inactivated in order to obtain significant reductions in heroin-induced effects. These results have important implications for future studies in which it will be possible to obtain estimates of relative affinity and efficacy of different agonists at mu opioid receptors.
Comer, Sandra D.; Walker, Ellen A.; Collins, Eric D.
Tobacco use disorder treatment in primary care
Abstract Objective To test a team-based, site-specific, multicomponent clinical system pathway designed for enhancing tobacco use disorder treatment by primary care physicians. Design A prospective cohort study. Setting Sixty primary care sites in Alberta. Participants A convenience sample of 198 primary care physicians from the population of 2857. Main outcome measures Data collection occurred between September 2010 and February 2012 on 3 distinct measures. Twenty-four weeks after the intervention, audits of the primary care practices assessed the adoption and sustainability of 10 tobacco clinical system pathway components, a survey measured changes in physicians� treatment intentions, and patient chart reviews examined changes in physicians� consistency with the treatment algorithm. Results The completion rate by physicians was 89.4%. An intention-to-treat approach was undertaken for statistical analysis. Intervention uptake was demonstrated by positive changes at 4 weeks in how many of the 10 clinical system measures were performed (mean [SD] = 4.22 [1.60] vs 8.57 [1.46]; P < .001). Physicians demonstrated significant favourable changes in 9 of the 12 measures of treatment intention (P < .05). The 18 282 chart reviews documented significant increases in 6 of the 8 algorithm components. Conclusion Our findings suggest that the provision of a tobacco clinical system pathway that incorporates other members of the health care team and builds on existing office infrastructures will support positive and sustainable changes in tobacco use disorder treatment by physicians in primary care. This study reaffirms the substantive and important role of supporting how treatment is delivered in physicians� practices.
Kunyk, Diane; Els, Charl; Papadakis, Sophia; Selby, Peter
Illicit use of methadone and buprenorphine among adolescents and young adults in Sweden
Background Illicit use of methadone and buprenorphine has been described as a growing problem in Sweden in recent years, and has been associated with an increased drug-related mortality. Critics claim that the substances have become popular among adolescents and that they function as a gateway to heroin use. The aim of this study is to investigate, firstly, the extent to which illicit use of methadone and buprenorphine occurs among adolescents and young adults in Sweden, and secondly, at what stage in a user�s drug career these substances tend to appear. Methods The study is based on surveys and structured interviews on drug use among various populations of young people, in addition to qualitative interviews with 86 informants who, in their professional capacity, encounter adolescents or young adults who are using illicit drugs. Results Illicit use of methadone and buprenorphine is rare among young people in Sweden. According to high school surveys, less than 0.1% have tried these substances. Among young drug users in general, few have tried the substances, and there is nothing to indicate that they act as gateway drugs. Among adolescents and young adults with severe drug problems, however, the illicit use of methadone and buprenorphine is more common (54% in a compulsory care sample). These substances normally enter the drug career late, and few use them as their main drug of choice. Other prescription drugs, like benzodiazepines and tramadol, are used by adolescents to a far greater extent. Diversion and illicit use of methadone and buprenorphine is not seen as a serious problem by the professionals interviewed. A general view is that the substances are mainly used by people with a heroin or polydrug addiction, often for �self-medication� purposes. However, several informants express concern that methadone and buprenorphine may cause fatalities among young drug users without an opioid tolerance. Conclusions Illicit use of methadone and buprenorphine among young drug users is not a widespread problem in Sweden. Harm-reduction measures should target drug users with more severe problems, among whom illicit use of methadone and buprenorphine is more common and pose a medical risk. Illicit use of other prescription drugs, which are less controlled and more widely used by young people, is an important issue for further research.
Utilizing buprenorphine-naloxone to treat illicit and prescription-opioid dependence
Objectives To review current evidence on buprenorphine�naloxone (bup/nx) for the treatment of opioid-use disorders, with a focus on strategies for clinical management and office-based patient care. Quality of evidence Medline and the Cochrane Database of Systematic Reviews were searched. Consensus reports, guidelines published, and other authoritative sources were also included in this review. Apart from expert guidelines, data included in this review constitute level 1 evidence. Findings Bup/nx is a partial ?-opioid agonist combined with the opioid antagonist naloxone in a 4:1 ratio. It has a lower abuse potential, carries less stigma, and allows for more flexibility than methadone. Bup/nx is indicated for both inpatient and ambulatory medically assisted withdrawal (acute detoxification) and long-term substitution treatment (maintenance) of patients who have a mild-to-moderate physical dependence. A stepwise long-term substitution treatment with regular monitoring and follow-up assessment is usually preferred, as it has better outcomes in reducing illicit opioid use, minimizing concomitant risks such as human immunodeficiency virus and hepatitis C transmission, retaining patients in treatment and improving global functioning. Conclusion Bup/nx is safe and effective for opioid detoxification and substitution treatment. Its unique pharmaceutical properties make it particularly suitable for office-based maintenance treatment of opioid-use disorder.
Mauger, Sofie; Fraser, Ronald; Gill, Kathryn
Children of Cocaine: Treatment and Child Care.
ERIC Educational Resources Information Center
Information concerning the treatment and care of children addicted to cocaine is provided. Contents: (1) describe the drug; (2) put cocaine use in its historical and demographic perspectives; (3) report findings of a study documenting the incidence of maternal substance abuse in Pinellas County, Florida; (4) point out false perceptions,�
Howze, Kate; Howze, Wendell M.
The impact of cocaine use on outcomes in HIV-infected patients receiving buprenorphine/naloxone
BACKGROUND Cocaine use is common in opioid dependent HIV-infected patients but its impact on treatment outcomes in these patients receiving buprenorphine/naloxone is not known. METHODS We conducted a prospective study in 299 patients receiving buprenorphine/naloxone who provided baseline cocaine data and a subset of 266 patients who remained in treatment for greater than or equal to one quarter. Assessments were conducted at baseline and quarterly for one year. We evaluated the association between baseline and in-treatment cocaine use on buprenorphine/naloxone retention, illicit opioid use, antiretroviral adherence, CD4 counts, HIV RNA, and risk behaviors. RESULTS Sixty-six percent (197/299) of patients reported baseline cocaine use and 65% (173/266) of patients with follow-up data reported in-treatment cocaine use. Baseline and in-treatment cocaine use did not impact buprenorphine/naloxone retention, antiretroviral adherence, CD4 lymphocytes, or HIV risk behaviors. However, baseline cocaine use was associated with a 14.8 (95% CI=9.0�24.2) times greater likelihood of subsequent cocaine use (95% CI=9.0 � 24.2), a 1.4 (95% CI=1.02 � 2.00) times greater likelihood of subsequent opioid use, and higher Log10 HIV RNA (p? .016) over time. In-treatment cocaine use was associated with a 1.4 (95% CI=1.01�2.00) times greater likelihood of concurrent opioid use. CONCLUSIONS Given cocaine use negatively impacts opioid and HIV treatment outcomes, interventions to address cocaine use in HIV-infected patients receiving buprenorphine/naloxone treatment are warranted.
Sullivan, Lynn E.; Botsko, Michael; Cunningham, Chinazo; O'Connor, Patrick G.; Hersh, David; Mitty, Jennifer; Lum, Paula J.; Schottenfeld, Richard S.; Fiellin, David A.
The reinforcing and subjective effects of intravenous and intranasal buprenorphine in heroin users.
Abuse of buprenorphine (BUP) by the intravenous (IV) route has been documented in several studies, and reports of intranasal (IN) abuse are increasing. However, no studies have directly compared the effects of BUP when it is administered intranasally and intravenously. The present secondary analysis used data from two separate studies to compare the reinforcing and subjective effects of IV and IN buprenorphine. One study evaluated IV buprenorphine (N=13) and the other evaluated IN buprenorphine (N=12). Participants were maintained on 2 mg sublingual (SL) BUP and tested with each intranasal or intravenous buprenorphine test dose (0 mg, 2 mg, 4 mg, 8 mg, and 16 mg). During morning laboratory sessions, participants received money (US $20) and sample doses of IN or IV BUP, and then completed subjective effects questionnaires. Later that day, they completed a self-administration task to receive 10% portions of the drug and/or money they previously sampled. In general, positive subjective ratings for both IV and IN BUP were significantly greater than placebo, with IV BUP having a greater effect than IN BUP. All active BUP doses (IV and IN) maintained significantly higher progressive ratio breakpoint values than placebo, but breakpoint values for IV BUP were greater than for IN BUP. Buprenorphine is an effective maintenance treatment for opioid dependence, valued for its ability to reduce the positive subjective effects of other opioids. Nevertheless, the present data demonstrate that in participants maintained on a low dose of SL BUP, the medication itself has abuse liability when used intravenously or intranasally. PMID:24793093
Jones, Jermaine D; Madera, Gabriela; Comer, Sandra D
Parenteral buprenorphine-naloxone abuse is a major cause of fatal buprenorphine-related poisoning.
Buprenorphine (BPN) medication for opioid maintenance treatment in Finland consists predominantly of buprenorphine-naloxone (BNX). Both BPN and BNX are associated with diversion, abuse and non-medically supervised use worldwide. Our purpose was to estimate the proportion of BNX to all BPN-related fatalities. The material consisted of 225 deceased drug abusers in Finland from January 2010 to June 2011 with a positive BPN and/or norbuprenorphine (NOR) and/or naloxone (NX) finding in urine. The data were divided into three groups based on the urine NX and BPN concentrations. The "Parenteral BNX" group (>100 ?g/l NX) was presumed to consist of injecting or snorting BNX abusers and the "Parenteral BPN" group (>50 ?g/l BPN, 0 ?g/l NX) of injecting or snorting BPN abusers, while the "Other BNX or BPN" group (?100 ?g/l NX, or ?50 ?g/l BPN combined with 0 ?g/l NX) was presumed to consist of mainly sublingual BNX or BPN users. In 12.4% of cases the NX urine concentration was higher than the threshold 100 ?g/l. In fatal BPN poisonings, the proportion of parenteral BNX was 28.4%. In the "Parenteral BNX", "Parenteral BPN" and "Other BNX or BPN" groups, the proportion of fatal BPN poisonings was 67.9, 31.0 and 22.6%, respectively. BNX abuse can be fatal. Among the 225 BPN-related fatalities, parenteral abuse of BNX was shown to be common (12.4%) and BNX poisoning was the underlying cause of death in 8.4%. Parenteral BNX caused fatal BPN poisoning proportionally more often than parenteral BPN. PMID:24053859
H�kkinen, Margareeta; Heikman, Pertti; Ojanper�, Ilkka
Drug Use and HIV Risk Outcomes in Opioid-Injecting Men in the Republic of Georgia: Behavioral Treatment + Naltrexone compared to Usual Care
Background To test the initial feasibility of a novel 22-week comprehensive intervention pairing behavioral treatment with naltrexone that aimed at engaging, retaining, and treating opioid-injecting men in the Republic of Georgia. Methods Forty opioid-injecting males and their drug-free female partners participated in a two-group randomized clinical trial at the field site of the Union Alternative Georgia, in Tbilisi, Republic of Georgia. The comprehensive intervention that paired behavioral treatment with naltrexone for the male participants (n=20) included counseling sessions using Motivational Interviewing for both the male participant and the couple, monetary incentives for drug abstinence, and research-supported detoxification followed by naltrexone treatment. Male participants in the usual care condition (n=20) had the opportunity to attend once-a-week individualized education sessions and upon request receive referrals to detoxification programs and aftercare that could or could not have included naltrexone. Outcome measures included entry into inpatient detoxification and naltrexone treatment, urine drug screening, reduction in illicit substance use, use of benzodiazepines, injection of buprenorphine, and needle and syringe sharing. Results The comprehensive intervention condition showed significantly more weekly urine samples negative for illicit opioids during weeks 1 through 22 (7.0 v. 1.4; p<.001) and reported significant declines in use of benzodiazepines and injection of buprenorphine (both ps<.004). Conclusions The first behavioral treatment randomized clinical trial in the Republic of Georgia found that the use of tailored behavioral therapy paired with naltrexone is both feasible and efficacious for treating drug use and reducing HIV drug-risk behavior in Georgian men.
Otiashvili, David; Kirtadze, Irma; O'Grady, Kevin E.; Jones, Hendree E.
Buprenorphine and the transdermal system: the ideal match in pain management.
A system for the transdermal administration of the opioid drug buprenorphine has recently been introduced. Buprenorphine has physico-chemical properties, including a low molecular weight and high analgesic potency, that make it an excellent compound for transdermal drug delivery. The new technology (buprenorphine TDS, Transtec) is an advanced system that contains the active drug incorporated into a polymer matrix, which is at the same time the adhesive layer. The patch precisely controls the rate of drug delivery and produces stable plasma concentrations. It is available in three doses (release rates of 35, 52.5 and 70 microg/h), and the suggested duration of use per patch is three days. Buprenorphine TDS was developed for the treatment of moderate to severe cancer pain and severe pain which does not respond to non-opioid analgesics. Not only does this transdermal system provide excellent analgesia and a low incidence of adverse events, but its ease of use results in greater compliance. The patch provides excellent adhesion and has a low susceptibility to damage that might lead to toxicity or opioid abuse. PMID:12665118
Budd, Keith
The treatment gap in mental health care.
Mental disorders are highly prevalent and cause considerable suffering and disease burden. To compound this public health problem, many individuals with psychiatric disorders remain untreated although effective treatments exist. We examine the extent of this treatment gap. We reviewed community-based psychiatric epidemiology studies that used standardized diagnostic instruments and included data on the percentage of individuals receiving care for schizophrenia and other non-affective psychotic disorders, major depression, dysthymia, bipolar disorder, generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), and alcohol abuse or dependence. The median rates of untreated cases of these disorders were calculated across the studies. Examples of the estimation of the treatment gap for WHO regions are also presented. Thirty-seven studies had information on service utilization. The median treatment gap for schizophrenia, including other non-affective psychosis, was 32.2%. For other disorders the gap was: depression, 56.3%; dysthymia, 56.0%; bipolar disorder, 50.2%; panic disorder, 55.9%; GAD, 57.5%; and OCD, 57.3%. Alcohol abuse and dependence had the widest treatment gap at 78.1%. The treatment gap for mental disorders is universally large, though it varies across regions. It is likely that the gap reported here is an underestimate due to the unavailability of community-based data from developing countries where services are scarcer. To address this major public health challenge, WHO has adopted in 2002 a global action programme that has been endorsed by the Member States.
Kohn, Robert; Saxena, Shekhar; Levav, Itzhak; Saraceno, Benedetto
A Preliminary Study Comparing Methadone and Buprenorphine in Patients with Chronic Pain and Co-existent Opioid Addiction
Patients with opioid addiction who receive prescription opioids for treatment of chronic non-malignant pain present a therapeutic challenge. Fifty-four patients with chronic pain and opioid addiction were randomized to receive methadone or buprenorphine/naloxone. At the 6-month follow-up, 26 (48.1%) participants who remained in the study noted a 12.75% reduction in pain (P = 0.043) and compared to 5 in the buprenorphine group, none in the methadone group reported illicit opioid use (P = 0.039). Other differences between the two conditions were not found. Long-term low-dose methadone or buprenorphine/naloxone treatment produced analgesia in patients with chronic pain and opioid addiction.
Neumann, Anne M.; Blondell, Richard D.; Jaanimagi, Urmo; Giambrone, Amanda K.; Homish, Gregory G.; Lozano, Jacqueline R.; Kowalik, Urszula; Azadfard, Mohammadreza
Prenatal buprenorphine exposure decreases neurogenesis in rats.
Perinatal opioid exposure has a negative effect on neurogenesis and produces neurological consequences. However, its mechanisms of action are incompletely understood. Buprenorphine, a mixed opioid agonist/antagonist, is an alternative medication for managing pregnant opioid addicts. This study provides evidence of decreased neurogenesis and depression-like consequences following prenatal exposure to buprenorphine and sheds light on mechanisms of action in a rat model involving administration of intraperitoneal injection to pregnant rats starting from gestation day 7 and lasting for 14 days and a cultured neurosphere model. Results of forced swimming test and tail suspension test showed that pups at postnatal day 21 had worse parameters of depression-like neurobehaviors, independent of gender. Neurobehavioral changes were accompanied by reduction of neuronal composition, biochemical parameters of neural stem/progenitor cells, brain-derived neurotrophic factor (BDNF) expression, tropomyosin-related kinase receptor type B phosphorylation, protein kinase A (PKA) activity, and cAMP response element-binding protein phosphorylation. Results of parallel cell studies further demonstrated a negative impact of buprenorphine on cultured neurospheres, including proliferation, differentiation, BDNF expression and signaling, and PKA activity. Taken together, our results suggest that prenatal exposure to buprenorphine might result in depression-like phenotypes associated with impaired BDNF action and decreased neurogenesis in the developing brain of weanlings. PMID:24321744
Wu, Chih-Cheng; Hung, Chih-Jen; Shen, Ching-Hui; Chen, Wen-Ying; Chang, Cheng-Yi; Pan, Hung-Chuan; Liao, Su-Lan; Chen, Chun-Jung
Effects of Multimodal Analgesia with Low-Dose Buprenorphine and Meloxicam on Fecal Glucocorticoid Metabolites after Surgery in New Zealand White Rabbits (Oryctolagus cuniculus)
Despite the increasing use of rabbits as companion animals and models for biomedical research, rabbits have not been extensively studied to identify an efficacious postsurgical analgesic that does not cause systemic complications. The synergy of NSAID and systemic opioids is well-documented, and their combined use reduces the amount of either drug required for adequate analgesia. We measured fecal corticosterone metabolites (FCM) in rabbits after a minimally invasive vascular cut-down procedure. Rabbits received buprenorphine (0.03 mg/kg SC every 12 h for 3 d), meloxicam (0.2 mg/kg SC every 24 h for 3 d), buprenorphine�meloxicam (0.01 mg/kg�0.1 mg/kg SC every 24 h for 3 d), or a single dose of 0.5% bupivacaine (0.5 mL) infused locally at the incision site. By day 3 after surgery, buprenorphine, meloxicam, and bupivacaine groups showed elevated FCM levels, which continued to rise until day 7 and then gradually returned to baseline by day 28. In the buprenorphine�meloxicam group, FCM was relatively unchanged until day 3, when treatment was discontinued, and then began to rise. Rabbits in the buprenorphine�meloxicam group gained more weight over the 28-d study than did those in the other 3 treatment groups. This study shows that in rabbits low-dose buprenorphine administered with meloxicam effectively mitigates the FCM response that develops after surgery without the adverse effects associated with higher doses.
Goldschlager, Gregg B; Gillespie, Virginia L; Palme, Rupert; Baxter, Mark G
Transdermal buprenorphine in clinical practice: a multicenter, noninterventional postmarketing study in the Czech Republic.
SUMMARY�Aim: To evaluate the use of transdermal buprenorphine patches (Transtec�) in routine clinical practice. Patients & methods: A prospective, noninterventional, postmarketing study performed in the Czech Republic by 71 investigators in various clinical practice settings. Patients with chronic moderate-to-severe cancer pain, or chronic severe noncancer pain insufficiently controlled by nonopioids, were prescribed buprenorphine transdermal patch 35, 52.5 or 70 �g/h, and evaluated for 3 months. Additional analgesia and adjuvant/supportive treatments were allowed (physician discretion). Results: Data were evaluated for 630 patients (54% female, mean age 64 years). Most (>60%) patients had cancer-related pain. Noncancer pain was musculoskeletal (66.4%), neuropathic (25.9%) or nociceptive (6.0%). The mean dose of transdermal buprenorphine at study initiation was 40.6 �g/h. Compared with baseline (numerical rating scale [NRS]: 6.9), mean pain intensity (0-10 NRS) decreased significantly (p < 0.01) at 1 month (NRS: 2.9) and study end (NRS: 2.2). Most (>90%) patients rated pain relief as 'very good' or 'good', >97% of evaluable patients reported improvements in sleep quality and 87% of all evaluated patients were willing to continue transdermal buprenorphine after study completion. During the study, supplemental analgesic use remained unchanged; laxative/antiemetic use reduced (30.9% of patients [baseline] vs 23.3% [study end]). Twenty four nonserious adverse drug reactions (mainly local skin reactions) occurred in 19 (3%) patients. Conclusion: In routine clinical practice in the Czech Republic, transdermal buprenorphine was efficacious and well tolerated in patients with chronic moderate-to-severe cancer pain or chronic severe noncancer pain insufficiently controlled by nonopioids. PMID:24645818
Vondr�?kov�, Dana
The emerging buprenorphine epidemic in the United States.
The authors sampled for expanded drug testing of 1,061 urine specimens collected by Maryland Division of Parole and Probation staff. They found an increase in the percentage of individuals testing positive for buprenorphine and found that these specimens often contained other drugs, suggesting misuse. Subsequent interviews with 15 probationers and parolees in Baltimore, Maryland, showed wide-scale availability of buprenorphine on the street and in prisons. Medical examiners and drug testing programs should immediately initiate routine testing for buprenorphine to track a possible outbreak of buprenorphine diversion and misuse. Physician education programs should redouble their efforts to teach strategies to deter diversion and misuse of the drug. PMID:22356664
Wish, Eric D; Artigiani, Erin; Billing, Amy; Hauser, Wanda; Hemberg, Jordana; Shiplet, Myron; DuPont, Robert L
A non-rewarding, non-aversive buprenorphine/naltrexone combination attenuates drug-primed reinstatement to cocaine and morphine in rats in a conditioned place preference paradigm.
Concurrent use of cocaine and heroin is a major public health issue with no effective relapse prevention treatment currently available. To this purpose, a combination of buprenorphine and naltrexone, a mixed very-low efficacy mu-opioid receptor agonist/kappa-opioid receptor antagonist/nociceptin receptor agonist, was investigated. The tail-withdrawal and the conditioned place preference (CPP) assays in adult Sprague Dawley rats were used to show that naltrexone dose-dependently blocked the mu-opioid receptor agonism of buprenorphine. Furthermore, in the CPP assay, a combination of 0.3?mg/kg buprenorphine and 3.0?mg/kg naltrexone was aversive. A combination of 0.3?mg/kg buprenorphine and 1.0?mg/kg naltrexone was neither rewarding nor aversive, but still possessed mu-opioid receptor antagonist properties. In the CPP extinction and reinstatement method, a combination of 0.3?mg/kg buprenorphine and 1.0?mg/kg naltrexone completely blocked drug-primed reinstatement in cocaine-conditioned rats (conditioned with 3?mg/kg cocaine, drug prime was 3?mg/kg cocaine) and attenuated drug-primed reinstatement in morphine-conditioned rats (conditioned with 5?mg/kg morphine, drug prime was 1.25?mg/kg morphine). These data add to the growing evidence that a buprenorphine/naltrexone combination may be protective against relapse in a polydrug abuse situation. PMID:23240906
Cordery, Sarah F; Taverner, Alistair; Ridzwan, Irna E; Guy, Richard H; Delgado-Charro, M Bego�a; Husbands, Stephen M; Bailey, Christopher P
Comparison of Buprenorphine and Butorphanol Analgesia in the Eastern Red-Spotted Newt (Notophthalmus viridescens)
The experimental use of amphibian models in biomedical research increases yearly, but there is a paucity of reports concerning analgesic use in many of these species. In this study, buprenorphine given by intracoelomic injection and butorphanol added to the tank water were compared for analgesic effect in the eastern red-spotted newt after bilateral forelimb amputations. Newts undergoing anesthesia but not surgery and newts having surgery but not given analgesia postoperatively were used as control groups. Animals were tested for food consumption, spontaneous movement, response to tapping on the tank, response to being touched, and body posture. Both buprenorphine by intracoelomic injection and butorphanol in tank water significantly promoted resumption of normal behavior after bilateral surgical amputation of the forelimbs. The difference between analgesic treatment and no analgesic treatment was maintained until 72 h after surgery.
Integrating Substance Use Treatment Into Adolescent Health Care
Substance use (SU) problems are common among adolescents, a serious health risk for them and a major public health problem, but are inadequately addressed in most pediatric health care settings. Primary care offers an excellent context for SU assessment and treatment for adolescents and their families, offering better access and a less stigmatized environment for receiving treatment than specialty programs. This paper examines the literature on the integration of substance use treatment with adolescent health care, focusing on 2 areas: Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Emergency Departments and Primary Care, and School- and College-Based Health Centers.
Sterling, Stacy; Valkanoff, Tina; Hinman, Agatha; Weisner, Constance
Pressley Ridge Treatment Foster Care: The Model of Care Thirty Years Later
ERIC Educational Resources Information Center
Since the early 1950s, trends in children's mental health have moved care from residential and office-based treatment to community-based interventions. The Pressley Ridge Treatment Foster Care (PRTFC) program was developed in 1981 in response to these trends. Currently, Pressley Ridge provides PR-TFC treatment in 15 programs in six states and the�
Trunzo, Annette C.; Bishop-Fitzpatrick, Lauren; Strickler, Amy; Doncaster, James
Drug interactions associated with methadone, buprenorphine, cocaine, and HIV medications: Implications for pregnant women
Pregnancy in substance-abusing women with HIV\\/AIDS presents a complex clinical challenge. Opioid-dependent women need treatment with opioid therapy during pregnancy to protect the health of mother and developing fetus. However, opioid therapies, methadone and buprenorphine, may have drug interactions with some HIV medications that can have adverse effects leading to suboptimal clinical outcomes. Further, many opioid-dependent individuals have problems with
Elinore F. McCance-Katz
Desipramine in Opioid-Dependent Cocaine Abusers Maintained on Buprenorphine vs Methadone
Background: Cocaine abuse occurs in 40% to 60% of patients entering opioid maintenance treatment, and ef- fective pharmacotherapies are needed for this com- bined dependence. Methods: This 13-week, randomized, double-blind, pla- cebo-controlled trial evaluated the efficacy of desipra- mine hydrochloride (0 or 150 mg\\/d) plus buprenorphine hydrochloride (12 mg\\/d) or methadone hydrochloride (65 mg\\/d) in 180 opioid-dependent cocaine abusers (124
Alison H. Oliveto; Alan Feingold; Richard Schottenfeld; Peter Jatlow; Thomas R. Kosten
Clinical pharmacology of buprenorphine: Ceiling effects at high doses
Objective: The purpose of this study was to characterize the acute effects of buprenorphine, an opioid partial (?-agonist, across a wide range of doses in comparison to methadone.Method: Healthy adult male volunteers, who had experience with but were not physically dependent on opioids, participated while residing on a closed research unit. Four subjects received buprenorphine (0, 1, 2, 4, 8,
Sharon L Walsh; Kenzie L Preston; Maxine L Stitzer; Edward J Cone; George E Bigelow
Do methadone and buprenorphine have the same impact on psychopathological symptoms of heroin addicts?
Background The idea that the impact of opioid agonist treatment is influenced by the psychopathological profile of heroin addicts has not yet been investigated, and is based on the concept of a specific therapeutic action displayed by opioid agents on psychopathological symptoms. In the present report we compared the effects of buprenorphine and methadone on the psychopathological symptoms of 213 patients (106 on buprenorphine and 107 on methadone) in a follow-up study lasting 12 months. Methods Drug addiction history was collected by means of the Drug Addiction History Rating Scale (DAH-RS) and psychopathological features were collected by means of the Symptom Checklist-90 (SCL-90), using a special five-factor solution. Toxicological urinalyses were carried out for each patient during the treatment period. Results No statistically significant differences were detected in psychopathological symptoms, including 'worthlessness-being trapped', 'somatization', and 'panic-anxiety'. Methadone proved to be more effective on patients characterized by 'sensitivity-psychoticism', whereas buprenorphine was more effective on patients displaying a 'violence-suicide' symptomatology. Conclusions Heroin-dependent patients with psychiatric comorbidities may benefit from opioid agonist treatment not only because it targets their addictive problem, but also, precisely due to this, because it is effective against their mental disorder too.
Change in symptoms of erectile dysfunction in depressed men initiating buprenorphine therapy?
Aims The aim of this study is to describe the change in erectile dysfunction (ED) symptoms in the first 12 weeks of outpatient buprenorphine therapy. Background Erectile dysfunction is highly prevalent in men who use illicit opioids when compared with the general population. To date, no study has examined ED symptoms over time in men initiating buprenorphine therapy for opioid dependence. Methods A randomized, double blind, placebo-controlled trial was conducted to determine whether escitalopram treatment of depressive symptoms begun 1 week prior to buprenorphine induction would improve treatment retention. Male patients completed the International Index of Erectile Function scale at baseline prior to induction and monthly thereafter. A score of 25 or less on the erectile function domain (range 1�30) is considered indicative of erectile dysfunction. Findings A total of 111 male subjects enrolled: mean age 38.5 (� 9.7) years, 80.1% non-Hispanic Caucasian; 67.3% reported heroin as their opioid of choice. Mean IIEF at baseline was 20.4 (� 10.5). At baseline, 44.1% of the entire cohort had erectile dysfunction; among those who identified as sexually active at baseline, 26.1% had ED. Baseline erectile function was inversely and significantly correlated with age (r = ?.27, p = .006), but was not associated significantly with race, heroin use, years of opioid use, smoking, or hazardous use of alcohol. Compared to baseline, mean erectile function was significantly improved (p = .001) at 3 months, and sexual desire (p = .002) improved significantly at both 2- and 3-month assessments. Conclusion Erectile dysfunction is highly prevalent in depressed males using illicit opioids. Men who remain in buprenorphine treatment for 3 months show improvement in erectile function and sexual desire.
Cioe, Patricia A.; Anderson, Bradley J.; Stein, Michael D.
Cocaine Use Reduction with Buprenorphine (CURB): Rationale, design, and methodology?
Background Effective medications to treat cocaine dependence have not been identified. Recent pharmacotherapy trials demonstrate the potential efficacy of buprenorphine (BUP) (alone or with naltrexone) for reducing cocaine use. The National Institute on Drug Abuse Clinical Trials Network (CTN) launched the Cocaine Use Reduction with Buprenorphine (CURB) investigation to examine the safety and efficacy of sublingual BUP (as Suboxone�) in the presence of extended-release injectable naltrexone (XR-NTX, as Vivitrol�) for the treatment of cocaine dependence. This paper describes the design and rationale for this study. Methods This multi-site, double-blind, placebo-controlled study will randomize 300 participants across 11 sites. Participants must meet the DSM-IV criteria for cocaine dependence and past or current opioid dependence or abuse. Participants are inducted onto XR-NTX after self-reporting at least 7 days of abstinence from opioids and tolerating a naloxone challenge followed by oral naltrexone and are then randomly assigned to one of three medication conditions (4 mg BUP, 16 mg BUP, or placebo) for 8 weeks. Participants receive a second injection of XR-NTX 4 weeks after the initial injection, and follow-up visits are scheduled at 1 and 3 months post-treatment. Participants receive weekly cognitive behavioral therapy (CBT). Recruitment commenced in September, 2011. Enrollment, active medication, and follow-up phases are ongoing, and recruitment is exceeding targeted enrollment rates. Conclusions This research using 2 medications will demonstrate whether BUP, administered in the presence of XR-NTX, reduces cocaine use in adults with cocaine dependence and opioid use disorders and will demonstrate if XR-NTX prevents development of physiologic dependence on BUP.
Mooney, Larissa J.; Nielsen, Suzanne; Saxon, Andrew; Hillhouse, Maureen; Thomas, Christie; Hasson, Albert; Stablein, Don; McCormack, Jennifer; Lindblad, Robert; Ling, Walter
Twelve reasons for considering buprenorphine as a frontline analgesic in the management of pain.
Buprenorphine is an opioid that has a complex and unique pharmacology which provides some advantages over other potent mu agonists. We review 12 reasons for considering buprenorphine as a frontline analgesic for moderate to severe pain: (1) Buprenorphine is effective in cancer pain; (2) buprenorphine is effective in treating neuropathic pain; (3) buprenorphine treats a broader array of pain phenotypes than do certain potent mu agonists, is associated with less analgesic tolerance, and can be combined with other mu agonists; (4) buprenorphine produces less constipation than do certain other potent mu agonists, and does not adversely affect the sphincter of Oddi; (5) buprenorphine has a ceiling effect on respiratory depression but not analgesia; (6) buprenorphine causes less cognitive impairment than do certain other opioids; (7) buprenorphine is not immunosuppressive like morphine and fentanyl; (8) buprenorphine does not adversely affect the hypothalamic-pituitary-adrenal axis or cause hypogonadism; (9) buprenorphine does not significantly prolong the QTc interval, and is associated with less sudden death than is methadone; (10) buprenorphine is a safe and effective analgesic for the elderly; (11) buprenorphine is one of the safest opioids to use in patients in renal failure and those on dialysis; and (12) withdrawal symptoms are milder and drug dependence is less with buprenorphine. In light of evidence for efficacy, safety, versatility, and cost, buprenorphine should be considered as a first-line analgesic. PMID:22809652
Davis, Mellar P
Improving Care for the Treatment of Alcohol and Drug Disorders
The Network for the Improvement of Addiction Treatment (NIATx) teaches alcohol and drug treatment programs to apply process improvement strategies and make organizational changes that improve quality of care. Participating programs reduce days to admission, increase retention in care and spread the application of process improvement within their treatment centers. More generally, NIATx provides a framework for addressing the Institute of Medicine�s six dimensions of quality care (i.e., safe, effective, patient-centered, efficient, timely and equitable) in treatments for alcohol, drug and mental health disorders. NIATx and its extensions illustrate how the behavioral health field can respond to the demand for higher quality treatment services.
McCarty, Dennis; Gustafson, David; Capoccia, Victor A.; Cotter, Frances
Results of a Pilot Randomized Controlled Trial of Buprenorphine For Opioid Dependent Women in the Criminal Justice System
Aims Recent studies have demonstrated the efficacy of both methadone and buprenorphine when used with opioid dependent men transitioning from prison to the community, but no studies have been conducted with women in the criminal justice (CJ) system. The aim of this study was to determine the efficacy of buprenorphine for relapse prevention among opioid dependent women in the CJ system transitioning back to the community. Methods 36 women under CJ supervision were recruited from an inpatient drug treatment facility that treats CJ individuals returning back to the community. Nine were enrolled in an open label buprenorphine arm then 27 were randomized to buprenorphine (n=15) or placebo (n=12; double-blind). All women completed baseline measures and started study medication prior to release. Participants were followed weekly, provided urine drug screens (UDS), received study medication for 12 weeks, and returned for a 3 month follow-up. Intent-to-treat analyses were performed for all time points through end-of-treatment (EOT). Results The majority of participants were Caucasian (88.9%), young (M�SD=31.8�8.4 years), divorced/separated (59.2%) women with at least a high school/GED education (M�SD =12�1.7 years). GEE analyses showed that buprenorphine was efficacious in maintaining abstinence across time compared to placebo. At End of Treatment, 92% of placebo and 33% of active medication participants were positive for opiates on urine drug screen (Chi-Square = 10.9, df=1; p<0.001). However, by the three month follow-up point, no differences were found between the two groups, with 83% of participants at follow-up positive for opiates. Conclusions Women in the CJ system who received buprenorphine prior to release from a treatment facility had fewer opiate positive UDS through the 12-weeks of treatment compared to women receiving placebo. Initiating buprenorphine in a controlled environment prior to release appears to be a viable strategy to reduce opiate use when transitioning back to the community.
Cropsey, Karen L.; Lane, Peter S.; Hale, Galen J.; Jackson, Dorothy O.; Clark, C. Brendan; Ingersoll, Karen S.; Islam, M. Aminul; Stitzer, Maxine L.
Follow-up Care After Cancer Treatment
... home care services, nutrition counseling, physical therapy, pain management, and occupational or vocational therapy. Some patients may also need financial aid or assistance with transportation to and from ...
Opioid rotation from high-dose morphine to transdermal buprenorphine (Transtec) in chronic pain patients.
Opioid rotation is increasingly becoming an option to improve pain management especially in long-term treatment. Because of insufficient analgesia and intolerable side effects, a total of 42 patients (23 male, 19 female; mean age 64.1 years) suffering from severe musculoskeletal (64%), cancer (21%) or neuropathic (19%) pain were converted from high-dose morphine (120 to >240 mg/day) to transdermal buprenorphine. The dose of buprenorphine necessary for conversion (at least 52.5 microg/h) was titrated individually by the treating physician. No conversion recommendations were given and the treating physician used his or her own judgment for dose adjustment. Pain relief, overall satisfaction and quality of sleep (very good, good, satisfactory, poor, or very poor), and the incidence and severity of adverse drug reactions over a period of at least 10 weeks and up to 1 year was assessed. Following rotation, patients experiencing good/very good pain relief increased from 5% to 76% (P < 0.001). Only 5% reported insufficient relief. Relief was achieved with buprenorphine alone in 77.4%, while 17% needed an additional opioid for breakthrough pain. Sleep quality (good/very good) increased from 14% to 74% (P < 0.005). Adverse effects were reported in 11.9%, mostly because of local irritation, did not result in termination of therapy. Neither tolerance nor refractory effect following rotation from morphine to buprenorphine was noted. Conversion tables with a fixed conversion ratio are of limited value in patients treated with high-dose morphine. PMID:17559481
Freye, Enno; Anderson-Hillemacher, Astrid; Ritzdorf, Ingrid; Levy, Joseph Victor
Effects of Buprenorphine, Meloxicam, and Flunixin Meglumine as Postoperative Analgesia in Mice
C57BL/6NCrl male mice (n = 60; age, 6 to 7 wk) underwent partial hepatectomy or no surgery and were given 1 of 3 analgesics pre- and postoperatively. Food and water consumption, body weight, running wheel activity, locomotor activity, and serum corticosterone concentrations were measured before and after surgery. Mice that were surgically manipulated weighed significantly less on days 1 through 3 after surgery than did mice not manipulated surgically. On the day of surgery, the surgery groups consumed significantly less feed (�1.5 � 0.35 g) than did nonsurgery groups. There were no differences in water consumption on any day between surgery and nonsurgery groups or among the 3 analgesic groups. For running wheel activity, significant decreases in the surgery groups were seen at day 1 after surgery compared with baseline. Surgery groups that received buprenorphine and meloxicam returned to baseline activity levels on day 2 after surgery. Open-field testing revealed no significant differences in locomotor activity in any groups; however, posttreatment locomotor activity in the buprenorphine nonsurgery group was increased compared with baseline, and posttreatment locomotor activity in the flunixin meglumine surgery group was decreased compared with baseline. Serum corticosterone concentrations were within normal limits regardless of treatment in all groups. Comparison of the overall results indicated that meloxicam and buprenorphine, at the dose given, appear to be suitable postoperative analgesics for partial hepatectomy in mice. Flunixin meglumine at the given dosage (2.5 mg/kg) may not provide adequate analgesia for partial hepatectomy.
Tubbs, Jacquelyn T; Kissling, Grace E; Travlos, Greg S; Goulding, David R; Clark, James A; King-Herbert, Angela P; Blankenship-Paris, Terry L
Sleep disordered breathing in patients receiving therapy with buprenorphine/naloxone.
Patients using chronic opioids are at risk for exceptionally complex and potentially lethal disorders of breathing during sleep, including central and obstructive apnoeas, hypopnoeas, ataxic breathing and nonapnoeic hypoxaemia. Buprenorphine, a partial ?-opioid agonist with limited respiratory toxicity, is widely used for the treatment of opioid dependency and chronic nonmalignant pain. However, its potential for causing sleep disordered breathing has not been studied. 70 consecutive patients admitted for therapy with buprenorphine/naloxone were routinely evaluated with sleep medicine consultation and attended polysomnography. The majority of patients were young (mean�sd age 31.8�12.3 years), nonobese (mean�sd body mass index 24.9�5.9 kg�m(-2)) and female (60%). Based upon the apnoea/hypopnoea index (AHI), at least mild sleep disordered breathing (AHI ?5 events�h(-1)) was present in 63% of the group. Moderate (AHI ?15- <30 events�h(-1)) and severe (AHI ?30 events�h(-1)) sleep apnoea was present in 16% and 17%, respectively. Hypoxaemia, defined as an arterial oxygen saturation measured by pulse oximetry, of <90% for ?10% of sleep time, was present in 27 (38.6%) patients. Despite the putative protective ceiling effect regarding ventilatory suppression observed during wakefulness, buprenorphine may induce significant alterations of breathing during sleep at routine therapeutic doses. PMID:23100497
Farney, Robert J; McDonald, Amanda M; Boyle, Kathleen M; Snow, Gregory L; Nuttall, R T; Coudreaut, Michael F; Wander, Theodore J; Walker, James M
Protein Innovations Advance Drug Treatments, Skin Care
NASA Technical Reports Server (NTRS)
Dan Carter carefully layered the sheets of tracing paper on the light box. On each sheet were renderings of the atomic components of an essential human protein, one whose structure had long been a mystery. With each layer Carter laid down, a never-before-seen image became clearer. Carter joined NASA s Marshall Space Flight Center in 1985 and began exploring processes of protein crystal growth in space. By bouncing intense X-rays off the crystals, researchers can determine the electron densities around the thousands of atoms forming the protein molecules, unveiling their atomic structures. Cultivating crystals of sufficient quality on Earth was problematic; the microgravity conditions of space were far more accommodating. At the time, only a few hundred protein structures had been mapped, and the methods were time consuming and tedious. Carter hoped his work would help reveal the structure of human serum albumin, a major protein in the human circulatory system responsible for ferrying numerous small molecules in the blood. More was at stake than scientific curiosity. Albumin has a high affinity for most of the world s pharmaceuticals, Carter explains, and its interaction with drugs can change their safety and efficacy. When a medication enters the bloodstream a cancer chemotherapy drug, for example a majority of it can bind with albumin, leaving only a small percentage active for treatment. How a drug interacts with albumin can influence considerations like the necessary effective dosage, playing a significant role in the design and application of therapeutic measures. In spite of numerous difficulties, including having no access to microgravity following the 1986 Space Shuttle Challenger disaster, the image Carter had hoped to see was finally clarifying. In 1988, his lab had acquired specialized X-ray and detection equipment a tipping point. Carter and his colleagues began to piece together albumin s portrait, the formation of its electron densities coalescing on the sheets of tracing paper he arranged on the light box. While space-grown crystals were ultimately not involved in the achievement, a year later, Carter says, we were on the cover of Science magazine, having determined the atomic structure of albumin.
Anaphylaxis after the injection of buprenorphine.
Cause of death rulings in cases when the concentration of a drug or drugs is higher than observed following therapeutic use are generally straightforward "drug deaths." However, when toxicology testing identifies drug concentrations consistent with therapeutic use or detects no drugs at all, then the cause of death determination is more complicated. Given the rapidity and protean manifestations of anaphylaxis, it should be considered in deaths where no other cause of death is apparent in a suspected drug death. This article reports two cases where an anaphylactic reaction was observed following either the actual or alleged use of therapeutic formulations of buprenorphine intravenously. PMID:23550514
Boggs, Cassie L; Ripple, Mary G; Ali, Zabiullah; Brassell, Melissa; Levine, Barry; Jufer-Phipps, Rebecca; Doyon, Suzanne; Fowler, David R
Tobacco use treatment in primary care patients with psychiatric illness.
The prevalence of smoking is higher in patients with psychiatric illness compared with the general population. Smoking causes chronic illnesses, which lead to premature mortality in those with psychiatric illness, is associated with greater burden of psychiatric symptoms, and contributes to the social isolation experienced by individuals with psychiatric disorders. Most patients with a psychiatric illness present initially to primary care rather than specialty care settings, and some patients receive care exclusively in the primary care setting. Therefore, family physicians and other primary care clinicians have an important role in the recognition and treatment of tobacco use disorders in patients with psychiatric illnesses. In this article we review common myths associated with smoking and psychiatric illness, techniques for implementing evidence-based tobacco use treatments, the evidence base for tobacco use treatment for patients with specific psychiatric diagnoses, and factors to consider when treating tobacco use disorders in patients with psychiatric illness. PMID:24808119
Cerimele, Joseph M; Halperin, Abigail C; Saxon, Andrew J
Bibliotherapy as a Treatment for Depression in Primary Care
This study was designed to determine whether a physician-delivered bibliotherapy prescription would compare favorably with\\u000a the prevailing usual care treatment for depression in primary care (that often involves medication) and potentially offer\\u000a an alternative. Six family physicians were trained to write and deliver prescriptions for cognitive-behavioral bibliotherapy.\\u000a Thirty-eight patients were randomly assigned to receive either usual care or a behavioral
Elizabeth V. Naylor; David O. Antonuccio; Mark Litt; Gary E. Johnson; Daniel R. Spogen; Richard Williams; Catherine McCarthy; Marcia M. Lu; David C. Fiore; Dianne L. Higgins
Depression Treatment Preferences in Older Primary Care Patients
ERIC Educational Resources Information Center
Purpose: For depressed older primary care patients, this study aimed to examine (a) characteristics associated with depression treatment preferences; (b) predictors of receiving preferred treatment; and (c) whether receiving preferred treatment predicted satisfaction and depression outcomes. Design and Methods: Data are from 1,602 depressed older�
Gum, Amber M.; Arean, Patricia A.; Hunkeler, Enid; Tang, Lingqi; Katon, Wayne; Hitchcock, Polly; Steffens, David C.; Dickens, Jeanne; Unutzer, Jurgen
Buprenorphine Prescribing Practices and Exposures Reported to a Poison Center: Utah, 2002-2011. Morbidity and Mortality Weekly Report Volume 61, No. 49.
National Technical Information Service (NTIS)
Buprenorphine is an effective medication for the treatment of opioid dependence. Its use has increased in the United States as a result of the Drug Addiction Treatment Act of 2000, which allowed physicians to prescribe certain medications as part of offic...
Consumer Attitudes about Opioid Addiction Treatment: A focus group study in New York City
Objective To develop effective programs for people who are opioid-dependent and to impact the opioid epidemic in New York City, it is crucial that we monitor attitudes about opioid addiction treatments among opioid users who have experienced barriers to engagement and retention in addiction treatment. Design We conducted a qualitative study using focus groups. Methods We conducted six focus groups in three needle exchanges in New York City, which were audio recorded, transcribed, and systematically coded. We report on the main themes related to the study objectives. Participants Participants of each needle exchange who were opioid-dependent and had some knowledge of both methadone and buprenorphine were eligible. Results There were four main findings. Participants felt: (1) buprenorphine is an appropriate option only for those heroin users who are motivated to stop using; (2) they have less control over their addiction treatment with methadone than they would have with buprenorphine; (3) buprenorphine treatment is not accessible to many New York City residents who would benefit from this treatment; and (4) lack of access to buprenorphine treatment is the cause of treatment-related diversion. Conclusions Both methadone maintenance and buprenorphine treatment opportunities are necessary to address the diverse treatment needs of opioid-dependent people in New York City. However, the current medical model of buprenorphine treatment may be too restrictive for some opioid-dependent people, and may be contributing to the use of illicit buprenorphine. New models to deliver buprenorphine treatment may address these problems.
Weiss, Linda; Egan, James E.; Lopez, Carolina; Favaro, Jamie; Cordero, Robert; Cunningham, Chinazo
Medical care treatment decision support system
US Patent & Trademark Office Database
Exemplary embodiments of the present invention will assist patients with their investigation of, and decision making about, the treatments that are available to them using conjoint analysis methods that measure individual preferences for risk-associated treatment options, while maintaining an acceptable interview length. In exemplary embodiments, such individual preferences, known as "utilities" in economics literature, will be combined with evidence-based outcomes data regarding the probabilities of treatment outcomes; exemplary embodiments will use "decision analysis" and modified "conjoint analysis" methods, to dynamically generate for patients real-time individualized, evidence-based feedback, rankings and recommendations regarding medical treatment alternatives that are available to the patient based on the patient's medical condition and prognostic indicators.
The readiness of addiction treatment agencies for health care reform
The Patient Protection and Affordable Care Act (PPACA) aims to provide affordable health insurance and expanded health care coverage for some 32 million Americans. The PPACA makes provisions for using technology, evidence-based treatments, and integrated, patient-centered care to modernize the delivery of health care services. These changes are designed to ensure effectiveness, efficiency, and cost-savings within the health care system. To gauge the addiction treatment field�s readiness for health reform, the authors developed a Health Reform Readiness Index (HRRI) survey for addiction treatment agencies. Addiction treatment administrators and providers from around the United States completed the survey located on the http://www.niatx.net website. Respondents self-assessed their agencies based on 13 conditions pertinent to health reform readiness, and received a confidential score and instant feedback. On a scale of �Needs to Begin,� �Early Stages,� �On the Way,� and �Advanced,� the mean scores for respondents (n?=?276) ranked in the Early Stages of health reform preparation for 11 of 13 conditions. Of greater concern was that organizations with budgets of?$5 million (n?=?193) were less likely than those with budgets?>?$5 million to have information technology (patient records, patient health technology, and administrative information technology), evidence-based treatments, quality management systems, a continuum of care, or a board of directors informed about PPACA. The findings of the HRRI indicate that the addiction field, and in particular smaller organizations, have much to do to prepare for a future environment that has greater expectations for information technology use, a credentialed workforce, accountability for patient care, and an integrated continuum of care.
A Comparison of Cigarette Smoking Profiles in Opioid-Dependent Pregnant Patients Receiving Methadone or Buprenorphine
Introduction: Little is known about the relationship between cigarette smoking and agonist treatment in opioid-dependent pregnant patients. The objective of this study is to examine the extent to which cigarette smoking profiles differentially changed during the course of pregnancy in opioid-dependent patients receiving either double-blind methadone or buprenorphine. Patients were participants in the international, randomized controlled Maternal Opioid Treatment: Human Experimental Research (MOTHER) study. Methods: A sample of opioid-maintained pregnant patients (18�41 years old) with available smoking data who completed a multisite, double-blind, double-dummy, randomized controlled trial of methadone (n = 67) and buprenorphine (n = 57) between 2005 and 2008. Participants were compared on smoking variables based on opioid agonist treatment condition. Results: Overall, 95% of the sample reported cigarette smoking at treatment entry. Participants in the two medication conditions were similar on pretreatment characteristics including smoking rates and daily cigarette amounts. Over the course of the pregnancy, no meaningful changes in cigarette smoking were observed for either medication condition. The fitted difference in change in adjusted cigarettes per day between the two conditions was small and nonsignificant (? = ?0.08, SE = 0.05, p = .132). Conclusions: Results support high rates of smoking with little change during pregnancy among opioid-dependent patients, regardless of the type of agonist medication received. These findings are consistent with evidence that suggests nicotine effects, and interactions may be similar for buprenorphine compared with methadone. The outcomes further highlight that aggressive efforts are needed to reduce/eliminate smoking in opioid-dependent pregnant women.
Patient-centred care: making cancer treatment centres accountable.
Patient-centred care is argued to be an essential component in the delivery of quality health and cancer care. This manuscript discusses the need to generate credible data which indicates the quality of patient-centred care provided by cancer treatment centres. Patient-centred care covers six domains including physical comfort; emotional support; respect for patients' preferences and values; integration and coordination; involvement of family and friends; and the provision of information, communication and education to enable patients to understand and make informed decisions about their care. First, we identify priority areas within each domain. Next, we propose three questions that should be asked of every patient across the six domains of patient-centred care. The first question explores whether patients were specifically asked by a healthcare provider at the cancer treatment centre about their concerns, values and preferences. Research indicates that it cannot be assumed that clinicians are aware of patient's needs or preferences in these six areas. Second, if the answer from the patient suggests that they would like assistance, then it would be expected that this would be offered. Thirdly, if the patient indicates that they would like such assistance and it is provided, then it might be expected that the patient would report that the provided assistance did relieve their suffering, or the assistance provided was consistent with their preferences, needs and values. Regular measurement and reporting of these aspects of patient-centred cancer care has the potential to identify deficits and inequities in care delivery, allow for comparisons across treatment centres and stimulate an improvement in the patient-centred care provided to cancer patients. PMID:24696084
Zucca, Alison; Sanson-Fisher, Rob; Waller, Amy; Carey, Mariko
Standard of Care for Antiretroviral Therapy Adherence and Retention in Care from the Perspective of Care Providers Attending the 5th International Conference on HIV Treatment Adherence
Objective: To characterize standard clinical care for antiretroviral therapy (ART) adherence and retention in HIV-care support strategies among care providers attending the 2010 5th International Conference on HIV Treatment Adherence. Methods: A brief survey was included in conference packets, covering adherence monitoring and support strategies and retention in care strategies used in standard clinical care. Results: A total of 51
K. Rivet Amico
Epidural analgesia with morphine or buprenorphine in ponies with lipopolysaccharide (LPS)-induced carpal synovitis
This study evaluated the analgesia effects of the epidural administration of 0.1 mg/kg bodyweight (BW) of morphine or 5 ?g/kg BW of buprenorphine in ponies with radiocarpal joint synovitis. Six ponies were submitted to 3 epidural treatments: the control group (C) received 0.15 mL/kg BW of a 0.9% sodium chloride (NaCl) solution; group M was administered 0.1 mg/kg BW of morphine; and group B was administered 5 ?g/kg BW of buprenorphine, both diluted in 0.9% NaCl to a total volume of 0.15 mL/kg BW administered epidurally at 10 s/mL. The synovitis model was induced by injecting 0.5 ng of lipopolysaccharide (LPS) in the left or right radiocarpal joint. An epidural catheter was later introduced in the lumbosacral space and advanced up to the thoracolumbar level. The treatment started 6 h after synovitis induction. Lameness, maximum angle of carpal flexion, heart rate, systolic arterial pressure, respiratory rate, temperature, and intestinal motility were evaluated before LPS injection (baseline), 6 h after LPS injection (time 0), and 0.5, 1, 2, 4, 6, 8, 10, 12, 16, 20, and 24 h after treatments. Although the model of synovitis produced clear clinical signs of inflammation, the lameness scores in group C were different from the baseline for only up to 12 h. Both morphine and buprenorphine showed a reduction in the degree of lameness starting at 0.5 and 6 h, respectively. Reduced intestinal motility was observed at 0.5 h in group M and at 0.5 to 1 h in group B. Epidural morphine was a more effective analgesic that lasted for more than 12 h and without side effects. It was concluded that morphine would be a valuable analgesic option to alleviate joint pain in the thoracic limbs in ponies.
Freitas, Gabrielle C.; Carregaro, Adriano B.; Gehrcke, Martielo I.; De La Corte, Flavio D.; Lara, Valeria M.; Pozzobon, Ricardo; Brass, Karin E.
Comparison of oral and subcutaneous administration of buprenorphine and meloxicam for preemptive analgesia in cats undergoing ovariohysterectomy
Objective - To compare the effectiveness of preoperative PO and SC administration of buprenorphine and meloxicam for prevention of postoperative pain-associated behaviors in cats undergoing ovariohysterectomy. Design - Randomized controlled study. Animals - 51 female cats (4 to 60 months old; weight range, 1.41 to 4.73 kg [3.1 to 10.4 lb]). Procedure - Cats received 1 of 5 treatments at
Adam D. Gassel; Karen M. Tobias; Christine M. Egger; Rohrbach Barton W
Effects of buprenorphine and an alternative nondrug reinforcer, alone and in combination on smoked cocaine self-administration in monkeys
The abuse of smoked cocaine base, also known as �crack�, continues to be a major public health problem and to date the success of pharmacological or behavioral interventions has been limited. The purpose of this study was to evaluate the efficacy of a behavioral (alternative reinforcer-saccharin) and pharmacological (0.01 mg\\/kg buprenorphine) treatment alone and in combination. Five adult male rhesus
Joshua S. Rodefer; Adande J. Mattox; Sherry S. Thompson; Marilyn E. Carroll
Adjustment of Natural Children in Treatment Foster Care.
ERIC Educational Resources Information Center
The negative effects of treatment foster care on the natural children in the foster homes in this study was apparent to foster parents and program staff. The program, William Roper Hull Child and Family Services, was losing some foster families due to the negative impact that the natural children in the foster homes were experiencing. A strategy�
Prosciak, Karen Victoria
Quality of Care Measures for the Treatment of Bipolar Disorder
The staff of the American Psychiatric Assocition (APA), the American Psychiatric Institute for Research and Education (APIRE), and a national panel of experts in bipolar disorder and practice guideline development have collaborated to generate a set of quality of care indicators for the pharmacologic and psychosocial treatment of bipolar disorder. The indicators were derived from APA�s evidence-based Practice Guideline for
Farifteh Firoozmand Duffy; William Narrow; Joyce C. West; Laura J. Fochtmann; David A. Kahn; Trisha Suppes; John M. Oldham; John S. McIntyre; Ronald W. Manderscheid; Paul Sirovatka; Darrel Regier
Prior Trauma Exposure for Youth in Treatment Foster Care
ERIC Educational Resources Information Center
Very little research has focused on rates of trauma exposure for youth in treatment foster care (TFC). Available research has utilized record review for assessing exposure, which presents limitations for the range of trauma types examined, as records are predominantly focused on abuse and neglect. The current study examines exposure rates and�
Dorsey, Shannon; Burns, Barbara J.; Southerland, Dannia G.; Cox, Julia Revillion; Wagner, H. Ryan; Farmer, Elizabeth M. Z.
Buprenorphine TDS: the clinical development rationale and results.
Buprenorphine, a powerful opioid, is newly available for delivery in a transdermal formulation. The transdermal system's matrix patch provides rate-controlled administration of the drug. Three double-blind, placebo-controlled trials were conducted to evaluate efficacy and tolerability of the buprenorphine transdermal system (buprenorphine TDS, Transtec). A total of 445 patients were enrolled in the studies. All suffered from moderate to severe and very severe pain, both cancer- or non-cancer-related. The percentage of responders increased as the rate of buprenorphine delivered by the transdermal system rose, ranging from a 29% (cancer) and 36% (non-cancer) response rate associated with the lowest dose (35 microg/h), to 40% (cancer) and 46% (non-cancer) with the highest dose (70 microg/h). Patients receiving buprenorphine TDS slept longer, uninterrupted by pain, than patients from the placebo group. Systemic adverse effects reported in the drug cohorts included nausea, vomiting and dizziness, and were typical of those reported in other studies of opioids; local adverse events, most commonly erythema and pruritus, were transient and mild to moderate. In an open-label, follow-up trial, in which 239 patients from the original clinical studies participated, 90% of patients reported that their analgesia was satisfactory or even better over a mean duration of 4.7 months; nearly 95% of patients found the patch to be user-friendly. The new buprenorphine TDS appears to be an important new modality for administering analgesia in patients with non-acute pain. PMID:12665119
Radbruch, Lukas; Vielvoye-Kerkmeer, Ans
[Access to cancer care: the cost of treatment matters].
The approval of new antiviral agents and the wide-ranging costs of ophthalmic therapies with comparable efficacy have renewed the debate over the cost-effectiveness of novel drugs. In oncology, more expensive treatments do not always substantially change the outcome of the disease, but they merely prolong life expectancy by a few weeks even at the cost of significant side effects. Treatment costs are a key factor the physician should consider when sharing care decisions with the patient. In addition, fund allocation for purchasing high cost medications results in limited investment in clinical research and human resources - doctors, nurses and other healthcare staff - that play a central role in patient care. Regulatory agencies should be more demanding, reimbursing pharmaceutical companies on the basis of treatment outcome. PMID:24873939
Tirelli, Umberto
A model for chronic care of obesity through dietary treatment.
Obesity is rapidly increasing to epidemic proportions. At the same time, obesity is not well accepted as a disease among health professionals or insurance companies. The primary care physician is often forced to ignore the obesity and treat the associated risks, and the dietitian is often compelled to treat the disease for only short periods and for little reimbursement. Therefore, to treat obesity more effectively both clinically and economically, it is necessary to create a health care team. This can be done by joining the dietitian and the primary care physician, even if each health professional sees patients at a different site. Through mutual referrals and more consistent coordination of care, the team can provide cost-effective management of obesity while providing improved clinical monitoring of the patient. Both members of the team need to understand the pathophysiology of obesity and when to refer to each other. The dietitian will see the patient more regularly throughout all stages of the obesity treatment, referring to the physician when appropriate (eg, for evaluation of medications, new laboratory tests, and electrocardiography). The physician will see the patient in the acute stage (i.e., weight change stage) of the obesity treatment for any clinical changes, but will schedule less frequent visits during the chronic stage (i.e., weight maintenance). The strength of the team, therefore, lies in its members' ability to communicate with each other, monitor the clinical changes concomitant with fluctuating weight, and offer treatment and support as intensively as the disease warrants. PMID:9787731
Nonas, C A
Acute effects of intramuscular and sublingual buprenorphine and buprenorphine\\/naloxone in non-dependent opioid abusers
Rationale��Buprenorphine is a partial mu opioid receptor agonist with clinical efficacy as a pharmacotherapy for opioid dependence. A\\u000a sublingual combination formulation was developed containing buprenorphine and naloxone with the intent of decreasing abuse\\u000a liability in opioid-dependent individuals. However, the addition of naloxone may not limit abuse potential of this medication\\u000a when taken by individuals without opioid physical dependence.\\u000a \\u000a \\u000a \\u000a \\u000a Objectives��The present
Angela N. Duke; Christopher J. Correia; Sharon L. Walsh; George E. Bigelow; Eric C. Strain
Buprenorphine Outpatient Outcomes Project: can Suboxone be a viable outpatient option for heroin addiction?
Background Opioid dependence treatment traditionally involves methadone clinics, for which dispensing schedules can be cumbersome. Buprenorphine, a partial agonist of the mu receptor and antagonist of the kappa receptor, is a potential outpatient alternative to methadone. Funded by a grant from the State of Maryland's Community Health Resources Commission (CHRC), the Buprenorphine Outpatient Outcomes Project (BOOP) evaluates the outcome of Suboxone (buprenorphine/naloxone) treatment on abstinence from heroin use, rates of emergency room visits and hospitalizations, legal issues, and quality of life. Methods Active heroin users were recruited between June 2007 and June 2010 and induction therapy with Suboxone was instituted during hospitalization. Once discharged, patients were followed as outpatients for maintenance treatment and counseling. Data were collected from electronic medical records, Maryland state legal records, and SF-36� Health Surveys regarding several parameters and patients were categorized according to duration of treatment with Suboxone into one of three groups: <1 month, 1�3 months, and >3 months. Results A total of 220 participants were included in the study. The age range of participants was 18�67 years with most being African American males. Eighty-three (38%) remained in the study for at least 1 month, with 37 of the 83 (45%) remaining in treatment for >3 months. Ten of the 37 (27%) never relapsed after their longest period of abstinence from heroin. During the first year after initiating treatment with Suboxone, hospitalization and emergency room visit rates for all 220 participants decreased by 45 and 23%, respectively, as compared to the year prior to starting treatment. The number of legal charges for drug possession decreased from 70 to 62. Anecdotally, the quality of life seemed to improve in those who were treated with Suboxone for longer periods of time and received regular counseling. Conclusion Overall, Suboxone is an effective treatment method for heroin addiction and is a viable outpatient therapy option. Individualized treatment plans and counseling must be implemented for maximum benefits to be seen. Retention of patients for a long duration of therapy was difficult, but for those who did remain, benefits were seen in overall health, abstinence from heroin use, cognition, and quality of life.
Sittambalam, Charmian D.; Vij, Radhika; Ferguson, Robert P.
[Quality of care in diabetic patients receiving pharmacologic treatment].
Diabetes mellitus is a chronic disease with an increasing prevalence. Appropriate treatment of the disease and prevention of chronic complications reduce morbidity and mortality in a cost-effective manner. These actions should be measured through the use of validated indicators for quality of care. The goal of this study was to assess the quality of care in diabetic patients under pharmacologic treatment in a private university hospital. A retrospective study was conducted in adult patients who bought insulin or oral hypoglycemic agents during a 3 month period; demographic and clinical data were obtained for 12 consecutive months following the buying period. The study included 305 adult patients; most were males (60%), with type 2 diabetes (95%), and using oral hipoglycemic agents (86%). Control of blood pressure was registered in 80%, foot exam in 5%, eye exam in 27%, HbA1C blood level in 85%, complete lipid profile in 82%, microalbuminuria in 27% and creatinine clearance in 22% of patients, respectively. Mean values were HbA1C 7.1(+/- 1.6)%, and < or = 7% in 66%, LDL 113 (+/- 33.6) mg/dl and <100 mg/dl in 30%, BP 136-79 mm Hg and < 130-80 mm Hg in 46% of patients, respectively. This study emphasizes the need for quality of care assessment through validated indicators and points out the aspects that should be improved within a health care system. PMID:18051222
Lombra�a, Mar�a A; Capetta, Mar�a E; Ugarte, Alejandro; Correa, Viviana; Giganti, Jorge; Saubidet, Cristian Lopez; Stryjewski, Martin E
Characteristics, treatment patterns, and outcomes of persistent depression despite treatment in primary care
We examine the sociodemographic and clinical characteristics of depressed primary care patients who receive at least minimal standards of evidence-based treatment, comparing those who remain depressed with those who recover; and their subsequent treatment patterns and other outcomes. We used observational data from a subset of 542 treated patients participating in a group-level randomized controlled trial of quality improvement interventions
Cathy Sherbourne; Michael Schoenbaum; Kenneth B Wells; Thomas W Croghan
Mental Health Treatment Program Locator
... Treatment Facility Locator Buprenorphine Physician Locator Find a Facility in Your State To locate the mental health ... Service . Privacy Policy . Home | About the Locator | Find Facilities Near You | Find Facilities by City, County, State ...
Psychomotor effects of ketorolac in comparison with buprenorphine and diclofenac.
1. Ketorolac is an investigational non-opioid analgesic. Buprenorphine, an opioid compound and diclofenac, a non-steroidal anti-inflammatory, are analgesics used in clinical practise. 2. The psychomotor effects of ketorolac (30 mg), buprenorphine (0.3 mg), diclofenac (50 mg) and placebo all administered i.m., were examined in 12 healthy male volunteers (age 19-38 years), up to 8 h post-dose. 3. Creatine phosphokinase (CPK) was measured up to 24 h post-dose, providing an indication of local tissue damage following injection. 4. Buprenorphine caused significant psychomotor impairment in seven out of eight psychomotor tests. The effects consistently peaked 4 h post-dose and were still apparent in many cases 8 h post-dose. These psychomotor effects were supported by marked symptoms in all volunteers. 5. Ketorolac and diclofenac had no clinically significant effects on psychomotor tests and only minimal symptoms were reported. 6. Diclofenac caused a marked increased in CPK (mean Cmax 298 iu l-1) compared with ketorolac (mean Cmax 70 iu l-1) and buprenorphine (mean Cmax 68 iu l-1). 7. These results suggest that ketorolac and diclofenac are suitable for administration following day case surgery.
MacDonald, F C; Gough, K J; Nicoll, R A; Dow, R J
Opioid substitution treatment in New Zealand: a 40 year perspective.
We provide an overview of the history and philosophy of the treatment for opioid dependence, which has been dominated by methadone substitution treatment for the past 40 years in New Zealand. Although changes in approach have occurred over this time, influenced by various sociopolitical events and changing ideologies, opioid substitution treatment has still "not come of age". It remains undermined by stigma and risk concerns associated with methadone and has struggled to be accessible and attractive to illicit opioid drug users, comprehensive and integrated into mainstream health care. However, the introduction in 2012 of Pharmac-subsidised buprenorphine combined with naloxone (Suboxone) in the context of an emerging trend towards a broader recovery and well-being orientation could signal a new era in treatment. The availability of buprenorphine-naloxone may also facilitate a further shift in treatment from primarily siloed specialist addiction services to integrated primary care services. This shift will help reduce stigma, promote patient self-management and community integration and align opioid substitution treatment with treatment for other chronic health conditions such as diabetes and asthma. PMID:24997702
Deering, Daryle; Sellman, J Douglas; Adamson, Simon
Development of an enhanced formulation for delivering sustained release of buprenorphine hydrochloride
To control the minimum effective dose, and reduce the number and quantity of administered potent drugs are unique features of advanced drug delivery in situ forming gel formulation. The efficacy, consistency, and increasing the application of existing injection therapies can be enhanced through optimization of controlled released systems by using FDA approved biodegradable PLGA (poly-d,l-lactide-co-glycolide) polymer. The purpose of this study was to develop different in situ forming implant (ISFI) formulations of buprenorphine hydrochloride for post treatment of drug addicts, acute and chronic pains. The drug releases from different ISFIs membranes with and without Tween 80 were compared over a period of time. Kinetic equation followed the Korsmeyer�Peppas model, as the plots showed high linearity. The influence of this additive on polymer properties was investigated using differential scanning calorimetry (DSC), and the membranes structure was studied by X-ray diffractometry (XRD) and scanning electron microscope (SEM). Data revealed that Tween 80 modified the drug release pattern using diffusion mechanism and decreased the glass transition temperature (Tg) significantly. The degree of crystallinity was decreased after phase inversion which helps the dissolution of drug from membrane. The porosity of modified membranes was in accordance with release profiles. These findings suggest four different in situ forming implant formulations which can release various dose of the buprenorphine hydrochloride in a prolonged time. Also this surfactant can be an attractive additive for modifying the release rate of drugs from PLGA-based membrane drug delivery systems.
Koocheki, S.; Madaeni, S.S.; Niroomandi, P.
Uses of diverted methadone and buprenorphine by opioid-addicted individuals in Baltimore, Maryland
This study examined the uses of diverted methadone and buprenorphine among opiate-addicted individuals recruited from new admissions to methadone programs and from out-of-treatment individuals recruited from the streets. Self-report data regarding diversion were obtained from surveys and semi-structured qualitative interviews. Approximately 16% (n=84) of the total sample (N=515) reported using diverted (street) methadone 2�3 times per week for six months or more, and for an average of 7.8 days (SD=10.3) within the past month. The group reporting lifetime use of diverted methadone as compared to the group that did not report such use was less likely to use heroin and cocaine in the 30 days prior to admission (ps < .01) and had lower ASI Drug Composite scores (p < .05). Participants in our qualitative sub-sample (n=22) indicated that street methadone was more widely used than street buprenorphine and that both drugs were largely used as self-medication for detoxification and withdrawal symptoms. Participants reported using low dosages and no injection of either medication was reported.
Mitchell, Shannon Gwin; Kelly, Sharon M.; Brown, Barry S.; Reisinger, Heather Schacht; Peterson, James A.; Ruhf, Adrienne; Agar, Michael H.; O'Grady, Kevin E.; Schwartz, Robert P.
Disaccharides in urine samples as markers of intravenous abuse of methadone and buprenorphine.
Methadone and buprenorphine are commonly used as oral substitutes in opiate maintenance programs to treat persons who are dependent on heroin. During these programs, patients are not allowed to continue using illicit drugs. Abstinence can easily be monitored by urine tests with immunochemical methods. It is well known that the intravenous abuse of heroin substitutes like methadone or buprenorphine has become common as well. The methadone-prescribing physician has no opportunity to check whether the opiate maintenance treatment patient takes his substitution medicines orally as intended or continues with his intravenous misuse now substituting the methadone instead of injecting heroin. In Germany, substitutes are available as liquids and tablets that contain carbohydrates as adjuvants. Sucrose is used to increase viscosity in liquids, while lactose is needed for pressing tablets (e.g., Methaddict� and Subutex�). In case of oral ingestion, disaccharides are broken down into monosaccharides by disaccharidases in the small intestine. These monosaccharides are absorbed into the blood stream by special monosaccharide transporters. Disaccharidases do not exist in blood, thus sucrose and lactose are not split if substitute medicines are injected intravenously. Our assumption, therefore, was that they are excreted unchanged in urine. We investigated a method for the detection of disaccharides in urine as markers of intravenous abuse of substitutes. Urine samples of 26 intravenous substitute abusers showed all positive results for lactose (76.9%) and/or sucrose (73.1%). The method is assumed to be useful to detect intravenous abuse of substitutes. PMID:24099717
Jungen, Hilke; Andresen-Streichert, Hilke; M�ller, Alexander; Iwersen-Bergmann, Stefanie
Pharmacokinetics of 2 Formulations of Buprenorphine in Macaques (Macaca mulatta and Macaca fascicularis)
Buprenorphine is the cornerstone of pain management in nonhuman primates, but the pharmacokinetics of this widely used drug are unknown. The purpose of this study was to evaluate the pharmacokinetic profiles of buprenorphine (0.01 and 0.03 mg/kg IM) and sustained-release buprenorphine (0.2 mg/kg SC) in 2 macaque species (M. mulatta and M. fascicularis) by using mass spectrometry. The pharmacokinetics did not differ significantly between species, and buprenorphine was dose-proportional at the tested doses. The low and high doses of buprenorphine had elimination half-lives of 2.6 � 0.7 and 5.3 � 2.0 h, respectively, but the low-dose data were constrained by the sensitivity of the analytical method. Sustained-release buprenorphine had an elimination half-life of 42.6 � 26.2 h. The AUC0-Tlast of buprenorphine were 9.1 � 4.3 and 39.0 � 25.1 ng�h/mL for the low and high doses, respectively, and sustained-release buprenorphine had an AUC0-Tlast of 177 � 74 ng�h/mL. Assuming a hypothesized therapeutic buprenorphine plasma concentration threshold of 0.1 ng/mL in macaques, these results suggest that buprenorphine doses of 0.01 mg/kg IM should be administered every 6 to 8 h, whereas doses of 0.03 mg/kg IM can be administered every 12 h. These results further demonstrate that a single 0.2-mg/kg SC injection of sustained-release buprenorphine maintains plasma concentrations above 0.1 ng/mL for 5 d in macaques. These findings support a new dosing strategy using sustained-release buprenorphine to improve pain management, decrease animal stress, improve animal welfare, and simplify the postoperative management of nonhuman primates in laboratory animal and zoological settings.
Nunamaker, Elizabeth A; Halliday, Lisa C; Moody, David E; Fang, Wenfang B; Lindeblad, Matthew; Fortman, Jeffrey D
Reassessment of buprenorphine in conditioned place preference: temporal and pharmacological considerations
Rationale Buprenorphine is widely used as an analgesic drug and it is also increasingly considered for maintenance and detoxification of heroin addicts. It is a potent �-receptor partial agonist with a long duration of action. An inverted U-shaped dose-effect curve for buprenorphine conditioned place preference (CPP) has been shown previously. Objectives We re-evaluated the CPP effects of buprenorphine by taking
Thomas M. Tzschentke
Motivational properties of buprenorphine as assessed by place and taste conditioning in rats
Buprenorphine, a mixed agonist-antagonist opioid with considerable analgesic activity, is currently indicated as a therapeutic\\u000a agent with low abuse potential. Nevertheless, buprenorphine abuse has been recently reported from some countries. Thus the\\u000a present experiments were performed to characterize further the motivational properties of buprenorphine in rats. Rewarding\\u000a and aversive effects were assessed by place preference and taste aversion conditioning, respectively.
M. Gaiardi; M. Bartoletti; A. Bacchi; C. Gubellini; M. Babbini
A multi-center randomized trial of buprenorphine-naloxone versus clonidine for opioid detoxification: findings from the National Institute on Drug Abuse Clinical Trials Network
AIMS: The clinical effectiveness of buprenorphine-naloxone (bup-nx) and clonidine for opioid detoxification in in-patient and out-patient community treatment programs was investigated in the first studies of the National Institute of Drug Abuse Clinical Trials Network.\\u000aDESIGN: Diagnostic and Statistical Manual version IV (DSM IV)-diagnosed opioid-dependent individuals seeking short-term treatment were randomly assigned, in a 2 : 1 ratio favoring bup-nx,
Walter Ling; Leslie Amass; Steve Shoptaw; Jeffrey J. Annon; Maureen Hillhouse; Dean Babcock; Greg Brigham; Judy Harrer; Malcolm S. Reid; Joan A. Muir; Betty J. Buchan; Debbie Orr; George Woody; Jonathan Krejci; Douglas M. Ziedonis
Evaluation of an improved sustained-release buprenorphine formulation for use in mice.
Objective-To evaluate analgesic effects of an improved sustained-release buprenorphine (BUP-SR) formulation administered to mice. Animals-36 male Swiss-Webster mice. Procedures-Mice were assigned to each of 3 treatment groups (n = 12 mice/group). Treatments were administered SC (vehicle [control treatment], 1.5 mg of buprenorphine hydrochloride [BUP-HCl]/kg, and 1.5 mg of BUP-SR/kg). Mice were evaluated (total activity, gastrointestinal tract motility, respiratory rate, cataleptic behavior, and tall-flick and hot plate nociception tests) to determine behavioral and physiologic responses at 4, 24, and 48 hours after treatment administration. Body weight and respiratory rate were measured before and at each time point after treatment administration. Results-SC administration of BUP-SR resulted in significant antinociception effects for 48 hours for the hot plate and tall-flick nociception tests without substantial adverse effects. Gastrointestinal tract motility and total activity were higher at 4 hours for mice receiving BUP-SR than for mice receiving the vehicle, but values were the same between these groups at 24 and 48 hours. The BUP-SR group had a lower respiratory rate than did the control group at all times after treatment administration. Mice treated with BUP-SR had no significant changes in body weight during the study, whereas mice treated with BUP-HCl had a significant decrease in body weight at 24 and 48 hours. Conclusions and Clinical Relevance-BUP-SR administration resulted in antinociception effects for 48 hours. Results of this study indicated that the improved BUP-SR formulation could be safely administered SC and conferred superior analgesia, compared with that for BUP-HCl, in mice. PMID:24959727
Healy, Jason R; Tonkin, Jennifer L; Kamarec, Stacey R; Saludes, Mitchell A; Ibrahim, Sherif Y; Matsumoto, Rae R; Wimsatt, Jeffrey H
Integrated care for pregnant women on methadone maintenance treatment
Abstract Objective To describe the characteristics of a national cohort of pregnant women on methadone maintenance treatment (MMT) and to provide treatment outcome data for integrated care programs. Design Retrospective chart review. Setting Three different integrated care programs in geographically distinct cities: the Toronto Centre for Substance Use in Pregnancy in Toronto, Ont; the Herzl Family Practice Centre in Montreal, Que; and the Sheway clinic in Vancouver, BC. Participants Pregnant women meeting criteria for opioid dependence and attending an integrated care program between 1997 and 2009. Women were excluded if they were on MMT only for chronic pain. Main outcome measures Patient demographic characteristics, concurrent medical and psychiatric disorders, and substance use outcome data. Results A total of 102 opioid-dependent pregnancies were included. The mean age was 29.7 years and 64% of women were white. Women in Montreal were more likely to have partners and had fewer children. Differences in living and housing situations among the sites tended to resolve by the time of delivery. Almost half of this cohort tested positive for hepatitis C. Women had a high prevalence of depression and anxiety across all sites. Half of this cohort was on MMT before conception and for the other half, MMT was initiated at a mean gestational age of 20.7 weeks, resulting in a mean dose of 82.4 mg at delivery. At the first visit, polysubstance use was common. Prescription opioid use was more frequent in Toronto and heroin use was more prevalent in Vancouver and Montreal. For the entire population, significant reductions were found by the time of delivery for illicit (P < .001) and prescription opioids (P = .001), cocaine (P < .001), marijuana (P = .009), and alcohol use (P < .001). Conclusion Despite geographic differences, all 3 integrated care programs have been associated with significant decreases in substance use in pregnant opioid-dependent women.
Ordean, Alice; Kahan, Meldon; Graves, Lisa; Abrahams, Ronald; Boyajian, Talar
Background A usual source of care (USOC) has been associated with improved preventive and chronic care, but its relationship with lipid management has not been well described. The objective of this study is: 1) to examine the association of USOC with statin use among persons meeting eligibility guidelines for treatment 2) to examine the association of USOC with low density lipoprotein goal attainment among those receiving statins. Methods We examined statin use among adults ages 21-79 years who participated in the National Health and Nutrition Examination Survey data, 1999-2006. We used criteria from the third Adult Treatment Panel (ATP III) on treatment of high cholesterol to assess eligibility and the examined factors that predicted current use of statins. Among those currently taking statins, we assessed achievement of target LDL-C based on ATP III goals. Results Among the 12,979 participants, nearly 14% were eligible. Having a USOC was significantly associated with use of statins among those eligible, but not with goal attainment among those taking statins. Significant predictors of goal attainment were higher income and education and more recent cohort. Conclusion In a national sample, USOC was significantly associated with use of statins among eligible adults, but not with LDL-C goal attainment for those using statins.
Winters, Paul; Tancredi, Daniel; Fiscella, Kevin
Living wills, duty of care and the right to treatment.
Case Study: Agnes Simon, a district nurse with 20 years' experience, has been caring for a man with motor neurone disease for the last 5 years. During this time the patient has shown remarkable tenacity but the disease has now progressed to the stage where artificial nutrition and hydration (ANH) is required. A percutaneous endoscopic gastrostomy tube has been inserted through which the patient receives food, water and medication. On her most recent visit the patient gave Agnes a signed and witnessed living will. Unusually, the living will did not indicate the patient's wishes regarding the limitation of treatment. Instead it made clear that the patient wished to continue to receive ANH up to the time of his death. He did not want the care team to withdraw this treatment without his permission, as he feared he would suffer from the indignity of slowly dying from thirst and starvation. Agnes has never seen a living will where a patient demands a right to treatment and wonders whether such a document is lawful and binding on her. PMID:15580100
Griffith, Richard
Buprenorphine: dose-related effects on cocaine and opioid use in cocaine-abusing opioid-dependent humans
Fifteen subjects dependent on both opioids and cocaine completed an ascending and tapering schedule of buprenorphine dosing, with maintenance for 21 days at each dose of buprenorphine (4, 8, 12, 16 mg sublingual daily) during both ascending and tapering phases. Higher doses of buprenorphine led to greater reductions in opioid use: 64.7% of subjects were opioid abstinent for 3 weeks
Richard S. Schottenfeld; Juliana Pakes; Douglas M. Ziedonis; Thomas R. Kosten
Clinical update on the pharmacology, efficacy and safety of transdermal buprenorphine.
Buprenorphine was not used widely in clinical practice over many years, mainly due to analgesic potency and clinical safety concerns based on misinterpreted animal data. Contrary to previous concerns, however, no analgesic ceiling effect and no antagonism of combined pure mu-opioid receptor agonists is seen within the therapeutic dose range. In recent studies, buprenorphine could be effectively and safely combined with full mu-agonists, and switching between buprenorphine and another opioid provided comparable pain relief based on equianalgesic doses. Moreover, buprenorphine exerts an antihyperalgesic effect, which is due -- at least in part -- to antagonistic activity at kappa-opioid receptors. Buprenorphine pharmacokinetics are not altered by advanced age or renal dysfunction. In addition, the risk of respiratory depression is lower than with other opioids including morphine, hydromorphone, methadone and fentanyl. Unlike morphine and fentanyl, there is no immunosuppressive activity with buprenorphine at therapeutic analgesic doses. Transdermal buprenorphine has significantly improved the clinical use of the drug, providing continuous buprenorphine release for up to 96 h. In clinical trials, patients receiving transdermal buprenorphine experienced significantly greater pain relief, better sleep, and a reduced need for rescue therapy, compared to placebo. Large-scale post-marketing studies have confirmed the effectiveness of transdermal buprenorphine in treating moderate-to-severe cancer and non-cancer pain including neuropathic syndromes. Finally, the comparably low incidence of CNS adverse events and constipation, and the possibility of use in severe renal dysfunction without a need for dose adjustment make buprenorphine well suited for chronic pain management in at-risk patients, such as diabetics, elderly or renally impaired individuals including those requiring haemodialysis. PMID:18567516
Kress, Hans G
Addiction treatment centers' progress in preparing for health care reform.
The Patient Protection and Affordable Care Act (PPACA) is expected to significantly alter addiction treatment service delivery. Researchers designed the Health Reform Readiness Index (HRRI) for addiction treatment organizations to assess their readiness for the PPACA. Four-hundred twenty-seven organizations completed the HRRI throughout a 3-year period, using a four-point scale to rank their readiness on 13 conditions. HRRI results completed during two different time periods (between 10/1/2010-6/30/2011 and 9/1/2011-9/30/2012) were analyzed and compared. Most respondents self-assessed as being in the early stages of preparation for 9 of the 13 conditions. Survey results showed that organizations with annual budgets < $5 million (n=295) were less likely to be prepared for the PPACA than organizations with annual budgets > $5 million (n=132). The HRRI results suggest that the addiction field, and in particular smaller organizations, is not preparing adequately for health care reform; organizations that are making preparations are making only modest gains. PMID:24074851
Molfenter, Todd D
Patient, Provider, and Treatment Factors Associated with Poor-Quality Care for Schizophrenia
Interventions are needed to improve the quality of care for schizophrenia. However, in designing these interventions it would be helpful to understand better which patients are at highest risk for poor-quality care and why care for this disorder is often of poor quality. We study the extent to which patient and treatment factors are associated with poor-quality care in 224
Alexander S. Young; Greer Sullivan; Naihua Duan
The Treatment of Anxiety Disorders in a Primary Care HMO Setting
Anxiety disorders are common, yet under diagnosed, in primary care settings. Many patients with anxiety and other psychiatric disorders do not seek care in mental health care settings. An integrated primary care\\/mental health model offers one approach to improving outcomes for patients with anxiety disorders. This model has been researched for the treatment of depression with positive results but has
David Price; Arne Beck; Carolee Nimmer; Stephen Bensen
Fever effects and treatment in critical care: Literature review.
Considering that the incidence of fever may reach up to 75% among critically ill adults, healthcare professionals employed in the Intensive Care Unit (ICU) are called to evaluate and manage patient temperature elevation on a daily basis. This literature review synthesizes the evidence about the effects of fever and antipyretic treatment in ICU patients. Although the febrile response acts protectively against infections, noxious effects are possible for patients with cerebral damage, neuropsychiatric disorders or limited cardiorespiratory reserve. Observational studies on ICU populations have reported associations between fever magnitude and patient mortality. Especially recent findings indicated that infected patients may significantly benefit from temperature elevation, while high fever may be maladaptive for non-infected ones. Aggressive antipyretic treatment of ICU patients has not been followed by decreased mortality in randomized trials. However, fever suppression and return to normothermia improved outcomes of septic shock patients. Antipyretic treatment should begin with drug administration and proceed with external cooling in case of refractory fever, but adverse effects of both antipyretic methods should always be considered. This article concludes by providing implications for antipyretic treatment of critically ill adults and suggesting areas for future research. PMID:23199670
Kiekkas, Panagiotis; Aretha, Diamanto; Bakalis, Nick; Karpouhtsi, Irini; Marneras, Chris; Baltopoulos, George I
45 CFR 156.245 - Treatment of direct primary care medical homes.
Code of Federal Regulations, 2013 CFR
...2013-10-01 false Treatment of direct primary care medical homes. 156.245 Section...156.245 Treatment of direct primary care medical homes. A QHP issuer may provide coverage through a direct primary care medical home that meets...
Problem-Solving Treatment and Coping Styles in Primary Care for Minor Depression
ERIC Educational Resources Information Center
Research was undertaken to compare problem-solving treatment for primary care (PST-PC) with usual care for minor depression and to examine whether treatment effectiveness was moderated by coping style. PST-PC is a 6-session, manual-based, psychosocial skills intervention. A randomized controlled trial was conducted in 2 academic, primary care�
Oxman, Thomas E.; Hegel, Mark T.; Hull, Jay G.; Dietrich, Allen J.
42 CFR 136a.34 - Care and treatment of people losing eligibility.
Code of Federal Regulations, 2010 CFR
...2009-10-01 2009-10-01 false Care and treatment of people losing...HUMAN SERVICES INDIAN HEALTH Transition Provisions § 136a.34 Care and treatment of people losing...and those receiving inpatient care under contract, including...
42 CFR 136a.34 - Care and treatment of people losing eligibility.
Code of Federal Regulations, 2010 CFR
...2010-10-01 2010-10-01 false Care and treatment of people losing...HUMAN SERVICES INDIAN HEALTH Transition Provisions § 136a.34 Care and treatment of people losing...and those receiving inpatient care under contract, including...
45 CFR 156.245 - Treatment of direct primary care medical homes.
Code of Federal Regulations, 2012 CFR
...2012-10-01 false Treatment of direct primary care medical homes. 156.245 Section...156.245 Treatment of direct primary care medical homes. A QHP issuer may provide coverage through a direct primary care medical home that meets...
Withdrawal from Buprenorphine/Naloxone and Maintenance with a Natural Dopaminergic Agonist: A Cautionary Note
Background While numerous studies support the efficacy of methadone and buprenorphine for the stabilization and maintenance of opioid dependence, clinically significant opioid withdrawal symptoms occur upon tapering and cessation of dosage. Methods We present a case study of a 35 year old Caucasian female (Krissie) who was prescribed increasing dosages of prescription opioids after carpel tunnel surgery secondary to chronic pain from reflex sympathetic dystrophy and fibromyalgia. Over the next 5 years, daily dosage requirements increased to over 80 mg of Methadone and 300 ug/hr Fentanyl transdermal patches, along with combinations of 12�14 1600 mcg Actig lollipop and oral 100 mg Morphine and 30 mg oxycodone 1�2 tabs q4-6hr PRN for breakthrough pain. Total monthly prescription costs including supplemental benzodiazepines, hypnotics and stimulants exceeded $50,000. The patient was subsequently transferred to Suboxone� in 2008, and the dosage was gradually tapered until her admission for inpatient detoxification with KB220Z a natural dopaminergic agonist. We carefully documented her withdrawal symptoms when she precipitously stopped taking buprenorphine/naloxone and during follow-up while taking KB220Z daily. We also genotyped the patient using a reward gene panel including (9 genes 18 alleles): DRD 2,3,4; MOA-A; COMT; DAT1; 5HTTLLR; OPRM1; and GABRA3. Findings At 432 days post Suboxone� withdrawal the patient is being maintained on KB220Z, has been urine tested and is opioid free. Genotyping data revealed a moderate genetic risk for addiction showing a hypodopaminergic trait. This preliminary case data suggest that the daily use of KB220Z could provide a cost effective alternative substitution adjunctive modality for Suboxone�. We encourage double-blind randomized �placebo controlled studies to test the proposition that KB220Z may act as a putative natural opioid substitution maintenance adjunct.
Blum, Kenneth; Oscar-Berman, Marlene; Femino, John; Waite, Roger L; Benya, Lisa; Giordano, John; Borsten, Joan; Downs, William B; Braverman, Eric R; Loehmann, Raquel; Dushaj, Kristina; Han, David; Simpatico, Thomas; Hauser, Mary; Barh, Debmalya; McLaughlin, Thomas
Buprenorphine and norbuprenorphine findings in hair during constant maintenance dosage
It is still a matter of debate whether a positive correlation between the dose and the amount of drug in the hair exists.\\u000a Drugs such as buprenorphine (BUP) used under controlled conditions present an opportunity to prove a possible relationship.\\u000a Due to discrepant findings of BUP\\/norbuprenorphine (NBUP) ratios in hair, in vitro degradation of both analytes in diluted\\u000a acid was
Gisela Skopp; Anja Kniest; Joerg Haisser; Karl Mann; Derik Hermann
False-positive buprenorphine by CEDIA in patients prescribed amisulpride or sulpiride.
Buprenorphine is a potent partial opioid agonist that is analyzed in urine to (i) monitor adherence to maintenance or detoxification therapy and (ii) detect illicit use. Buprenorphine analysis is commonly conducted on urine by immunoassay, but is subject to cross-reactivity from other drugs/drug metabolites, including morphine, codeine and dihydrocodeine. This study reports false-positive buprenorphine analysis [Thermo Fisher Scientific cloned enzyme donor immunoassay (CEDIA)] in patients who denied unauthorized buprenorphine use prior to sampling, but who had been prescribed amisulpride. In two cases, confirmatory analysis by liquid chromatography-tandem mass spectrometry was negative (<0.5 �g/L) for buprenorphine and metabolites and positive for amisulpride. Although the cross-reactivity of amisulpride and sulpiride in the CEDIA buprenorphine assay is low (estimated at 0.003 and 0.002%, respectively), it remains a significant consideration given the likely high concentrations of these compounds in urine relative to the low cutoff of the buprenorphine assay. Neither amisulpride nor sulpiride was listed as potential sources of interference on the CEDIA data sheet when this work was performed. These findings highlight the importance of confirming immunoassay-positive buprenorphine results using a more selective analytical technique. PMID:23471956
Birch, M A; Couchman, L; Pietromartire, S; Karna, T; Paton, C; McAllister, R; Marsh, A; Flanagan, R J
Short communication Abuse liability of buprenorphine-naloxone tablets in untreated IV drug users
Buprenorphine (Subutex�) is widely abused in Finland. A combination of buprenorphine plus naloxone (Suboxone�) has been available since late 2004, permitting a comparison of the abuse of the two products among untreated intravenous (IV) users. A survey was distributed to attendees at a Helsinki needle exchange program over 2-weeks in April, 2005, At least 30% were returned anonymously. Survey variables
Hannu Alho; David Sinclair; Erkki Vuori; Antti Holopainen
Abuse liability of buprenorphine�naloxone tablets in untreated IV drug users
Buprenorphine (Subutex�) is widely abused in Finland. A combination of buprenorphine plus naloxone (Suboxone�) has been available since late 2004, permitting a comparison of the abuse of the two products among untreated intravenous (IV) users. A survey was distributed to attendees at a Helsinki needle exchange program over 2-weeks in April, 2005, At least 30% were returned anonymously. Survey variables
Hannu Alho; David Sinclair; Erkki Vuori; Antti Holopainen
Evaluation of a Combined Online and in Person Training in the Use of Buprenorphine
ERIC Educational Resources Information Center
To evaluate buprenorphine training methodology, we surveyed physicians who had completed a combined online and in person buprenorphine curriculum. Of 53/70 (76%) survey respondents, 57% were psychiatrists and 40% generalists. On a scale of 1 (very poor) to 7 (superlative), the overall training rated a mean of 5.8. The online course (5.0) rated�
Gunderson, Erik W.; Levin, Frances R.; Kleber, Herbert D.; Fiellin, David A.; Sullivan, Lynn E.
The Effectiveness of an Experimental Treatment when Compared to Care as Usual Depends on the Type of Care as Usual
ERIC Educational Resources Information Center
In psychotherapy, effectiveness of an experimental treatment often is compared to care as usual. However, little if any attention has been paid to the heterogeneity of care as usual. The authors examined the effectiveness of manualized behavior therapy on school-aged disruptive behavior disordered (DBD) children in everyday clinical practice. A�
van de Wiel, Nicolle M. H.; Matthys, Walter; Cohen-Kettenis, Peggy T.; Maassen, Gerard H.; Lochman, John E.; van Engeland, Herman
Treatment of knee pain in older adults in primary care: development of an evidence-based model of care
Objective. To develop a stepped model of care for the treatment of knee pain in older adults in primary care based on recommended interventions. Methods. A systematic search was undertaken to identify interventions recommended for knee osteoarthritis or knee pain in clinical guidelines and systematic reviews. Following this, a nominal group consensus exercise was conducted with members of the Primary
M. Porcheret; K. Jordan; P. Croft
Treatment of hypophosphatemia in the intensive care unit: a review
Introduction Currently no evidence-based guideline exists for the approach to hypophosphatemia in critically ill patients. Methods We performed a narrative review of the medical literature to identify the incidence, symptoms, and treatment of hypophosphatemia in critically ill patients. Specifically, we searched for answers to the questions whether correction of hypophosphatemia is associated with improved outcome, and whether a certain treatment strategy is superior. Results Incidence: hypophosphatemia is frequently encountered in the intensive care unit; and critically ill patients are at increased risk for developing hypophosphatemia due to the presence of multiple causal factors. Symptoms: hypophosphatemia may lead to a multitude of symptoms, including cardiac and respiratory failure. Treatment: hypophosphatemia is generally corrected when it is symptomatic or severe. However, although multiple studies confirm the efficacy and safety of intravenous phosphate administration, it remains uncertain when and how to correct hypophosphatemia. Outcome: in some studies, hypophosphatemia was associated with higher mortality; a paucity of randomized controlled evidence exists for whether correction of hypophosphatemia improves the outcome in critically ill patients. Conclusions Additional studies addressing the current approach to hypophosphatemia in critically ill patients are required. Studies should focus on the association between hypophosphatemia and morbidity and/or mortality, as well as the effect of correction of this electrolyte disorder.
Effect of Introducing a Care Pathway to Standardize Treatment and Nursing of Schizophrenia
Care pathways can help to implement evidence-based clinical practice. The introduction of care pathways is difficult for psychiatric\\u000a disorders. This study examined whether the organization and the effectiveness of care provided to schizophrenic patients can\\u000a be improved by care pathways. Outcomes from 19 patients receiving treatment using evidence-based care pathways were compared\\u000a with 17 patients receiving a traditional approach to
Sara Marchisio; Michele Vanetti; Roberta Valsesia; Lidia Carnevale; Massimiliano Panella
Illicit Use of Buprenorphine in a Community Sample of Young Adult Non-Medical Users of Pharmaceutical Opioids
BACKGROUND There is growing evidence about illicit use of buprenorphine in the U.S. The study aims to: 1) identify prevalence and predictors of illicit buprenorphine use in a community sample of 396 young adult (18-23 years old) non-medical users of pharmaceutical opioids; 2) describe knowledge, attitudes and behaviors linked to illicit buprenorphine use as reported by a qualitative sub-sample (n=51). METHODS Participants were recruited using respondent-driven sampling. Qualitative interview participants were selected from the larger sample. The sample (n=396) was 54% male and 50% white; 7.8% reported lifetime illicit use of buprenorphine. RESULTS Logistic regression analysis results indicate that white ethnicity, intranasal inhalation of pharmaceutical opioids, symptoms of opioid dependence, and a greater number of pharmaceutical opioids used in lifetime were statistically significant predictors of illicit buprenorphine use. Qualitative interviews revealed that buprenorphine was more commonly used by more experienced users who were introduced to it by their �junkie friends.� Those who used buprenorphine to self-medicate withdrawal referred to it as a �miracle pill.� When used to get high, reported experiences ranged from �the best high ever� to �puking for days.� Participants reported using buprenorphine/naloxone orally or by intranasal inhalation. Injection of buprenorphine without naloxone was also reported. CONCLUSION Our findings suggest that illicit buprenorphine use is gaining ground primarily among whites and those who are more advanced in their drug use careers. Continued monitoring is needed to better understand evolving patterns and trends of illicit buprenorphine use.
Daniulaityte, Raminta; Falck, Russel; Carlson, Robert G.
Preliminary Support for Multidimensional Treatment Foster Care in Reducing Substance Use in Delinquent Boys
Although effective outpatient treatments have been identified for the well-documented negative outcomes associated with delinquency and substance use, effective treatments for youths in out-of-home care are rare. In this study, 12- and 18-month substance use outcomes were examined for a sample of 79 boys who were randomly assigned to Multidimensional Treatment Foster Care (experimental condition) or to group care (comparison
Dana K. Smith; Patricia Chamberlain; J. Mark Eddy
Predictors of treatment satisfaction among older adults with anxiety in a primary care psychology program.
Increasing numbers of patients are treated in integrated primary care mental health programs. The current study examined predictors of satisfaction with treatment in patients from a randomized clinical trial of late-life generalized anxiety disorder (GAD) in primary care. Higher treatment satisfaction was associated with receiving CBT rather than enhanced usual care. Treatment credibility, treatment expectancies, social support, and improvements in depression and anxiety symptoms predicted higher treatment satisfaction in the total sample. In the CBT group, only credibility and adherence with treatment predicted satisfaction. This suggests that older patients receiving CBT who believe more strongly in the treatment rationale and follow the therapist's recommendations more closely are likely to report satisfaction at the end of treatment. In addition, this study found that adherence mediated the relationship between treatment credibility and treatment satisfaction. In other words, patients' perceptions that the treatment made sense for them led to greater treatment adherence which then increased their satisfaction with treatment. PMID:23434724
Hundt, Natalie E; Armento, Maria E A; Porter, Bennett; Cully, Jeffrey A; Kunik, Mark E; Stanley, Melinda
Prescription opioid abuse, chronic pain, and primary care: a Co-occurring Disorders Clinic in the chronic disease model.
Abuse of opioids has become a public health crisis. The historic separation between the addiction and pain communities and a lack of training in medical education have made treatment difficult to provide, especially in primary care. The Co-occurring Disorders Clinic (COD) was established to treat patients with co-morbid chronic pain and addiction. This retrospective chart review reports results of a quality improvement project using buprenorphine/naloxone to treat co-occurring chronic non-cancer pain (CNCP) and opioid dependence in a primary care setting. Data were collected for 143 patients who were induced with buprenorphine/naloxone (BUP/NLX) between June 2009 and November 2011. Ninety-three patients (65%) continued to be maintained on the medication and seven completed treatment and were no longer taking any opioid (5%). Pain scores showed a modest, but statistically significant improvement on BUP/NLX, which was contrary to our expectations and may be an important factor in treatment retention for this challenging population. PMID:22980449
Pade, Patricia A; Cardon, Karen E; Hoffman, Richard M; Geppert, Cynthia M A
Transdermal buprenorphine in clinical practice: a multicenter, postmarketing study in the Czech Republic, with a focus on neuropathic pain components.
SUMMARY�Aim: A 3-month evaluation of transdermal buprenorphine (Transtec�) in routine clinical practice in the Czech Republic. Patients & methods: A prospective, noninterventional, postmarketing study performed in 45 clinical practices (82 investigators). Buprenorphine transdermal patches 35, 52.5 or 70 �g/h were prescribed to patients with chronic moderate-to-severe cancer pain or chronic severe noncancer pain insufficiently controlled by nonopioids. Additional analgesia and adjuvant/supportive treatment was allowed at the discretion of the physician. Results: Data were evaluated for 617 patients (59% female, mean age 65 years). 55% of patients had cancer-related pain; 33% of all patients had neuropathic pain components. At month 3 (study end), mean pain intensity was reduced significantly from baseline (p < 0.01). Similar effectiveness outcomes were observed in patients (n = 203) with neuropathic pain components. Most patients rated pain relief as 'very good' (47.7%) or 'good' (45.7%) and >98% of evaluable patients reported improvements in sleep quality. During the study, supplemental analgesic use remained unchanged; laxative/antiemetic use was reduced (25.1% of patients [baseline] vs 17.7% [study end]). A total of 22 nonserious adverse drug reactions (mainly local skin reactions) occurred in 14 (2.3%) patients; no previously unknown adverse drug reactions occurred. Conclusion: In routine clinical practice, transdermal buprenorphine provided efficacious analgesia and was well-tolerated in patients with chronic moderate-to-severe cancer pain or chronic severe nonmalignant pain insufficiently controlled by nonopioids, including pain with neuropathic components. PMID:24645819
Hakl, Marek
Budgetary impact analysis of buprenorphine-naloxone combination (Suboxone�) in Spain
Background Opioid addiction is a worldwide problem. Agonist opioid treatment (AOT) is the most widespread and frequent pharmacotherapeutic approach. Methadone has been the most widely used AOT, but buprenorphine, a partial ?-opiod agonist and a ?-opiod antagonist, is fast gaining acceptance. The objective was to assess the budgetary impact in Spain of the introduction of buprenorphine-naloxone (B/N) combination. Methods A budgetary impact model was developed to estimate healthcare costs of the addition of B/N combination to the therapeutic arsenal for treating opioid dependent patients, during a 3-year period under the National Health System perspective. Inputs for the model were obtained from the specialized scientific literature. Detailed information concerning resource consumption (drug cost, logistics, dispensing, medical, psychiatry and pharmacy supervision, counselling and laboratory test) was obtained from a local expert panel. Costs are expressed in euros (�, 2010). Results The number of patients estimated to be prescribed B/N combination was 2,334; 2,993 and 3,589 in the first, second and third year respectively. Total budget is �85,766,129; �79,855,471 and �79,137,502 in the first, second and third year for the scenario without B/N combination. With B/N combination the total budget would be �86,589,210; �80,398,259 and �79,708,964 in the first, second and third year of the analyses. Incremental cost/patient comparing the addition of the B/N combination to the scenario only with methadone is �10.58; �6.98 and �7.34 in the first, second and third year respectively. Conclusion Addition of B/N combination would imply a maximum incremental yearly cost of �10.58 per patient compared to scenario only with methadone and would provide additional benefits.
Treatment of Youth Depression in Primary Care Under Usual Practice Conditions: Observational Findings from Youth Partners in Care
Abstract Objectives The effectiveness of treatments for youth depression in primary care, under usual practice conditions, is largely unstudied. This study aims at estimating the effect of �appropriate treatment,� defined as treatment that approximates guideline standards, on clinical outcomes for depressed primary care youth patients by using observational analyses from a randomized trial. Methods Participants were 344 youths aged 13�21 enrolled in the Youth Partners in Care trial. Youths screening positive for depression from six primary care practices in five different health care organizations were randomly assigned to either (1) usual care enhanced by provider education on depression evaluation and management, or (2) a quality improvement (QI) intervention designed to improve access to antidepressant medications and/or cognitive behavior therapy for depression; usual practice conditions otherwise applied. Observational analysis was conducted on the effects of appropriate treatment (antidepressant medication use by algorithms or 6 or more psychotherapy visits) on severe depression (Center for Epidemiologic Studies-Depression score ?24) at 6 months. Selection into treatment is accounted for by using instrumental variables analysis, with randomized QI intervention status as the instrument. Results At 6 months, youths receiving �appropriate treatment,� compared with others, were significantly less likely to have severe depression (10.9% vs. 45.2%, p<0.0001). Similar findings were observed among youths with depressive disorders and sub-syndromal depressive symptoms, and among Latino and other youths. Conclusions Among depressed primary care youths, care that approximates guideline standards but retains leniency substantially reduces the likelihood of severe depression at 6 months. Such findings apply to youths with or without depressive disorder, and among Latino youth.
Wells, Kenneth B.; Tang, Lingqi; Carlson, Gabrielle A.
Hepatitis B prevention, diagnosis, treatment and care: a review.
Hepatitis B virus (HBV) infection is a major cause of morbidity and mortality worldwide. Chronic hepatitis B (CHB) infection is associated with an increased risk of cirrhosis, hepatic decompensation and hepatocellular carcinoma (HCC). The likelihood of developing CHB is related to the age at which infection is acquired; the risk being lowest in adults and >90% in neonates whose mothers are hepatitis B e antigen positive. Treatment of CHB infection aims to clear HBV DNA and prevent the development of complications. There are currently seven drugs available for the treatment of CHB: five nucleos(t)ide analogues and two interferon-based therapies. Long-term treatment is often required, and the decision to treat is based on clinical assessment including the phase of CHB infection and the presence and extent of liver damage. A safe and effective HBV vaccine has been available since the early 1980s. Vaccination plays a central role in HBV prevention strategies worldwide, and a decline in the incidence and prevalence of HBV infection following the introduction of universal HBV vaccination programmes has been observed in many countries including the USA and parts of South East Asia and Europe. Post-exposure prophylaxis (PEP) with HBV vaccine +/- hepatitis B immunoglobulin is highly effective in preventing mother to child transmission and in preventing transmission following sharps injuries, sexual contact and other exposures to infected blood and body fluids. Transmission of HBV in the health care setting has become an increasingly rare event in developed nations. However, it remains a significant risk in developing countries reflecting the higher prevalence of CHB, limited access to HBV vaccination and PEP and a lack of adherence to standard infection control precautions. PMID:22114089
Aspinall, E J; Hawkins, G; Fraser, A; Hutchinson, S J; Goldberg, D
[Long-term outcome of elderly patients after intensive care treatment].
In general, elderly patients have poorer outcomes than younger patients after intensive care treatment. Diagnosis at admission and high age mainly influence short-term mortality within the first few months after intensive care, while comorbitities and functional status are more pivotal regarding long-term mortality. Furthermore, the main reasons for reduced physical fitness and neurocognitive consequences that often last for many months after intensive care treatment of older patients are described. Many outcome studies show that physical und mental sequelae after intensive care treatment are not only substantial but also unpredictable. Due to the constant improvement of intensive care treatment during recent decades, increasingly more patients survive their acute critical disease. Now it is time to focus on translational research to discover causal relationships between intensive care treatment and morbidity during follow-up to improve the quality of survival. PMID:21975839
Wehler, M
A personalized framework for medication treatment management in chronic care
The ongoing efforts toward continuity of care and the recent advances in information and communication technologies have led to a number of successful personal health systems for the management of chronic care. These systems are mostly focused on monitoring efficiently the patient's medical status at home. This paper aims at extending home care services delivery by introducing a novel framework
Vassilis G. Koutkias; Ioanna Chouvarda; Andreas Triantafyllidis; Andigoni Malousi; Georgios D. Giaglis; Nicos Maglaveras
Impact of Advanced Health Care Directives on Treatment Decisions by Physicians in Patients with Acute Stroke
Background The implementation of advance health care directives, prepared by almost half of the adult population in United States remains relatively under studied. We determined the impact of advance health care directives on treatment decisions by multiple physicians in stroke patients. Methods A de-identified summary of clinical and radiological records of 28 patients with stroke was given to six stroke physicians who were not involved in the care of the patients. Each physician independently rated 28 treatment decisions per patient in the presence or absence of advance health care directives 1 month apart to allow memory washout. The percentage agreement to treat/intervene per patient and proportion of treatment withheld as a group were estimated for each of the 28 treatment decision items. We also determined the interobserver reliability between the two raters (attorneys) in interpretation of 6 items characterizing the adequacy of documentation within the 28 advance health care directives. Results The percentage agreement among physician raters for treatment decisions in 28 stroke patients was highest for treatment of hyperpyrexia (100%, 100%) and lowest for intensive care unit monitoring duration based on family-physician considerations outside of accepted criteria within institution (68%, 69%) in presence and absence of advance care health directives. The physician rater agreement in choosing �yes� was highest for �routine complexity� treatment decisions and lowest for �moderate complexity� treatment decisions. The choice of withholding treatment in routine complexity,� �moderate complexity,� or �high complexity� treatment decisions was remarkably similar among raters in presence or absence of advance care health directives. The only treatment decision that showed an impact of advance care health directives was intensive care unit monitoring withheld in 32% of treatment decisions in presence of directives (compared with 8% in the absence of directives). Intravenous medication and defibrillation for cardiac arrest was withheld in 29% (compared with 19%) of the treatment decisions in the presence of advance health care directives. The two attorney raters found the description of acceptable outcome inadequate in 14 and 21 of 28 advance health care directives reviewed, respectively. The overall mean kappa for agreement regarding adequacy of documentation was modest (43%) for �does the advance health care directive specify which treatments the patient would choose, or refuse to receive if they were diagnosed with an acute, terminal condition?� and lowest (3%) for �description of acceptable outcome�. Conclusions We did not find any prominent differences in most �routine complexity,� �moderate complexity,� or �high complexity� treatment decisions in patient management in the presence of advance health care directives. Presence of advance health care directives also did not reduce the prominent variance among physicians in treatment decisions.
Qureshi, Adnan I; Chaudhry, Saqib A.; Connelly, Bo; Abott, Emily; Janjua, Tariq; Kim, Stanley H.; Miley, Jefferson T.; Rodriguez, Gustavo J.; Uzun, Guven; Watanabe, Masaki
Comparison of Intravenous Buprenorphine and Methadone Self-administration by Recently Detoxified Heroin Abusers
Although buprenorphine is used worldwide as a safe and effective maintenance medication for opioid dependence, some countries have reported a growing incidence of abuse of this medication. Buprenorphine is considered to have lower abuse potential because of its partial agonist profile, but no studies have directly compared the reinforcing effects of buprenorphine with those of full mu opioid agonists in humans. The present double-blind, placebo-controlled, inpatient study compared the reinforcing and subjective effects of intravenously administered buprenorphine (0.5, 2 and 8 mg) and methadone (5, 10, and 20 mg). Participants (N=6) were detoxified from heroin during the first 1-2 weeks after admission. During subsequent weeks, participants received a sample drug dose and $20 on Monday, and they could self-administer either the sampled dose or $20 during one choice session per day on Thursday and Friday. Participants responded under a modified progressive ratio schedule during each choice session. All active doses maintained higher progressive ratio break points (largest completed ratio) than placebo. There were no significant differences in break point values between buprenorphine and methadone or among the different doses of drug. However, several subjective ratings, including �Good Drug Effect,� �High,� and �Liking� dose-dependently increased after administration of buprenorphine and methadone. The peak ratings for these effects did not significantly differ for the two drugs. These results demonstrate that under these experimental conditions, buprenorphine and methadone were equally effective in producing reinforcing and subjective effects.
Comer, Sandra D.; Sullivan, Maria A.; Walker, Ellen A.
Predictors of Placement Outcomes in Treatment Foster Care: Implications for Foster Parent Selection and Service Delivery
Treatment foster care (TFC) is a normalizing environment in which to treat those children whose particular needs are not addressed in traditional foster care and for whom an institutional setting is a restrictive and unnecessary alternative. However, when the foster care placements of these emotionally and behaviorally disturbed children fail, as they often do, the children are shifted from one
Richard E. Redding; Carrie Fried; Preston A. Britner
Primary Care Providers' Knowledge, Practices, and Perceived Barriers to the Treatment and Prevention of Childhood Obesity
This study evaluated primary care providers' (PCPs, pediatricians, and nurse practitioners) knowledge, current practices, and perceived barriers to childhood obesity prevention and treatment, with an emphasis on first-year well-child care visits. A questionnaire was distributed to 192 PCPs in the primary care network at The Children's Hospital of Philadelphia (CHOP) addressing (i) knowledge of obesity and American Academy of Pediatrics
Jordan G. Spivack; Maggie Swietlik; Evaline Alessandrini; Myles S. Faith
Economic Evaluation of Continuing Care Interventions in the Treatment of Substance Abuse: Recommendations for Future Research
ERIC Educational Resources Information Center
The chronic and relapsing nature of substance abuse points to the need for continuing care after a primary phase of treatment. This article reviews the economic studies of continuing care, discusses research gaps, highlights some of the challenges of conducting rigorous economic evaluations of continuing care, and offers research guidelines and�
Popovici, Ioana; French, Michael T.; McKay, James R.
Pregnancy Rates among Juvenile Justice Girls in Two Randomized Controlled Trials of Multidimensional Treatment Foster Care
ERIC Educational Resources Information Center
Preventing adolescent pregnancy is a national research priority that has had limited success. In the present study, the authors examined whether Multidimensional Treatment Foster Care (MTFC) relative to intervention services as usual (group care [GC]) decreased pregnancy rates among juvenile justice girls mandated to out-of-home care. Girls (13-17�
Kerr, David C. R.; Leve, Leslie D.; Chamberlain, Patricia
Using Motivational Interviewing as a Supplement to Obesity Treatment: A Stepped-Care Approach
Objective: This investigation was designed to improve behavioral weight loss program (BWLP) treatment outcomes by providing stepped care (SC) to individuals experiencing difficulties with weight loss during treatment. SC entails transition to more intensive treatments when less intensive treatments fail to meet treatment goals. In a BWLP, motivational interviewing (MI) may increase participants� motivation toward behavioral change and thus complement
Robert A. Carels; Lynn Darby; Holly M. Cacciapaglia; Krista Konrad; Carissa Coit; Jessica Harper; Mary E. Kaplar; Kathleen Young; Chelsea A. Baylen; Amelia Versland
Pharmacokinetics of buprenorphine hydrochloride following intramuscular and intravenous administration to American kestrels (Falco sparverius).
Objective-To determine the pharmacokinetics of buprenorphine hydrochloride after IM and IV administration to American kestrels (Falco sparverius). Animals-13 healthy 3-year-old captive-bred American kestrels. Procedures-Buprenorphine hydrochloride (0.6 mg/kg) was administered IM to all birds. Blood samples were collected at 9 times, ranging from 5 minutes to 9 hours after drug administration. Plasma buprenorphine concentrations were measured by use of tandem liquid chromatography-mass spectrometry. Pharmacokinetic parameters were determined by use of least squares linear regression and noncompartmental analysis of na�ve pooled data. After a washout period of 2 weeks, the same dose of buprenorphine was administered IV to all birds and blood samples were collected at the same times after drug administration. Results-Maximum plasma buprenorphine concentration was achieved within 5 minutes after IM administration. For IM administration, bioavailability was 94.8% and elimination half-life was 92.1 minutes. For IV administration, steady-state volume of distribution was 4,023.8 mL/kg, plasma clearance was 49.2 mL/min/kg, and elimination half-life was 105.5 minutes. Conclusions and Clinical Relevance-Buprenorphine was rapidly absorbed, and bioavailability was good after IM administration to American kestrels. Plasma buprenorphine concentrations were > 1 ng/mL for 9 hours after both IM and IV administration. These results, in combination with those of a pharmacodynamic study, suggested that the analgesic effects of buprenorphine could last at least 6 to 9 hours in this species. Further investigations of the duration of analgesic effects, multiple-dose protocols, and potential adverse effects of buprenorphine are warranted in American kestrels and other raptors. PMID:25061701
Gustavsen, Kate A; Guzman, David Sanchez-Migallon; Knych, Heather K; Petritz, Olivia A; Olsen, Glenn H; Paul-Murphy, Joanne R
Treatment for substance use disorder: opportunities and challenges under the affordable care act.
Addiction is a chronic brain disease with consequences that remain problematic years after discontinuation of use. Despite this, treatment models focus on acute interventions and are carved out from the main health care system. The Patient Protection and Affordable Care Act (2010) brings the opportunity to change the way substance use disorder (SUD) is treated in the United States. The treatment of SUD must adapt to a chronic care model offered in an integrated care system that screens for at-risk patients and includes services needed to prevent relapses. The partnering of the health care system with substance abuse treatment programs could dramatically expand the benefits of prevention and treatment of SUD. Expanding roles of health information technology and nonphysician workforces, such as social workers, are essential to the success of a chronic care model. PMID:23731411
Tai, Betty; Volkow, Nora D
Diagnosis and treatment of older adults with depression in primary care
This article provides an overview of current challenges in the diagnosis and treatment of depressed older adults in primary care and considers suggestions for clinicians, researchers, and policy makers to improve care for this population. Despite the enormous toll of depression on individuals and society and the availability of effective treatments, depressed older adults remain largely untreated or undertreated. They
J�rgen Un�tzer
Prevalence of problem alcohol use among patients attending primary care for methadone treatment
BACKGROUND: Problem alcohol use is associated with adverse health outcomes among current or former heroin users and primary care is providing methadone treatment for increasing numbers of this population. This study aimed todetermine the prevalence of problem alcohol use among current or former heroin users attending primary care for methadone treatment and to describe the socio-demographic characteristics and health service
Niamh Ryder; Walter Cullen; Joseph Barry; Gerard Bury; Eamon Keenan; Bobby P Smyth
US practitioner prescribing practices and patient characteristics of those newly treated with a buprenorphine transdermal patch system.
Abstract Objectives: Medication prescribing information provides guidance to healthcare providers on how to prescribe a drug properly. Oftentimes patient factors in addition to the prescribing information are considered when selecting medications. Utilizing real-world pharmacy and medical claims data, this study assessed US practitioner prescribing practices of US approved transdermal buprenorphine system (BTDS) in relation to BTDS's full prescribing information (FPI) as well as the relationship between patient factors and initial BTDS dose. Research design and methods: Patients aged ?18 years initiating BTDS between 1 January 2011 and 30 November 2011 were identified in the IMS Pharmacy and Private Practitioner Medical Claims databases. The index date was defined as the first filled BTDS prescription. Demographics, chronic pain-related medical conditions in the 12 months pre-index and prior medication use in the 6 months pre-index were assessed. Initial BTDS dosing strength, receipt of approved initial BTDS dose per the FPI, and concomitant medications were assessed in the post-index 6 month period. Results: The study included 10,457 patients newly treated with BTDS. The majority of patients were female (69.9%) with a mean (�SD) age of 54.5 (�15.2) years. Within the 6 months prior to the index BTDS prescription, 91.7% of the patients used opioids. Overall, 48.9% of patients were prescribed the FPI approved BTDS dose. When stratified, 73.5% of opioid-na�ve patients received the FPI approved initial dose compared to 46.0% of those with prior opioid experience of ?80?mg morphine-equivalent daily dose. Patients on BTDS alone (i.e. monotherapy) had a higher rate of receiving the FPI approved initial BTDS dose compared to patients on BTDS concomitant regimens (p?0.05). Conclusions: Practitioners demonstrated that they prescribe in accordance with BTDS's prescribing information in the majority of opioid-na�ve patients and in approximately half of opioid-experienced patients. The initial opioid dose is a critical step in treatment, setting the stage for preventing side-effects and improving treatment effectiveness. Understanding practitioner prescribing practices with regard to the initial dose selection of BTDS may provide insight on how to improve outcomes of care and reduce healthcare resource utilization and costs associated with pain management. Limitations: Data obtained from prescription claims reflect only the activities of prescriptions filled, not medication use or other clinical characteristics observed by physicians when treating patients. PMID:24689806
Pergolizzi, Joseph V; Ben-Joseph, Rami; Chang, Chun-Lan; Hess, Gregory
Comorbid Chronic Illness and the Diagnosis and Treatment of Depression in Safety Net Primary Care Settings
Objective To estimate the impact of chronic medical conditions on depression diagnosis, treatment, and follow-up care in primary care settings. Design This was a cross-sectional study that used interviewer-administered surveys and medical record reviews. Three hundred fifteen participants were recruited from 3 public primary care clinics. Depression diagnosis, guideline-concordant treatment, and follow-up care were the primary outcomes examined in individuals with depression alone compared with individuals with depression and chronic medical conditions measured using the Charlson Comorbidity Index (CCI). Results Physician diagnosis of depression (32.6%), guideline-concordant depression treatment (32.7%), and guideline-concordant follow-up care (16.3%) were all low. Logistic regression analysis showed no significant difference in the likelihood of depression diagnosis, guideline-concordant treatment, or follow-up care in individuals with depression alone compared with those with both depression and chronic medical conditions. Participants with severe depression were, however, twice as likely to receive a diagnosis of depression as participants with moderate depression. In addition, participants with moderately severe and severe depression received much less appropriate follow-up care than participants with moderate depression. Among participants receiving a depression diagnosis, 74% received guideline-concordant treatment. Conclusion Physician depression care in primary care settings is not influenced by competing demands for care for other comorbid medical conditions.
Ani, Chizobam; Bazargan, Mohsen; Hindman, David; Bell, Douglas; Rodriguez, Michael; Baker, Richard S.
[Guidelines for treatment of pneumonia in intensive care units].
Patients affected by pneumonia can be admitted in Intensive Care Units (ICUs) independently by the setting where the infection has been acquired (community, hospital, long-term care facilities); even more frequently pneumonia can develop in patients already hospitalized in ICU especially in those requiring mechanical ventilation for different reasons. Within the severe community acquired pneumonia requiring admission in ICU, the most frequently responsible micro-organisms are mainly represented by Streptococcus pneumoniae, but also by Legionella and Haemophilus. Pseudomonas aeruginona, anyway, cannot be excluded. The most recent Canadian and American guidelines for treatment of the above mentioned infections suggest the use of a combination therapy with beta-lactams (ceftriaxone, cefotaxime, ampicillin/sulbactam, piperacillin/tazobactam) and a new generation macrolide or respiratory fluoroquinolone. In case of allergy to beta-lactams, the association fluoroquinolone-clindamycin should be preferred. Whenever a Pseudomonas etiology is suspected because of the presence of risk factors such as COPD, cystic fibrosis, bronchiectasis, previous and/or frequent therapies with antibiotics and/or steroids, the same guidelines suggest the use of an anti-pseudomonas beta-lactam (such as piperacillin/tazobactam, carbapenems, cefepime) associated with an anti-pseudomonas fluoroquinolone (high doses ciprofloxacin). An anti-pseudomonas beta-lactam plus an aminoglycoside or aminoglicosyde plus fluoroquinolone can be an alternative. Early onset Hospital Acquired Pneumonia (HAP) and early onset Ventilator Associated Pneumonia (VAP) in patients without risk factors for multi-resistant etiological agents are generally sustained by S. pneumoniae, H. influenzae, methicillin-susceptible Staphylocccus aureus e Gram negative enteric rods. These infections can be treated with one of the following antibiotics: ceftriaxone or fluoroquinolones (moxifloxacin or ciprofloxacin or levofloxacin) or ampicillin/sulbactam or ertapenem. Late onset VAP and HAP in patients with risk factors for multi-resistant, by contrast, should be treated with a combination therapy: in case of defined or suspected P. aeruginosa, Klebsiella pneumoniae (ESbL+), Acinetobacter sp etiology, it is required the use of an anti-pseudomonas cephalosporin or an anti-pseudomonas carbapenem or b-lactam + beta-lactamase inhibitor associated with an anti-pseudomonas fluoroquinolone or an aminoglicoside. The possible presence of MRSA or Legionella pneumophila suggests the use of anti-Gram positive antibiotics such as glycopeptides or linezolid. These quidelines confirm the role of ciprofloxacin combined with beta-lactams whenever P. aeruginosa, Klebsiella pneumoniae (ESbL+), Acinetobacter sp. etiology is suspected. PMID:16801748
Emmi, V
Online PTSD Diagnosis and Treatment Training for Primary Care Physicians.
National Technical Information Service (NTIS)
Recently returned Iraq and Afghanistan veterans with symptoms of PTSD often present first to primary care providers (PCPs) and are reluctant to seek specialty mental health care. Most PCPs have not been trained to assess for and initiate management of PTS...
Buprenorphine as a safe alternative to methadone in a patient with acquired long QT syndrome: a case report.
A 52-year-old man with a medical history of intravenous drug abuse was admitted to our hospital with syncope due to torsades de pointes (TdP). Two days earlier, he had used methadone. The electrocardiogram showed a prolonged corrected QT interval (QTc) of 600�ms. Continuous telemetry observation showed multiple episodes of TdP. The patient was diagnosed with bradyarrhythmia-induced TdP with acquired long QT syndrome resulting from methadone use. The QTc normalised within 2�weeks after discontinuation of the methadone. In this case of a patient with opioid dependency, there is a reasonable risk of repeated methadone use. Therefore, implantable cardioverter defibrillator or pacemaker implantation is justified but risky because of possible infections when using intravenous drugs. Given the high mortality rates seen in untreated illicit opioid users, this patient needs an alternative pharmacological treatment. Buprenorphine is an opiate-receptor agonist associated with less QTc prolongation. The patient was referred to a rehab clinic and treated with an oral combination of buprenorphine and naloxone (Suboxone). During this therapy, his QTc remained normal. PMID:22020456
de Jong, I M; de Ruiter, G S
Bridging the treatment gap: the secondary care perspective
Protocols and integrated care pathways can be valuable in the hospital care of patients with heart failure or left ventricular systolic dysfunction after acute myocardial infarction. A designated member of staff, often a specialist nurse, must be responsible for identifying patients suitable for management by the protocol and for ensuring that the protocol is adhered to. A new training scheme for "limited echocardiography" might enable specialist nurses to investigate left ventricular function within the first 24 hours of admission. Patients should be discharged from hospital as soon as they are out of danger. At present, they are often kept in hospital for process reasons. A "continuing care" clinic run by a specialist nurse, where patients can be seen daily after discharge until they are stabilised, is one way of bridging the gap between secondary and primary care. Communication between secondary and primary care needs to improve and same day discharge summaries are essential.
Dancy, M
The ethics of care and treatment of sex offenders.
The ethics of care acknowledges the importance of establishing and maintaining practices that help people to meet their needs, develop and protect basic capabilities for problem solving, emotional functioning, and social interaction, and avoid pain and suffering. In this article, we explore the contribution an ethics of care perspective can make to work with sex offenders. First, we briefly describe five classes of ethical problems evident in work with sex offenders. Second, the concept of care is defined and a justification for a version of care theory provided. Third, we apply the care ethical theory to ethical issues with sex offenders and demonstrate its value in responding to the five classes of problems outlined earlier. PMID:20944060
Ward, Tony; Salmon, Karen
Methadone- and buprenorphine-related ambulance attendances: a population-based indicator of adverse events.
This study examined the nature and extent of methadone- and buprenorphine-related morbidity through a retrospective analysis of ambulance service records (N = 243) in Melbourne, Australia. Cases in which methadone and buprenorphine were implicated are examined. Demographic and presenting characteristics, transport outcomes, and other substance use were explored. There were 84 buprenorphine-related attendances and 159 methadone-related attendances recorded on the database over the 4-year period. Presenting signs (respiratory rate and Glasgow Coma Scale score) were lower in the methadone-related attendances. Most of the attendances resulted in transport to hospital. Most presentations did not involve traditional signs of opioid overdose, a finding that warrants further investigation. This is the first article to describe characteristics of methadone- and buprenorphine-related ambulance attendances, with results suggesting this may be a useful way to monitor harms associated with these medications in the future. PMID:18295435
Nielsen, Suzanne; Dietze, Paul; Cantwell, Kate; Lee, Nicole; Taylor, David
Barriers to initiating depression treatment in primary care practice
OBJECTIVE AND DESIGN: This study used qualitative and quantitative methods to examine the reasons primary care physicians and nurses offered for\\u000a their inability to initiate guideline-concordant acute-phase care for patients with current major depression.\\u000a \\u000a \\u000a PARTICIPANTS AND SETTING: Two hundred thirty-nine patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices were\\u000a randomized to the
Paul A. Nutting; Kathryn Rost; Miriam Dickinson; James J. Werner; Perry Dickinson; Jeffrey L. Smith; Beth Gallovic
Race and Beliefs about Mental Health Treatment Among Anxious Primary Care Patients
Large racial disparities in the utilization of mental health care persist. Differences in treatment preferences could partially explain the differences in care between minority and non-minority populations. We compared beliefs about mental illness and treatment preferences among adult African Americans, Hispanics, Asian Americans, Native Americans, and whites, with diagnosed anxiety disorders. Measures of beliefs about mental illness and treatment were drawn from the National Comorbidity Survey Replication and from our previous work. There were no significant differences between African-Americans� and whites� beliefs. Hispanics� and Native Americans� beliefs were most distinctive, but the differences were small in magnitude. Across race/ethnicity, the associations between beliefs and service use were generally weak and statistically insignificant. Differences in illness beliefs and treatment preferences do not fully explain the large, persistent racial disparities in mental health care. Other crucial barriers to quality care exist in our health care system and our society as a whole.
Hunt, Justin; Sullivan, Greer; Chavira, Denise A.; Stein, Murray B.; Craske, Michelle G.; Golinelli, Daniella; Roy-Byrne, Peter P.; Sherbourne, Cathy D.
Long term outcomes of pharmacological treatments for opioid dependence: does methadone still lead the pack?
The aim of this review was to update and summarize the scientific knowledge on the long term outcomes of the different pharmacological treatment options for opioid dependence currently available and to provide a critical discussion on the different treatment options based on these results. We performed a literature search using the PubMed databases and the reference lists of the identified articles. Data from research show that the three pharmacological options reviewed are effective treatments for opioid dependence with positive long term outcomes. However, each one has its specific target population and setting. While methadone and buprenorphine are first line options, heroin-assisted treatment is a second line option for those patients refractory to treatment with methadone with concomitant severe physical, mental, social and/or functional problems. Buprenorphine seems to be the best option for use in primary care offices. The field of opioid dependence treatment is poised to undergo a process of reinforcement and transformation. Further efforts from researchers, clinicians and authorities should be made to turn new pharmacological options into clinical reality and to overcome the structural and functional obstacles that maintenance programmes face in combatting opioid dependence. PMID:23145768
Garcia-Portilla, Maria Paz; Bobes-Bascaran, Maria Teresa; Bascaran, Maria Teresa; Saiz, Pilar Alejandra; Bobes, Julio
Evaluation of the perioperative analgesic efficacy of buprenorphine, compared with butorphanol, in cats.
Objective-To compare the analgesic effects of buprenorphine and butorphanol in domestic cats. Design-2-phase positive-controlled randomized masked clinical trial. Animals-39 healthy female cats (10 in phase 1 and 29 in phase 2). Procedures-Cats admitted for ovariohysterectomy received buprenorphine (4 in phase 1; 14 in phase 2) or butorphanol (6 in phase 1; 15 in phase 2). In phase 1, cats were premedicated with buprenorphine (0.02 mg/kg [0.009 mg/lb], IM) or butorphanol (0.4 mg/kg [0.18 mg/lb], IM), in combination with medetomidine. Anesthesia was induced with propofol (IV) and maintained with isoflurane in oxygen. After extubation, medetomidine was antagonized with atipamezole. A validated multidimensional composite scale was used to assess signs of pain after surgery starting 20 minutes after extubation and continuing for up to 360 minutes, and pain score comparisons were made between the 2 groups. Phase 2 proceeded similar to phase 1 with the following addition: during wound closure, cats from the butorphanol and buprenorphine groups received butorphanol (0.4 mg/kg, IM) or buprenorphine (0.02 mg/kg, IM), respectively. Results-Phase 1 of the study was stopped after 10 cats were ovariohysterectomized because 9 of 10 cats required rescue analgesia at the first evaluation. In phase 2, at the first pain evaluation, pain scores from the buprenorphine group were lower, and all cats from the butorphanol group required rescue analgesia. None of the cats from the buprenorphine group required rescue analgesia at any time. Conclusions and Clinical Relevance-Buprenorphine (0.02 mg/kg, IM) given before surgery and during wound closure provided adequate analgesia for 6 hours following ovariohysterectomy in cats, whereas butorphanol did not. PMID:24984130
Warne, Leon N; Beths, Thierry; Holm, Merete; Carter, Jennifer E; Bauquier, S�bastien H
Successful transition to buprenorphine in a patient with methadone-induced torsades de pointes.
A 56-year-old-man presented with syncope and torsades de pointes secondary to methadone-induced QT prolongation. After transition from methadone to buprenorphine, a partial mu-opiate-receptor agonist and a kappa-opiate-receptor antagonist, the QT normalized and ventricular arrhythmias resolved. Buprenorphine should be used for opiate dependence and chronic pain in patients with methadone-induced QT prolongation and as first line therapy in patients with risk factors for torsades de pointes. PMID:18686025
Esses, Jason Levi; Rosman, Jonathan; Do, Lien Thanh; Schweitzer, Paul; Hanon, Sam
Diabetes Care and Treatment Program: A Joslin Telemedicine Initiative.
National Technical Information Service (NTIS)
The major goals of this continuing project are the establishment of a telemedicine system for comprehensive diabetes management and the assessment of diabetic retinopathy that provides increased access for diabetic patients to appropriate care, that centr...
D. Birkmire-Peters D. S. Vincent J. Humphry K. Parisi
Diabetes Care and Treatment Project: A Joslin Telemedicine Initiative.
National Technical Information Service (NTIS)
The major goals of this continuing project are the establishment of a telemedicine system for comprehensive diabetes management and the assessment of diabetic retinopathy that provides increased access for diabetic patients to appropriate care, that centr...
S. E. Bursell L. M. Aiello
Transforming Assertive Community Treatment Into an Integrated Care System: The Role of Nursing and Primary Care Partnerships
Despite the high rate of co-occurring medical conditions experienced by individuals receiving assertive community treatment (ACT), this comprehensive service model continues to be considered primarily a mental health intervention. Without compromising fidelity to the model, ACT can serve as an ideal platform from which to provide both primary and behavioral health care to those with complex service needs. Using a
Lara Carson Weinstein; Benjamin F. Henwood; Julianne W. Cody; Maria Jordan; Rebecca Lelar
Simultaneous quantification of buprenorphine, norbuprenorphine, buprenorphine glucuronide, and norbuprenorphine glucuronide in human placenta by liquid chromatography mass spectrometry
A LCMS method was developed and validated for the determination of buprenorphine (BUP), norbuprenorphine (NBUP), buprenorphine glucuronide (BUP-Gluc), and norbuprenorphine glucuronide (NBUP-Gluc) in placenta. Quantification was achieved by selected ion monitoring of m/z 468.4 (BUP), 414.3 (NBUP), 644.4 (BUP-Gluc), and 590 (NBUP-Gluc). BUP and NBUP were identified monitoring MS2 fragments m/z 396, 414 and 426 for BUP, and 340, 364 and 382 for NBUP, and glucuronide conjugates monitoring MS3 fragments m/z 396 and 414 for BUP-Gluc, and 340 and 382 for NBUP-Gluc. Linearity was 1�50 ng/g. Intra-day, inter-day and total assay imprecision (% RSD) were <13.4%, and analytical recoveries were 96.2�113.1%. Extraction efficiencies ranged from 40.7�68%, process efficiencies 38.8�70.5%, and matrix effect 1.3�15.4%. Limits of detection were 0.8 ng/g for all compounds. An authentic placenta from an opioid-dependent pregnant woman receiving BUP pharmacotherapy was analyzed. BUP was not detected but metabolite concentrations were NBUP-Gluc 46.6, NBUP 15.7 and BUP-Gluc 3.2 ng/g.
Concheiro-Guisan, Marta; Shakleya, Diaa M.; Huestis, Marilyn A.
Analysis of buprenorphine in whole blood using liquid chromatography-tandem mass spectrometry.
With buprenorphine use on the rise it has become more important than ever for the forensic laboratory to be capable of analyzing for it. Described is the approach used by the Georgia Bureau of Investigation for the screening and confirmation of buprenorphine in whole blood by liquid chromatography-tandem mass spectrometry (LC-MS-MS), along with case reviews for the first 2 months of method implementation. Screening by LC-MS-MS is capable of identifying buprenorphine cases at concentrations as low as 1-2 �g/L. Confirmatory testing is performed on both indicatively screened samples and cases where buprenorphine is specifically requested. Confirmatory analysis by LC-MS-MS has a limit of detection and limit of quantitation of 0.75 �g/L with estimated uncertainties of 7.2% at 1 �g/L, 3.5% at 10 �g/L and 4.8% at 20 �g/L based on a 95% confidence interval, with the highest percent coefficient of variation being 3.7% for the 1 �g/L level. Since its implementation, the laboratory has reported out nine cases for buprenorphine. Seven of those cases were detected by the initial screen and two were identified by a specific request for buprenorphine. The cases' average concentration was 4.25 �g/L with a mode of 3.1 �g/L. PMID:23983012
Stephenson, Jon B
Reducing the health consequences of opioid addiction in primary care.
Addiction to prescription opioids is prevalent in primary care settings. Increasing prescription opioid use is largely responsible for a parallel increase in overdose nationally. Many patients most at risk for addiction and overdose come into regular contact with primary care providers. Lack of routine addiction screening results in missed treatment opportunities in this setting. We reviewed the literature on screening and brief interventions for addictive disorders in primary care settings, focusing on opioid addiction. Screening and brief interventions can improve health outcomes for chronic illnesses including diabetes, hypertension, and asthma. Similarly, through the use of screening and brief interventions, patients with addiction can achieve improved health outcome. A spectrum of low-threshold care options can reduce the negative health consequences among individuals with opioid addiction. Screening in primary care coupled with short interventions, including motivational interviewing, syringe distribution, naloxone prescription for overdose prevention, and buprenorphine treatment are effective ways to manage addiction and its associated risks and improve health outcomes for individuals with opioid addiction. PMID:23664112
Bowman, Sarah; Eiserman, Julie; Beletsky, Leo; Stancliff, Sharon; Bruce, R Douglas
Managed care and technical efficiency in outpatient substance abuse treatment units.
This article examines (1) the extent to which managed care participation is associated with technical efficiency in outpatient substance abuse treatment (OSAT) organizations and (2) the contributions of specific managed care practices as well as other organizational, financial, and environmental attributes to technical efficiency in these organizations. Data are from a nationally representative sample survey of OSAT organizations conducted in 1995. Technical efficiency is modeled using data envelopment analysis. Overall, there were few significant associations between managed care dimensions and technical efficiency in outpatient treatment organizations. Only one managed care oversight procedure, the imposition of sanctions by managed care firms, was significantly associated with relative efficiency of these provider organizations. However, several organizational factors were associated with the relative level of efficiency including hospital affiliation, mental health center affiliation, JCAHO accreditation, receipt of lump sum revenues, methadone treatment modality, percentage clients unemployed, and percentage clients who abuse multiple drugs. PMID:9796161
Alexander, J A; Wheeler, J R; Nahra, T A; Lemak, C H
Tolerance to the mydriatic effect of buprenorphine, butorphanol, nalbuphine, and cyclorphan, and cross-tolerance to morphine in mice.
An increase in the use of opioid derivatives in the treatment of pain syndrome in clinical practice, and especially in the treatment of cancer, has added impetus to the search for an agent which does not induce tolerance and cross-tolerance to other opiodis. The mydriatic effect of opioids in mice, the correlation between analgesia and mydriasis, and tolerance to the analgesic effect of morphine in mice were evaluated previously. In the present work, tolerance to the mydriatic effect of four agonist-antagonists and cross-tolerance to morphine were examined. Measurement of the pupillary diameter was performed using a binocular operating microscope. Tolerance and cross-tolerance to morphine were developed following a chronic use of buprenorphine, nalbuphine, and cyclorphan. After chronic injection of butorphanol, no tolerance or cross-tolerance to morphine was observed. PMID:23568116
Kaadan, M; Stav, A; Rabinowitz, R; Shavit, S; Korczyn, A D
Screening and treatment of diabetic nephropathy by primary care physicians
Objective��To describe the practices of Indiana primary care physicians related to diabetic nephropathy screening and management.\\u000a \\u000a \\u000a \\u000a Design��Cross-sectional, observational.\\u000a \\u000a \\u000a \\u000a Setting��The state of Indiana.\\u000a \\u000a \\u000a \\u000a Participants��Active primary care physicians [defined as general internists, family practitioners, and general practitioners) in Indiana\\u000a who provided care for diabetic patients at the time of the survey (n=1,018)\\u000a \\u000a \\u000a \\u000a Measurements and Main Results��Practice patterns relevant to microalbuminuria and overt
Stephanie Kakos Kraft; Emmanuel N. Lazaridis; Chunfu Qiu; Charles M. Clark; David G. Marrero
[Nutrition, lifestyle, physical activity, and supportive care during chemotherapeutic treatment].
With improvements in cancer survival rates, more patients with cancer are living longer and the influence of nutrition, lifestyle, physical activity as well as supportive care during and after chemotherapy is of increasing interest. In several malignancies smoking cessation increases cancer survival. Similar effects are expected by healthy nutrition. Regular physical activity of cancer patients reduces drug interactions of chemotherapy, decreases the number of comorbid conditions, and helps patients maintain independence as long as possible. For supportive care during chemotherapy the 5-HT3 receptor antagonists are more effective for the prevention of chemotherapy-induced nausea and vomiting. There are several colony-stimulating factors (e.g. GCSF, erythropoietin) for hematopoietic recovery post-chemotherapy. Altogether supportive care of chemotherapy reduces toxicity and increases efficacy. PMID:16607518
L�mmen, G; J�ger, T; Sommer, F; Ebert, T; Schmitz-Draeger, B
[Intensive care unit acquired weakness. Pathogenesis, treatment, rehabilitation and outcome].
The diagnosis of intensive care unit acquired weakness (ICUAW) in the setting of neurological rehabilitation is steadily increasing. This is due to the fact that the intensive care of patients with sepsis or after cardiac or abdominal surgery is improving. A longer duration of respiratory weaning and comorbidities frequently complicate rehabilitation. Clinically, patients present with a flaccid (tetra) paresis and electrophysiological studies have shown axonal damage. Besides involvement of peripheral nerves, muscle can also be affected (critical illness myopathy) leading to ICUAW with inconstant myopathic damage patterns found by electrophysiological testing. Mixed forms can also be found. A specific therapy for ICUAW is not available. Early mobilization to be initiated on the intensive care unit and commencing neurological rehabilitation improve the outcome of ICUAW. This review highlights the current literature regarding the etiology and diagnosis of ICUAW. Furthermore, studies about rehabilitation and outcome of ICUAW are discussed. PMID:24463649
Ponfick, M; B�sl, K; L�demann-Podubecka, J; Neumann, G; Pohl, M; Nowak, D A; Gdynia, H-J
Can audit improve patient care and treatment outcomes in endodontics?
Clinical audit is part of the NHS clinical governance framework for dentistry and is recommended as a quality improvement process for patient care, yet there is very mixed evidence supporting audit's ability to produce change in practice. Findings show evidence of changes following audit which improved patient care and practice efficiency. However, there is a general lack of dissemination of audit results, little useful feedback provided to participants, limited use of formal re-auditing of a particular topic and little reported on whether audit improves outcomes for patients. As part of its clinical governance responsibility, the Community Dental Service (CDS) is committed to ensuring that its clinical audit is robust, strategic and measures patient outcomes in its evaluation. The aim of this paper is to present a complete endodontic audit cycle; its recommendations and effects on the process and on outcomes of clinical patient endodontic care; and to evaluate if audit was a useful tool in this case. PMID:23660929
Simons, D; Williams, D
Gonadal failure after treatment of hematologic malignancies: from recognition to management for health-care providers
Many cancer treatments induce gonadal failure, which can cause infertility and menopausal symptoms in women. Improvements in treatments for hematologic malignancies have extended survival, thus making treatment-induced gonadal failure (TIGF) a more widespread problem. We reviewed the published literature on TIGF with the goal of providing practical information for health-care providers engaged in the management of hematologic malignancies. We conclude
Kazutaka Nakayama; Andrea Milbourne; Leslie R Schover; Richard E Champlin; Naoto T Ueno
Primary Care Screening of Depression and Treatment Engagement in a University Health Center: A Retrospective Analysis
ERIC Educational Resources Information Center
Objectives: This retrospective study analyzed a primary care depression screening initiative in a large urban university health center. Depression detection, treatment status, and engagement data are presented. Participants: Participants were 3,713 graduate and undergraduate students who presented consecutively for primary care services between�
Klein, Michael C.; Ciotoli, Carlo; Chung, Henry
Streamlining tasks and roles to expand treatment and care for HIV: randomised controlled trial protocol
BACKGROUND: A major barrier to accessing free government-provided antiretroviral treatment (ART) in South Africa is the shortage of suitably skilled health professionals. Current South African guidelines recommend that only doctors should prescribe ART, even though most primary care is provided by nurses. We have developed an effective method of educational outreach to primary care nurses in South Africa. Evidence is
Lara R Fairall; Max O Bachmann; Merrick F Zwarenstein; Carl J Lombard; Kerry Uebel; Cloete van Vuuren; Dewald Steyn; Andrew Boulle; Eric D Bateman
Quality Adjustment for Health Care Spending on Chronic Disease: Evidence from Diabetes Treatment, 1999-2009
Although US health care expenditures reached 17.6 percent of GDP in 2009, quality measurement in this important service sector remains limited. Studying quality changes associated with 11 years of health care for patients with diabetes, we find that the value of reduced mortality and avoided treatment spending, net of the increase in annual spending, was $9,094 for the average patient.
Karen N. Eggleston; Nilay D. Shah; Steven A. Smith; Ernst R. Berndt; Joseph P. Newhouse
Assessment of preferences for self-treatment and information in health care
Reports the development and validation of the Krantz Health Opinion Survey, a measure of preferences for different treatment approaches. This measure yields a total score and 2 relatively independent subscales that measure preferences for information and for behavioral involvement (i.e., self-care and active participation) in medical care. The pilot studies with 764 undergraduates and 3 related studies with 230 Ss
David S. Krantz; Andrew Baum; Margaret V. Wideman
Electronic health records: essential tools in integrating substance abuse treatment with primary care.
While substance use problems are considered to be common in medical settings, they are not systematically assessed and diagnosed for treatment management. Research data suggest that the majority of individuals with a substance use disorder either do not use treatment or delay treatment-seeking for over a decade. The separation of substance abuse services from mainstream medical care and a lack of preventive services for substance abuse in primary care can contribute to under-detection of substance use problems. When fully enacted in 2014, the Patient Protection and Affordable Care Act 2010 will address these barriers by supporting preventive services for substance abuse (screening, counseling) and integration of substance abuse care with primary care. One key factor that can help to achieve this goal is to incorporate the standardized screeners or common data elements for substance use and related disorders into the electronic health records (EHR) system in the health care setting. Incentives for care providers to adopt an EHR system for meaningful use are part of the Health Information Technology for Economic and Clinical Health Act 2009. This commentary focuses on recent evidence about routine screening and intervention for alcohol/drug use and related disorders in primary care. Federal efforts in developing common data elements for use as screeners for substance use and related disorders are described. A pressing need for empirical data on screening, brief intervention, and referral to treatment (SBIRT) for drug-related disorders to inform SBIRT and related EHR efforts is highlighted. PMID:24474861
Tai, Betty; Wu, Li-Tzy; Clark, H Westley
Two pragmatic trials of treatment for shoulder disorders in primary care: generalisability, course, and prognostic indicators
OBJECTIVE: To investigate predictors of long term prognosis in patients treated for shoulder pain in primary care. METHODS: Data were taken from two pragmatic randomised clinical trials investigating the effectiveness of conservative treatments for shoulder pain presenting to primary care. Shoulder pain severity, disability, and perceived recovery measured in the long term (UK, 18 months; Netherlands, 12 months) were considered
E. Thomas; Windt-Mens van der D. A. W. M; E. M. Hay; N. Smidt; K. Dziedzic; L. M. Bouter; P. R. Croft
A Clinical Trial Comparing Tapering Doses of Buprenorphine with Steady Doses for Chronic Pain and Co-existent Opioid Addiction
Objectives Effective strategies are needed to manage individuals with chronic non-cancer pain and coexistent opioid addiction. This study compared opioid discontinuation and opioid replacement protocols. Methods We planned to enroll 60 individuals into an open-label trial who had been treated with opioids for chronic non-cancer pain, and who also had opioid addiction. Participants were randomly assigned to one of two 6-month treatment protocols of buprenorphine/naloxone sublingual tablets: 1) tapering doses for opioid weaning or �detoxification� (active comparator group) or 2) steady doses for opioid replacement (experimental group). They were followed monthly for the study outcomes: completion of the 6-month treatment protocol and self-reported pain control, physical functioning, alcohol consumption and illicit drug use. Results Enrollment was terminated after enrolling 12 participants because none of the 6 assigned to receive tapering doses could successfully complete the protocol (5 were given steady doses and 1 was admitted to an inpatient chemical dependency treatment program); whereas, of the 6 assigned to receive steady doses, 5 completed the protocol (1 withdrew). This difference between the 2 treatment conditions was significant (P = 0.015). Of the 10 participants who completed the 6 month follow-up, 8 reported improved pain control and physical functioning and 5 used alcohol and/or illicit drugs. Conclusions We conclude that over 6 months, these participants with chronic pain and co-existent opioid addiction were more likely to adhere to an opioid replacement protocol than an opioid weaning protocol and that opioid replacement therapy with steady doses of buprenorphine/naloxone is associated with improved pain control and physical functioning.
Blondell, Richard D.; Ashrafioun, Lisham; Dambra, Christina M.; Foschio, Elisa M.; Zielinski, Amy L.; Salcedo, Daniel M.
Effectiveness of Cognitive-Behavioral Treatment for Panic Disorder versus Treatment as Usual in a Managed Care Setting
ERIC Educational Resources Information Center
Eighty clients enrolled in a managed care health plan who identified panic disorder as their primary presenting problem were randomly assigned to treatment by a therapist recently trained in a manual-based empirically supported psychotherapy (M. G. Craske, E. Meadows, & D. H. Barlow, 1994) or a therapist conducting treatment as usual (TAU).�
Addis, Michael E.; Hatgis, Christina; Krasnow, Aaron D.; Jacob, Karen; Bourne, Leslie; Mansfield, Abigail
Enhancing Entrance into PTSD Treatment for Post-Deployment Veterans through Collaborative/Integrative Care.
National Technical Information Service (NTIS)
High rates of posttraumatic stress disorder (PTSD) among post- deployment veterans and the associated long-term consequences highlight the importance of early identification and treatment. The Veterans Health Administration (VHA) s Primary Care Mental Hea...
A. M. Brugh J. Mastnak P. A. Brawer R. P. Martielli S. P. O'Connor
Patterns of Care, Utilization, and Outcomes of Treatments for Localized Prostate Cancer.
National Technical Information Service (NTIS)
The purpose of the research is to characterize patterns of care, utilization, and outcomes of treatments for localized prostate cancer such as surgery, external beam radiation, and brachytherapy. In particular, the research characterizes the patterns of c...
J. C. Hu
Patterns of Care, Utilization, and Outcomes of Treatments for Localized Prostate Cancer.
National Technical Information Service (NTIS)
The purpose of the research is to characterize patterns of care, utilization, and outcomes of treatments for localized prostate cancer such as surgery, external beam radiation, and brachytherapy. In particular, the research characterizes the patterns of c...
J. C. Hu
Patterns of Care, Utilization, and Outcomes of Treatments for Localized Prostate Cancer.
National Technical Information Service (NTIS)
The purpose of the research is to characterize patterns of care, utilization, and outcomes of treatments for localized prostate cancer such as surgery, external beam radiation, and brachytherapy. In particular, the research characterizes the patterns of c...
J. C. Hu
Patterns of free (unconjugated) buprenorphine, norbuprenorphine, and their glucuronides in urine using liquid chromatography-tandem mass spectrometry.
Patterns of buprenorphine and metabolites were examined in 1946 positive urine samples analyzed by liquid chromatography-tandem mass spectrometry for free (unconjugated) buprenorphine and norbuprenorphine (quantitative, 2 to 1000 ng/mL) and buprenorphine-glucuronide (B3G) and norbuprenorphine-glucuronide (N3G) (semi-quantitative, 5 to 1000 ng/mL). Two distribution patterns predominated with 49.1% positive for norbuprenorphine, B3G, and N3G and 41.6% positive for buprenorphine, norbuprenorphine, B3G, and N3G. Buprenorphine, positive in 45.5% of samples, was mostly < 5 ng/mL (median 6.1 ng/mL), but 9.8% were > 1000 ng/mL. Norbuprenorphine, B3G, and N3G had semi-Gaussian distributions with medians of 64.7, 108, and 432 ng/mL, respectively. With buprenorphine < 100 ng/mL (767 samples) or ? 100 ng/mL (19 quantifiable samples), the respective median metabolic ratios (free norbuprenorphine/free buprenorphine) were 25.0 and 0.15. In 12 retested "> 1000 ng/mL" buprenorphine samples, free buprenorphine was 4160 to 39,400 ng/mL and free naloxone 2140 to 9560 ng/mL. In 87 subsequent samples with buprenorphine < 20 ng/mL, naloxone concentrations were < 50 ng/mL. Concentrations of buprenorphine > 100 ng/mL (particularly with low metabolite concentrations) are suspect of urine adulteration with medication (4% in the database) that can be checked in most cases by concurrent analysis for naloxone. PMID:22337776
McMillin, Gwendolyn A; Davis, Rebecka; Carlisle, Heidi; Clark, Chantry; Marin, Stephanie J; Moody, David E
Edinburgh primary care depression study: treatment outcome, patient satisfaction, and cost after 16 weeks.
OBJECTIVE--To compare the clinical efficacy, patient satisfaction, and cost of three specialist treatments for depressive illness with routine care by general practitioners in primary care. DESIGN--Prospective, randomised allocation to amitriptyline prescribed by a psychiatrist, cognitive behaviour therapy from a clinical psychologist, counselling and case work by a social worker, or routine care by a general practitioner. SUBJECTS AND SETTING--121 patients aged between 18 and 65 years suffering depressive illness (without psychotic features) meeting the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition for major depressive episode in 14 primary care practices in southern Edinburgh. MAIN OUTCOME MEASURES--Standard observer rating of depression at outset and after four and 16 weeks. Numbers of patients recovered at four and 16 weeks. Total length and cost of therapist contact. Structured evaluation of treatment by patients at 16 weeks. RESULTS--Marked improvement in depressive symptoms occurred in all treatment groups over 16 weeks. Any clinical advantages of specialist treatments over routine general practitioner care were small, but specialist treatment involved at least four times as much therapist contact and cost at least twice as much as routine general practitioner care. Psychological treatments, especially social work counselling, were most positively evaluated by patients. CONCLUSIONS--The additional costs associated with specialist treatments of new episodes of mild to moderate depressive illness presenting in primary care were not commensurate with their clinical superiority over routine general practitioner care. A proper cost-benefit analysis requires information about the ability of specialist treatment to prevent future episodes of depression.
Scott, A. I.; Freeman, C. P.
Treatment of depressive disorders in primary care - protocol of a multiple treatment systematic review of randomized controlled trials
Background Several systematic reviews have summarized the evidence for specific treatments of primary care patients suffering from depression. However, it is not possible to answer the question how the available treatment options compare with each other as review methods differ. We aim to systematically review and compare the available evidence for the effectiveness of pharmacological, psychological, and combined treatments for patients with depressive disorders in primary care. Methods/Design To be included, studies have to be randomized trials comparing antidepressant medication (tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), hypericum extracts, other agents) and/or psychological therapies (e.g. interpersonal psychotherapy, cognitive therapy, behavioural therapy, short dynamically-oriented psychotherapy) with another active therapy, placebo or sham intervention, routine care or no treatment in primary care patients in the acute phase of a depressive episode. Main outcome measure is response after completion of acute phase treatment. Eligible studies will be identified from available systematic reviews, from searches in electronic databases (Medline, Embase and Central), trial registers, and citation tracking. Two reviewers will independently extract study data and assess the risk of bias using the Cochrane Collaboration's corresponding tool. Meta-analyses (random effects model, inverse variance weighting) will be performed for direct comparisons of single interventions and for groups of similar interventions (e.g. SSRIs vs. tricyclics) and defined time-windows (up to 3 months and above). If possible, a global analysis of the relative effectiveness of treatments will be estimated from all available direct and indirect evidence that is present in a network of treatments and comparisons. Discussion Practitioners do not only want to know whether there is evidence that a specific treatment is more effective than placebo, but also how the treatment options compare to each other. Therefore, we believe that a multiple treatment systematic review of primary-care based randomized controlled trials on the most important therapies against depression is timely.
Engagement in primary care treatment by persons with severe and persistent mental illness.
Even when primary care provider relationships exist, persons with severe and persistent mental illness (SPMI) are more likely to be undertreated and seek care from emergency room settings. The purpose of this study was to describe the social process of engagement in primary care treatment from the perspective of persons with SPMI. Using grounded theory and semistructured interviews, 32 adults were interviewed. The process of engagement includes mattering, being perceived as credible and capable, and working together. Clinical, education, and research implications are discussed. Future studies should explore engagement in primary care with this population from the perspective of providers. PMID:22835747
Galon, Patricia; Graor, Christine Heifner
Diagnosis and treatment of osteoporosis before and after admission to long-term care institutions
Summary��Bisphosphonate treatment rates were examined before and after admission to long-term residential care. Bisphosphonate treatment\\u000a rates were low (16%) pre-admission but doubled after long-term residential care admission (30%). Men were very undertreated\\u000a for osteoporosis, while a history of falls with injury was not associated with treatment.\\u000a \\u000a \\u000a \\u000a \\u000a Introduction��To determine the rates and independent correlates of bisphosphonate treatment in elderly residents before
L. A. Beaupre; S. R. Majumdar; S. Dieleman; A. Au; D. W. Morrish
Intraclass correlation coefficients for cluster randomized trials in care pathways and usual care: hospital treatment for heart failure
Background Cluster randomized trials are increasingly being used in healthcare evaluation to show the effectiveness of a specific intervention. Care pathways (CPs) are becoming a popular tool to improve the quality of health-care services provided to heart failure patients. In order to perform a well-designed cluster randomized trial to demonstrate the effectiveness of Usual care (UC) and CP in heart failure treatment, the intraclass correlation coefficient (ICC) should be available before conducting a trial to estimate the required sample size. This study reports ICCs for both demographical and outcome variables from cluster randomized trials of heart failure patients in UC and care pathways. Methods To calculate the degree of within-cluster dependence, the ICC and associated 95% confidence interval were calculated by a method based on analysis of variance. All analyses were performed in R software version 2.15.1. Results ICCs for baseline characteristics ranged from 0.025 to 0.058. The median value and interquartile range was 0.043 [0.026-0.052] for ICCs of baseline characteristics. Among baseline characteristics, the highest ICCs were found for admission by referral or admission from home (ICC?=?0.058) and the disease severity at admission (ICC?=?0.046). Corresponding ICCs for appropriateness of the stay, length of stay and hospitalization cost were 0.069, 0.063, and 0.001 in CP group and 0.203, 0.020, 0.046 for usual care, respectively. Conclusion Reported values of ICCs from present care pathway trial and UC results for some common outcomes will be helpful for estimating sample size in future clustered randomized heart failure trials, in particular for the evaluation of care pathways.
Treatment of Osteoporosis in Long-Term Care
The major determinants of admission at longterm care institutions (LTCI) include severe disability, poor social\\/familial support,\\u000a advanced cognitive impairment, and either sequelae or end stages of chronic diseases such as Alzheimer's disease, diabetes,\\u000a and heart and renal failure. All these conditions have made elderly patients unable to cope with their life in the community\\u000a (1), requiring a higher amount of
Gustavo Duque; Louise Mallet
Treatment of children in foster care: issues of collaboration.
Therapists assessing and treating children in foster care face unique issues, due to the complicated relational system generated by a foster placement. At a minimum, the mental health clinician must negotiate a role relative to the foster family, especially the foster parents, biological parents, and the Child Protective Service Agency (CPS) represented by the caseworker. The system of relationships and the ambiguous status of the child in foster care affects both the range of issues that need to be assessed to identify factors contributing to a child's problems and the context of possible interventions. The therapeutic relationship with the child is also affected by the child's understanding of and feelings about the connections, or lack of them, between the therapist and other meaningful adults in the child's life. This paper considers issues affecting the role of the therapist relative to each relationship and then considers the broader role of the therapist as an intervener in the foster care and protective service system. PMID:3293722
Molin, R
Overcoming Barriers to Prevention, Care, and Treatment of Hepatitis C in Illicit Drug Users
Injection drug use accounts for most of the incident infections with hepatitis C virus (HCV) in the United States and other developed countries. HCV infection is a complex and challenging medical condition in injection drug users (IDUs). Elements of care for hepatitis C in illicit drug users include prevention counseling and education; screening for transmission risk behavior; testing for HCV and human immunodeficiency virus infection; vaccination against hepatitis A and B viruses; evaluation for comorbidities; coordination of substance-abuse treatment services, psychiatric care, and social support; evaluation of liver disease; and interferon-based treatment for HCV infection. Caring for patients who use illicit drugs presents challenges to the health-care team that require patience, experience, and an understanding of the dynamics of substance use and addiction. Nonetheless, programs are successfully integrating hepatitis C care for IDUs into health-care settings, including primary care, methadone treatment and other substance-abuse treatment programs, infectious disease clinics, and clinics in correctional facilities.
Edlin, Brian R.; Kresina, Thomas F.; Raymond, Daniel B.; Carden, Michael R.; Gourevitch, Marc N.; Rich, Josiah D.; Cheever, Laura W.; Cargill, Victoria A.
Rethinking the mental health treatment skills of primary care staff: a framework for training and research.
Health care reforms may offer several opportunities to build the mental health treatment capacity of primary care. Capitalizing on these opportunities requires identifying the types of clinical skills that the primary care team requires to deliver mental health care. This paper proposes a framework that describes mental health skills for primary care receptionists, medical assistants, nurses, nurse practitioners, and physicians. These skills are organized on three levels: cross-cutting skills to build therapeutic alliance; broad-based, brief interventions for major clusters of mental health symptoms; and evidence-based interventions for diagnosis specific disorders. This framework is intended to help inform future mental health training in primary care and catalyze research that examines the impact of such training. PMID:21915748
Brown, Jonathan D; Wissow, Lawrence S
Treatment of hypophosphatemia in the intensive care unit: a review
INTRODUCTION: Currently no evidence-based guideline exists for the approach to hypophosphatemia in critically ill patients. METHODS: We performed a narrative review of the medical literature to identify the incidence, symptoms, and treatment of hypophosphatemia in critically ill patients. Specifically, we searched for answers to the questions whether correction of hypophosphatemia is associated with improved outcome, and whether a certain treatment
Dani�l A Geerse; Alexander J Bindels; Michael A Kuiper; Arnout N Roos; Peter E Spronk; Marcus J Schultz
Buprenorphine/Naloxone and Methadone Effects on Laboratory Indices of Liver Health: a Randomized Trial
BACKGROUND Buprenorphine/naloxone (BUP) and methadone (MET) are efficacious treatments for opioid dependence, although concerns about a link between BUP and drug-induced hepatitis have been raised. This study compares the effects of BUP and MET on liver health in opioid-dependent participants. METHODS This was a randomized controlled trial of 1269 opioid-dependent participants seeking treatment at 8 federally licensed opioid treatment programs and followed for up to 32 weeks between May 2006 and August 2010; 731 participants met �evaluable� criteria defined as completing 24 weeks of medication and providing at least 4 blood samples for transaminase testing. Participants were randomly assigned to receive BUP or MET for 24 weeks. Shift table analysis determined how many evaluable participants moved between categories of low and elevated transaminase levels. Predictors of moving from low to high transaminase levels were identified. RESULTS Changes in transaminase levels did not differ by medication condition. Baseline infection with hepatitis C or B was the only significant predictor of moving from low to elevated transaminase levels; 9 BUP and 15 MET participants showed extreme liver test elevations and were more likely than those without extreme elevations to have seroconverted to both hepatitis B and C during the study, or to use illicit drugs during the first 8 weeks of treatment. MET participants were retained longer in treatment than BUP participants. CONCLUSIONS This study demonstrated no evidence of liver damage during the initial 6 months of treatment in either condition. Physicians can prescribe either medication without major concern for liver injury.
Saxon, Andrew J.; Ling, Walter; Hillhouse, Maureen; Thomas, Christie; Hasson, Albert; Ang, Alfonso; Doraimani, Geetha; Tasissa, Gudaye; Lokhnygina, Yuliya; Leimberger, Jeff; Bruce, R. Douglas; McCarthy, John; Wiest, Katharina; McLaughlin, Paul; Bilangi, Richard; Cohen, Allan; Woody, George; Jacobs, Petra
A dose�effect study of repeated administration of buprenorphine\\/naloxone on performance in opioid-dependent volunteers
Based on its unique pharmacological profile, buprenorphine may produce less impairment in psychomotor and cognitive performance than methadone. However, the few studies that have investigated the performance effects of buprenorphine in opioid-abusing volunteers examined effects of single acute doses rather than effects of repeated dosing and included a very limited range of measures. The present inpatient study evaluated dose-related effects
Miriam Z. Mintzer; Christopher J. Correia; Eric C. Strain
Pathways to Care: Narratives of American Indian Adolescents Entering Substance Abuse Treatment
Using data from 89 American Indian adolescents and guided by the Network Episode Model, this paper analyses pathways to residential substance abuse treatment and their correlates. These adolescents were recruited at admission to a tribally-operated substance abuse treatment program in the southern United States from October 1998 to May 2001. Results from the qualitative analyses of these adolescent�s pathways to care narratives indicated that 35% ultimately agreed with the decision for their entry into treatment; 41% were compelled to enter treatment by others, usually by their parents, parole officers, and judges; and 24% did not describe a clear pathway to care. In the multinomial logistic regression model examining correlates of these pathways to care classifications, adolescents who described pathways indicative of agreement also reported greater readiness for treatment than the adolescents who described compelled or no clear pathways to care. Adolescents who described a compelled pathway were less likely to meet diagnostic criteria for Conduct Disorder and described fewer social network ties. We were unable to find a relationship between pathways classifications and referral source, suggesting these narratives were subjective constructions of pathways to care rather than a factual representation of this process. In the final logistic regression model examining correlates of treatment completion, articulating a pathway to care, whether it was one of agreement or of being compelled into treatment, predicted a greater likelihood of completing treatment. Overall, these narratives and their correlates are highly consistent with the Network-Episode Model�s emphasis on the interaction of self, situation, and social network in shaping the treatment seeking process, demonstrating the applicability of this model to understanding the treatment seeking process in this special population and suggests important considerations for understanding the dynamics of service utilization across diverse communities.
Novins, Douglas K.; Spicer, Paul; Fickenscher, Alexandra; Pescosolido, Bernice
A Role for Health Communication in the Continuum of HIV Care, Treatment, and Prevention.
: Health communication has played a pivotal role in HIV prevention efforts since the beginning of the epidemic. The recent paradigm of combination prevention, which integrates behavioral, biomedical, and structural interventions, offers new opportunities for employing health communication approaches across the entire continuum of care. We describe key areas where health communication can significantly enhance HIV treatment, care, and prevention, presenting evidence from interventions that include health communication components. These interventions rely primarily on interpersonal communication, especially individual and group counseling, both within and beyond clinical settings to enhance the uptake of and continued engagement in care. Many successful interventions mobilize a network of trained community supporters or accompagnateurs, who provide education, counseling, psychosocial support, treatment supervision, and other pragmatic assistance across the care continuum. Community treatment supporters reduce the burden on overworked medical providers, engage a wider segment of the community, and offer a more sustainable model for supporting people living with HIV. Additionally, mobile technologies are increasingly seen as promising avenues for ongoing cost-effective communication throughout the treatment cascade. A broader range of communication approaches, traditionally employed in HIV prevention efforts, that address community and sociopolitical levels through mass media, school- or workplace-based education, and entertainment modalities may be useful to interventions seeking to address the full care continuum. Future interventions would benefit from development of a framework that maps appropriate communication theories and approaches onto each step of the care continuum to evaluate the efficacy of communication components on treatment outcomes. PMID:25007201
Tomori, Cecilia; Risher, Kathryn; Limaye, Rupali J; Van Lith, Lynn M; Gibbs, Susannah; Smelyanskaya, Marina; Celentano, David D
Job Satisfaction Differences between Primary Health Care and Treatment Sectors: An Experience from Iran
Background: The aim of this study was to compare the levels of job satisfaction and its predictors among primary health care and treatment sectors' staff in East Azerbaijan Province, Iran. Methods: This comparative study was conducted in East Azerbaijan Province,Iran in 2011. A questionnaire survey was performed on 420 staff from health care and treatment sectors using multi-stage proportional cluster sampling method. Job satisfaction was measured in five aspects namely: structural and managerial; individual; social; work-itself; environmental and welfare job satisfaction factors.The job satisfaction measurement score was normalized to fall into a range of zero to 100. Statistical analyses were performed using Friedman and independent sample t-tests. Results: Overall satisfaction in health and treatment sectors was moderate with a mean score above 50. Hospital General Practitioners reported significantly higher job satisfaction score (mean � SD=57.34 � 17.02) compared to health care center General Practitioners (mean � SD= 31.74�14.99). The highest satisfaction scores belonged to individual factors both in health care sector staff (64.83�18.50) and treatment sector staff (63.55�17.44). The lowest job satisfaction was observed with environmental and welfare factors (38.47�19.86 and 36.83�19.86, respectively). Conclusion: The job satisfaction significantly differs between primary health care and treatment sectors. Based on the results, environmental and welfare factors may be targeted to improve the job satisfaction in public health care system.
Bagheri, Shokoufe; Janati, Ali; Kousha, Ahmad; Sadeghi-Bazargani, Homayoun; Asghari-Jafarabadi, Mohammad; Farahbakhsh, Mostafa
Drug interactions associated with methadone, buprenorphine, cocaine, and HIV medications: implications for pregnant women
Pregnancy in substance-abusing women with HIV/AIDS presents a complex clinical challenge. Opioid-dependent women need treatment with opioid therapy during pregnancy to protect the health of mother and developing fetus. However, opioid therapies, methadone and buprenorphine, may have drug interactions with some HIV medications that can have adverse effects leading to suboptimal clinical outcomes. Further, many opioid-dependent individuals have problems with other forms of substance abuse, for example, cocaine abuse, that could also contribute to poor clinical outcomes in a pregnant woman. Physiological changes, including increased plasma volume and increased hepatic and renal blood flow, occur in the pregnant woman as the pregnancy progresses and may alter medication needs with the potential to exacerbate drug interactions, although there is sparse literature on this issue. Knowledge of possible drug interactions between opioids, other abused substances such as cocaine, HIV therapeutics, and other frequently required medications such as antibiotics and anticonvulsants is important to assuring the best possible outcomes in the pregnant woman with opioid dependence and HIV/AIDS.
McCance-Katz, Elinore F.
Drug interactions associated with methadone, buprenorphine, cocaine, and HIV medications: implications for pregnant women.
Pregnancy in substance-abusing women with HIV/AIDS presents a complex clinical challenge. Opioid-dependent women need treatment with opioid therapy during pregnancy to protect the health of mother and developing fetus. However, opioid therapies, methadone and buprenorphine, may have drug interactions with some HIV medications that can have adverse effects leading to suboptimal clinical outcomes. Further, many opioid-dependent individuals have problems with other forms of substance abuse, for example, cocaine abuse, that could also contribute to poor clinical outcomes in a pregnant woman. Physiological changes, including increased plasma volume and increased hepatic and renal blood flow, occur in the pregnant woman as the pregnancy progresses and may alter medication needs with the potential to exacerbate drug interactions, although there is sparse literature on this issue. Knowledge of possible drug interactions between opioids, other abused substances such as cocaine, HIV therapeutics, and other frequently required medications such as antibiotics and anticonvulsants is important to assuring the best possible outcomes in the pregnant woman with opioid dependence and HIV/AIDS. PMID:20965297
McCance-Katz, Elinore F
A costly separation between withdrawing and withholding treatment in intensive care
Ethical analyses, professional guidelines and legal decisions support the Equivalence Thesis for life-sustaining treatment: if it is ethical to withhold treatment, it would be ethical to withdraw the same treatment. In this article we explore reasons why the majority of medical professionals disagree with the conclusions of ethical analysis. Resource allocation is considered by clinicians to be a legitimate reason to withhold but not to withdraw intensive care treatment. We analyse 5 arguments in favour of non-equivalence, and find only relatively weak reasons to restrict rationing to treatment withholding. On the contrary, resource allocation provides a strong argument in favour of equivalence: non-equivalence causes preventable death in critically ill patients. We outline two proposals for increasing equivalence in practice: (1) reduction of the mortality threshold for treatment withdrawal, (2) time-limited trials of intensive care. These strategies would help to move practice towards more rational treatment limitation decisions.
Wilkinson, DJC; Savulescu, J
Bipolar-I Depression Outpatient Treatment Quality and Costs in Usual Care Practice
Objective To examine the longitudinal usual care quality and costs of bipolar-I depression treatment in adults. Experimental Design Observational study of claims data from a privately insured population, ages 18?64, diagnosed with bipolar-I depression (N=925), treated in 1999 and 2000, examining depressed phase specific and annualized treatment quality (receipt of antimanic medication and/or psychotherapy). Treatment costs were calculated and stratified by quality. Principal Observations Little more than half (56%) of the patients diagnosed with bipolar-I depression received both an antimanic agent and psychotherapy during their acute phase depression treatment, whereas fifteen percent received an antimanic agent without psychotherapy. Eighteen to 28% of spending was accounted for by treatment that did not meet the standards of practice guidelines�and two-thirds to three-quarters of it was treatment that included an antidepressant without an antimanic agent (care that is advised against by guidelines). Conclusions Considerable resources were spent in care inconsistent with guidelines�much of that was care that could worsen the course of bipolar illness. This provides an opportunity for policy makers to develop mechanisms of quality improvement that redirects a substantial proportion of resource dollars to care that is more efficacious. Further, when conducting quality assessment and examining outcomes using administrative data, hospital admissions alone are an inadequate measure of bipolar disorder affective instability in claims data.
Busch, Alisa B.; Frank, Richard G.; Sachs, Gary
Unequal treatment in the US: lessons and recommendations for cancer care internationally.
Despite interventions that have improved the overall health of the majority of Americans, racial and ethnic minorities have benefited less from these advances. Research has shown that multiple factors contribute to racial and ethnic disparities in health, health care, and cancer care. The Institute of Medicine Report, "Unequal Treatment" provides a detailed examination of racial/ethnic disparities in health care in the U.S., highlighting three clinical contributors--poor provider-patient communication, stereotyping in clinical decisionmaking, and patient mistrust. Although the findings and recommendations in "Unequal Treatment" are broad in scope, they provide a blueprint for how to address disparities in health care in general-as well as cancer care-and have direct implications for clinical practice, both nationally and internationally. We propose a patient-based approach to cross-cultural care as a model to improve communication with racial and ethnic minorities, and cross-cultural populations in general. We also highlight the importance of community based interventions, such as those that use health care navigators to promote cancer screening. If we hope to provide effective cancer care around the world, we must be attentive to the factors that impact minorities and vulnerable populations, and be prepared to address them. PMID:21952574
Betancourt, Joseph R; Renfrew, Megan R
A meta-analysis of the efficacy of fibromyalgia treatment according to level of care
INTRODUCTION: The aim of this paper was to compare the efficacy of the treatments for fibromyalgia currently available in both primary care and specialised settings. METHODS: Published reports of randomised controlled trials (RCTs) researching pharmacological and non-pharmacological treatments in patients with fibromyalgia were found in the MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and PsychInfo databases. The most
Javier Garcia-Campayo; Jesus Magdalena; Rosa Magall�n; Esther Fern�ndez-Garc�a; Montserrat Salas; Eva Andr�s
Factors Associated With Pharmacologic Treatment of Osteoporosis in an Older Home Care Population
Background. A number of studies have shown low rates of osteoporosis treatment. Few, if any, have assessed a comprehensive range of functional and clinical correlates of treatment coverage. Our objective was to examine which sociodemographic, clinical, and functional characteristics are associated with pharmacotherapy for osteoporosis among community-based seniors. Methods. The study sample included 48,689 home care clients aged ? 65
Shelly A. Vik; Micaela Jantzi; Jeff Poss; John Hirdes; David A. Hanley; David B. Hogan; Colleen J. Maxwell
Treatment of Anxiety, Depression, and Alcohol Disorders in the Elderly: Social Work Collaboration in Primary Care
Anxiety and depressive disorders and symptoms are quite prevalent in older adults as are alcohol problems. Older adults tend to minimize psychological problems and consider psychological symptoms to be related to physical illness. Engagement of the older adult in mental health\\/substance abuse treatment has been found to be more successful if it occurs in collaboration with primary care treatment. Collaboration
Elaine S. Rinfrette
Characterizing the Passage of Personal Care Products Through Wastewater Treatment Processes
Wastewater treatment facilities use secondary treatment to stabilize the effect of discharged effluent on receiving waters by oxidizing biodegradable organic matter and reducing suspended solids and nutrients. The process was never specifically intended to remove trace quantities of xenobiotics, such as endocrine-disrupting compounds (EDCs) and pharmaceu- ticals and personal care products (PPCPs). Nevertheless, European studies performed at bench-scale or at
Joan Oppenheimer; Roger Stephenson; Arturo Burbano; Li Liu
The Continuing Care Model of Substance Use Treatment: What Works, and When Is "Enough," "Enough?"
There is little disagreement in the substance use treatment literature regarding the conceptualization of substance dependence as a cyclic, chronic condition consisting of alternating episodes of treatment and subsequent relapse. Likewise, substance use treatment efforts are increasingly being contextualized within a similar disease management framework, much like that of other chronic medical conditions (diabetes, hypertension, etc.). As such, substance use treatment has generally been viewed as a process comprised of two phases. Theoretically, the incorporation of some form of lower intensity continuing care services delivered in the context of outpatient treatment after the primary treatment phase (e.g., residential) appears to be a likely requisite if all stakeholders aspire to successful long-term clinical outcomes. Thus, the overarching objective of any continuing care model should be to sustain treatment gains attained in the primary phase in an effort to ultimately prevent relapse. Given the extant treatment literature clearly supports the contention that treatment is superior to no treatment, and longer lengths of stay is associated with a variety of positive outcomes, the more prudent question appears to be not whether treatment works, but rather what are the specific programmatic elements (e.g., duration, intensity) that comprise an adequate continuing care model. Generally speaking, it appears that the duration of continuing care should extend for a minimum of 3 to 6 months. However, continuing care over a protracted period of up to 12 months appears to be essential if a reasonable expectation of robust recovery is desired. Limitations of prior work and implications for routine clinical practice are also discussed.
Proctor, Steven L.; Herschman, Philip L.
Toward Quality Care in ADHD: Defining the Goals of Treatment.
Objective: Therapeutic goals for chronic mental disorders like major depressive disorder (MDD) and schizophrenia have evolved in parallel with the growing medical knowledge about the course and treatment of these disorders. Although the knowledge base regarding the clinical course of ADHD, a chronic psychiatric disorder, has evolved beyond symptomatic improvement and short-term treatment response, long-term goals, such as functional remission, have not yet been clearly defined. Method: A PubMed literature search was conducted to investigate the therapeutic goals of pharmacologic treatment referenced in the published literature from January 1998 through February 2010 using the following commonly used ADHD treatments as keywords: amphetamine, methylphenidate, atomoxetine, lisdexamfetamine, guanfacine, and clonidine. This search was then combined with an additional search that included the following outcome keywords: remission, relapse, remit, response, normal, normalization, recovery, and effectiveness. Results: Our search identified 102 publications. The majority (88.2% [90/102]) of these contained predefined criteria for treatment response. Predefined criteria for normalization and remission and/or relapse were presented in 4.9% (5/102), 12.7% (13/102), and 3.9% (4/102) of publications, respectively. There was a lack of consistency between the instruments used to measure outcomes as well as the criteria used to define treatment response, normalization, and remission as well as relapse. Conclusion: The therapeutic goals in treating ADHD should address optimal treatment outcomes that go beyond modest reductions of ADHD symptoms to include syndromatic, symptomatic, and functional remission. Future work should focus on reliable and valid tools to measure these outcomes in the clinical trial setting. (J. of Att. Dis. 2013; XX(X) 1-XX). PMID:23422237
Rostain, Anthony; Jensen, Peter S; Connor, Daniel F; Miesle, Laura M; Faraone, Stephen V
Managed Care's Dual Impact on Outpatient Substance Abuse Treatment: Methadone Maintenance vs. Drug Free
The number and type of services offered at substance abuse treatment (SAT) facilities are important aspects of the quality of care. Managed care (MC) is a growing presence in SAT and has been shown to affect the provision of treatment. We expand on earlier work and examine the impact of managed care on the number and type of services offered by methadone maintenance (MM) and drug-free (DF) outpatient treatment facilities. We use the econometric technique of instrumental variables to address the issue of endogeneity of MC and service offerings, thereby allowing a causal interpretation of results. Using data from the 2000 National Survey of Substance Abuse Treatment Services, we find that MC significantly increases the total number of services offered in MM outpatient facilities by four, yet decreases the number by two in DF outpatient facilities. We also show how the impact on specific services differs by modality and provide explanations for our findings.
Sindelar, Jody L.; Olmstead, Todd A.
Uncovering Treatment Burden as a Key Concept for Stroke Care: A Systematic Review of Qualitative Research
Background Patients with chronic disease may experience complicated management plans requiring significant personal investment. This has been termed �treatment burden� and has been associated with unfavourable outcomes. The aim of this systematic review is to examine the qualitative literature on treatment burden in stroke from the patient perspective. Methods and Findings The search strategy centred on: stroke, treatment burden, patient experience, and qualitative methods. We searched: Scopus, CINAHL, Embase, Medline, and PsycINFO. We tracked references, footnotes, and citations. Restrictions included: English language, date of publication January 2000 until February 2013. Two reviewers independently carried out the following: paper screening, data extraction, and data analysis. Data were analysed using framework synthesis, as informed by Normalization Process Theory. Sixty-nine papers were included. Treatment burden includes: (1) making sense of stroke management and planning care, (2) interacting with others, (3) enacting management strategies, and (4) reflecting on management. Health care is fragmented, with poor communication between patient and health care providers. Patients report inadequate information provision. Inpatient care is unsatisfactory, with a perceived lack of empathy from professionals and a shortage of stimulating activities on the ward. Discharge services are poorly coordinated, and accessing health and social care in the community is difficult. The study has potential limitations because it was restricted to studies published in English only and data from low-income countries were scarce. Conclusions Stroke management is extremely demanding for patients, and treatment burden is influenced by micro and macro organisation of health services. Knowledge deficits mean patients are ill equipped to organise their care and develop coping strategies, making adherence less likely. There is a need to transform the approach to care provision so that services are configured to prioritise patient needs rather than those of health care systems. Systematic Review Registration International Prospective Register of Systematic Reviews CRD42011001123 Please see later in the article for the Editors' Summary
Gallacher, Katie; Morrison, Deborah; Jani, Bhautesh; Macdonald, Sara; May, Carl R.; Montori, Victor M.; Erwin, Patricia J.; Batty, G. David; Eton, David T.; Langhorne, Peter; Mair, Frances S.
Stepping Down and Stepping In: Youth's Perspectives on Making the Transition from Residential Treatment to Treatment Foster Care
Older youth preparing to emancipate from the foster care system are often served in residential treatment settings where they have limited opportunities to practice skills for independent living in a community setting. Stepping these youth down to less restrictive environments such as treatment foster care is a growing trend, especially for youth with mental health issues. Yet, few studies have explored the youth�s perspective on making this transition. This study utilized qualitative interviews with youths who were participating in a treatment foster care intervention study (n=8) to gain their perspectives on the process of transitioning from residential care. Youths were interviewed right before they exited residential care and two months after placement in the new foster home. Youths reported hopes for gaining family in the new home as well as fears of placement disruption. Findings point to the need to enlist youths in discussion and problem solving about difficulties they anticipate in the new home and expectations for their relationship with the new foster parents. In addition, the struggles described after two months in the home point to the need for youths to build specific skills to better manage ongoing relationships with foster parents and for foster parent training on how to help build these skills.
Narendorf, Sarah Carter; Fedoravicius, Nicole; McMillen, J. Curtis; McNelly, David; Robinson, Debra R.
Antiretroviral HIV treatment and care for injecting drug users: an evidence-based overview
AIDS-related mortality and the rate of progression to AIDS have dramatically decreased since the advent of highly-active antiretroviral treatment (HAART). The overall benefit from antiretroviral HIV treatment has, however, been lesser in HIV-infected IDUs than in other patient groups (e.g. men who have sex with men). Poorer outcomes in HIV-infected IDUs are related to a variety of factors, including increased rates of non-HIV related deaths, hepatitis C, delayed access to effective treatment, lower adherence to care and treatment regimens, continuation of illicit drug use, depression and negative life events. The available evidence strongly suggests the need for the large-scale implementation of comprehensive treatment and care strategies for IDUs that include both treatment of drug-dependence and HAART.
Lert, France; Kazatchkine, Michel D.
Prediction of treatment outcomes: lifetime depression versus the continuum of care.
We sought to determine the impact of a lifetime diagnosis of major depression on addiction treatment outcome. Structured interviews were conducted upon admission, and consecutive structured interviews were conducted prospectively for treatment outcome at 6 and 12 month follow-up periods. A multisite evaluation study of patients undergoing addiction treatment for alcohol and drug dependence was conducted in private outpatient facilities. Two thousand twenty-nine subjects from 33 independent programs were enrolled in a national registry for addiction treatment outcomes. The patients received abstinence-based addiction treatment with referral to a 12-step recovery program, often Alcoholics Anonymous, and continuing care in the treatment programs. The outcome areas measured were treatment completion, posttreatment substance use, exposure to psychosocial relapse risk factors, involvement with continuing care (formal aftercare and peer support groups), and posttreatment vocational functioning, health care utilization, and legal involvement. The prevalence rate of depressive symptoms over at least a 2-week period (major depression) in our sample was 28%. Multivariate analysis with stepwise multiple regression indicated that the most powerful predictors (relatively) of posttreatment alcohol/drug use were peer support group attendance and program continuing care involvement. Lifetime depression by itself and in interaction with each of these factors accounted for less than 2% of the variance in outcome. Logistic regression yielded similar results in the prediction of abstinence versus relapse. Posttreatment more than pretreatment factors appear to be more decisive in predicting risk for relapse. PMID:10506905
Miller, N S; Ninonuevo, F; Hoffmann, N G; Astrachan, B M
One-year treatment costs of trauma care in the USA.
Although injuries are a leading cause of morbidity and mortality in the USA, few prior studies exist on the costs of trauma care. This article estimates treatment costs of care for 12 months following injury. Primary and secondary data were collected on over 5000 moderate-to-severely injured patients 18-84 years of age discharged from 69 US hospitals. Acute and post-acute costs of care were estimated from a combination of data sources: UB92 hospital bills, patient surveys, medical record abstracts, and where available, Medicare claims. Key analysis variables were demographic characteristics, insurance status and nature and severity of injury. Mean 1-year cost per patient of trauma care in our population was $75,210. On average, 58% of cost was accounted for by the index hospitalization. Total 1-year treatment cost of adult major trauma in the USA was conservatively estimated to be US$27 billion annually (2005). PMID:20384565
Weir, Sharada; Salkever, David S; Rivara, Frederick P; Jurkovich, Gregory J; Nathens, Avery B; Mackenzie, Ellen J
Impact of HIV on clinical presentation and outcomes of tuberculosis treatment at primary care level.
Little is known on how human immunodeficiency virus (HIV) infection impacts pediatric tuberculosis (TB) in primary care. We compared TB type, HIV care and case fatality rates between 5685 adults and 830 children with TB treated at primary care clinics in Kinshasa, Democratic Republic of Congo. Children represented a substantial burden (13%) of TB, and presented predominantly with difficult to diagnose smear-negative TB and extra-pulmonary TB. The HIV co-infection rate was lower in children than in adults, and fewer children than adults received antiretroviral therapy during anti-tuberculosis treatment. Case fatality was four times higher in HIV-infected than non-infected children. Child-friendly point-of-care TB diagnostics and decentralized pediatric TB-HIV care should receive greater attention. PMID:24125443
Henegar, C; Behets, F; Vanden Driessche, K; Tabala, M; Van Rie, A
Improving the prevention, early recognition, and treatment of pediatric obesity by primary care physicians.
To determine if participation in a learning collaborative (LC) would improve care processes for prevention, early recognition, and treatment of childhood obesity by primary care physicians (PCP), the authors conducted pre-post evaluations of the use of obesity related care processes by 18 primary care practices following participation in a 9-month LC based on the Model for Improvement. Prior to the LC, chart audits revealed that 55% of patients had a BMI recorded; this rose to 97% of patients at its conclusion. Following the LC, 11 practices had implemented systematic prevention advice to parents of infants compared with 3 prior to the LC. All practices developed plans for evaluation and management of children with an elevated BMI. Participation in an LC increased the number of primary care practices that provided anticipatory guidance regarding obesity prevention and that identified and treated overweight or obese children. PMID:20837628
Young, Paul C; DeBry, Sandra; Jackson, W Daniel; Metos, Julie; Joy, Elizabeth; Templeman, Mark; Norlin, Chuck
The Effect of Integrating Substance Abuse Treatment With Prenatal Care on Birth Outcome
OBJECTIVE:To determine whether engaging pregnant substance abusers in an integrated program of prenatal care and substance abuse treatment would improve neonatal outcomes.STUDY DESIGN:The subjects were women who voluntarily enrolled in Project Link, an intensive outpatient substance abuse treatment program at Women and Infants Hospital, Providence, RI. A total of 87 women received substance abuse treatment in conjunction with their prenatal
Patrick J Sweeney; Rachel M Schwartz; Noreen G Mattis; Betty Vohr
Treatment of juvenile idiopathic arthritis: a revolution in care.
A generation ago, children with arthritis faced a lifetime of pain and disability. Today, there are a multitude of treatment options, including a variety of biologics targeting key cytokines and other inflammatory mediators. While non-steroidal anti-inflammatory drugs and corticosteroids were once the mainstay of therapy, they are now largely used as bridge or adjunctive therapies. Among the conventional disease-modifying anti-rheumatic drugs, methotrexate remains first-line therapy for most children with juvenile idiopathic arthritis (JIA) due to its long track record of safety and effectiveness in the management of peripheral arthritis. Sulfasalazine and leflunomide may also have a secondary role. The tumor necrosis factor inhibitors (TNFi) have shown tremendous benefit in children with polyarticular JIA and likely in enthesitis-related arthritis and psoriatic JIA as well. There may be additional benefit in combining TNFi with methotrexate. Abatacept and tocilizumab also appear to benefit polyarticular JIA; the role of rituximab remains unclear. For the treatment of systemic JIA, while the TNFi are of less benefit, blockade of interleukin-1 or interleukin-6 is highly effective. Additionally, interleukin-1 blockade appears to be effective treatment of macrophage activation syndrome, one of the most dangerous complications of JIA; specifically, anakinra in combination with cyclosporine and corticosteroids may obviate the need for cytotoxic approaches. In contrast, methotrexate along with the TNFi and abatacept are effective agents for the management of uveitis, another complication of JIA. Overall, the biologics have demonstrated an impressive safety record in children with JIA, although children do need to be monitored for rare but potentially dangerous adverse events, such as tuberculosis and other infections; paradoxical development of additional autoimmune diseases; and possibly an increased risk of malignancy. Finally, there may be a window of opportunity during which children with JIA will demonstrate most optimal responses to aggressive therapy, underscoring the need for rapid diagnosis and initiation of treatment. PMID:24782683
Stoll, Matthew L; Cron, Randy Q
Treatment of juvenile idiopathic arthritis: a revolution in care
A generation ago, children with arthritis faced a lifetime of pain and disability. Today, there are a multitude of treatment options, including a variety of biologics targeting key cytokines and other inflammatory mediators. While non-steroidal anti-inflammatory drugs and corticosteroids were once the mainstay of therapy, they are now largely used as bridge or adjunctive therapies. Among the conventional disease-modifying anti-rheumatic drugs, methotrexate remains first-line therapy for most children with juvenile idiopathic arthritis (JIA) due to its long track record of safety and effectiveness in the management of peripheral arthritis. Sulfasalazine and leflunomide may also have a secondary role. The tumor necrosis factor inhibitors (TNFi) have shown tremendous benefit in children with polyarticular JIA and likely in enthesitis-related arthritis and psoriatic JIA as well. There may be additional benefit in combining TNFi with methotrexate. Abatacept and tocilizumab also appear to benefit polyarticular JIA; the role of rituximab remains unclear. For the treatment of systemic JIA, while the TNFi are of less benefit, blockade of interleukin-1 or interleukin-6 is highly effective. Additionally, interleukin-1 blockade appears to be effective treatment of macrophage activation syndrome, one of the most dangerous complications of JIA; specifically, anakinra in combination with cyclosporine and corticosteroids may obviate the need for cytotoxic approaches. In contrast, methotrexate along with the TNFi and abatacept are effective agents for the management of uveitis, another complication of JIA. Overall, the biologics have demonstrated an impressive safety record in children with JIA, although children do need to be monitored for rare but potentially dangerous adverse events, such as tuberculosis and other infections; paradoxical development of additional autoimmune diseases; and possibly an increased risk of malignancy. Finally, there may be a window of opportunity during which children with JIA will demonstrate most optimal responses to aggressive therapy, underscoring the need for rapid diagnosis and initiation of treatment.
Sublingual Buprenorphine/Naloxone for Chronic Pain in At-Risk Patients: Development and Pilot Test of a Clinical Protocol
Objective Sublingual buprenorphine/naloxone (Bup/Nx) is approved for addiction treatment and may be useful for pain management, particularly in opioid-treated pain patients with nonadherence behaviors. The transition of opioid-treated pain patients to buprenorphine carries the risk of precipitated withdrawal and increased pain. This study convened pain and addiction specialists to develop and pilot a clinical protocol for safe transitioning to Bup/Nx. Design The protocol was revised three times based on outside expert review and pilot study observations. The pilot was conducted with a prospective cohort of 12 patients with moderate to severe chronic pain, who were receiving long-term opioid therapy with any full ?-agonist drug, and had exhibited one or more aberrant drug-related behaviors. Patients were followed up for 3 to 6 months with the expectation that they would experience few adverse events and report lower pain severity. Results The three patients on the highest baseline opioid dose (equivalent to 303�450 mg of oral morphine) and the three on the lowest doses (?20 mg) had early adverse events (AEs) when switched to Bup/Nx and did not complete the trial. Of the remaining six, one withdrew due to AEs; one responded well, then withdrew; and four completed a three-month trial. A mixed effects model controlling for dropouts found that average and worst pain significantly decreased after the switch to Bup/Nx (both p < .01). Conclusion Based on this experience, the protocol recommends Bup/Nx for pain only when baseline opioid doses are within bounds that reduce AEs at transition and incorporates dose flexibility to further reduce risks. This protocol warrants further testing.
Rosenblum, Andrew; Cruciani, Ricardo A.; Strain, Eric C; Cleland, Charles M.; Joseph, Herman; Magura, Stephen; Marsch, Lisa A; McNicholas, Laura F; Savage, Seddon R; Sundaram, Arun; Portenoy, Russell K.
Development of sensitization to methamphetamine in offspring prenatally exposed to morphine, methadone and buprenorphine.
Heroin use among young women of reproductive age has drawn much attention around the world. However, there is lack of information on the long-term effects of prenatal exposure to opioids on their offspring. Our previous study demonstrated that prenatally buprenorphine-exposed offspring showed a marked change in the cross-tolerance to morphine compared with other groups. In the current study, this animal model was used to study effects of methamphetamine (METH)-induced behavioral sensitization in the offspring at their adulthood. The results showed no differences in either basal or acute METH-induced locomotor activity in any of the groups of animals tested. When male offspring received METH injections of 2?mg/kg, i.p., once a day for 5?days, behavioral sensitization was induced, as determined by motor activity. Furthermore, the distance and rate of development (slope) of locomotor activity and conditioned place preference induced by METH were significantly increased in the prenatally buprenorphine-exposed animals compared with those in other groups. The dopamine D1 R in the nucleus accumbens of the prenatally buprenorphine-exposed offspring had lower mRNA expression; but no significant changes in the ?-, ?-opioid, nociceptin, D2 R and D3 R receptors were noted. Furthermore, significant alterations were observed in the basal level of cAMP and the D1 R agonist enhanced adenylyl cyclase activity in the prenatally buprenorphine-exposed group. Overall, the study demonstrates that D1 R and its downregulated cAMP signals are involved in enhancing METH-induced behavioral sensitization in prenatally buprenorphine-exposed offspring. The study reveals that prenatal exposure to buprenorphine caused long-term effects on offspring and affected the dopaminergic system-related reward mechanism. PMID:23551991
Chiang, Yao-Chang; Hung, Tsai-Wei; Ho, Ing-Kang
Taking away the fear: a grounded theory study of cooperative care in the treatment of head and neck cancer.
Cooperative care is a relatively new treatment model that seeks to improve quality, conserve resources, and manage chronic conditions by providing patient and carepartner education in a homelike setting. Support from health care professionals is immediately available as patients and carepartners learn the skills needed to manage a disease and its treatment. This study sought to describe the effect of cooperative care on the treatment of head and neck cancer. Grounded theory methodology and focused interviews of 21 participants were used to answer three research questions: (1) Do the patients, carepartners, and providers involved in cooperative care perceive the potential psychosocial and self-care benefits? (2) How does the cooperative care treatment model affect the achievement of self-care for patients with surgical treatment of head and neck cancer? (3) What are appropriate theories regarding the benefits of cooperative care in the treatment of head and neck cancer that can be tested with quantitative methods? Results indicate that providers perceived cooperative care as a time-consuming process that resulted in less anxious, more communicative patients who required fewer post-discharge resources. Patients and carepartners perceived cooperative care as an experience that took away their fear by providing self-care education within a caring community. PMID:12833560
McLane, Lani; Jones, Katherine; Lydiatt, William; Lydiatt, Daniel; Richards, Alan
Buprederm�, a New Transdermal Delivery System of Buprenorphine: Pharmacokinetic, Efficacy and Skin Irritancy Studies
Purpose��The pharmacokinetics, analgesic efficacy, and irritancy potential of Buprederm�, a new transdermal delivery system of buprenorphine,\\u000a was evaluated.\\u000a \\u000a \\u000a \\u000a Methods��Single and multiple dose pharmacokinetic studies were conducted in mice and rabbits. The analgesic efficacy and skin irritation\\u000a potential were determined by tail flick and writhing tests in mice and by the Draize dermal scoring system in rabbits.\\u000a \\u000a \\u000a \\u000a Results��Fast absorption of buprenorphine
Dongwon Kim; Jindeog Song; Chang Hoon In; Seung-Wei Jeong; Sang Hun Lee; Bumchan Min; Dongho Lee; Sun-Ok Kim
Oral and dental care and treatment protocols for the management of HIV-infected patients.
This paper describes the workings of the workshop dedicated to oral and dental care and treatment protocols for the management of HIV-infected patients. The questions addressed were: 1) What are the current ethical issues in dental care of HIV patients, do they need to be addressed? 2) Do we need to modify the dental care we give HIV-positive patients? 3) When is it necessary to give antibiotic prophylaxis to HIV-positive patients? 4) What is the evidence for the effective treatment of oral lesions associated with HIV? 5) What is the most successful palliative treatment for KS? 6) Can we provide clinical treatment that has a scientific basis rather being trial based? 7) Is ddI + hydroxy-urea an effective African alternative to HAART? 8) What is the influence of protease inhibitors and HAART on the excretion of HIV in saliva? 9) What is the effect of anti-HIV therapy on the oral mucosa and oral health? This workshop did not fully cover the issue of ddI and hydroxy-urea as an alternative HIV therapy as this was considered to be the remit of general physicians caring for patients with HIV and AIDS rather than that of oral health care workers. PMID:12164647
Shirlaw, P J; Chikte, U; MacPhail, L; Schmidt-Westhausen, A; Croser, D; Reichart, P
Disclosure of sexual abuse among youth in residential treatment care: a multiple informant comparison.
This exploratory study describes the child sexual abuse experiences of 53 youth (ages 14-17) in child protective services residential treatment care using three informants: youth (via the Childhood Trauma Questionnaire), residential treatment workers (via the Child Welfare Trauma Referral Tool), and the child protective services record. Child sexual abuse was self-reported by 38% of youth, with reporting by females almost four times higher. Child sexual abuse co-occurred with physical abuse, emotional abuse, and neglect in 75% of cases. Agreement between youth and residential treatment worker reports was high, while agreement between youth reports and their child protective services record was low. The study suggests systematic child sexual abuse screening among residential treatment care youth through self-reports and residential treatment worker reports. Case studies are provided, and implications for practice, policy, and future research are discussed. PMID:24640965
Milne, Lise; Collin-V�zina, Delphine
A primary care approach to substance misuse.
Substance misuse is common among patients in primary care settings. Although it has a substantial health impact, physicians report low levels of preparedness to identify and assist patients with substance use disorders. An effective approach to office-based treatment includes a coherent framework for identifying and managing substance use disorders and specific strategies to promote behavior change. Brief validated screening tools allow rapid and efficient identification of problematic drug use, including prescription medication misuse. After a positive screening, a brief assessment should be performed to stratify patients into three categories: hazardous use, substance abuse, or substance dependence. Patients with hazardous use benefit from brief counseling by a physician. For patients with substance abuse, brief counseling is also indicated, with the addition of more intensive ongoing follow-up and reevaluation. In patients with substance dependence, best practices include a combination of counseling, referral to specialty treatment, and pharmacotherapy (e.g., drug tapering, naltrexone, buprenorphine, methadone). Comorbid mental illness and intimate partner violence are common in patients with substance use disorders. The use of a motivational rather than a confrontational communication style during screening, counseling, and treatment is important to improve patient outcomes. PMID:23939642
Shapiro, Brad; Coffa, Diana; McCance-Katz, Elinore F
Achievement of guideline-defined treatment goals in primary care: the German Coronary Risk Management (CoRiMa) study
Aims The success in achieving treatment goals for cardiovascular risk factors in primary care is largely unknown. Therefore, the goals of this study were (i) to assess whether routinely collected practice data can be used to evaluate treatment in primary care, (ii) to compare current treatment with goals of published guidelines, and (iii) to calculate future risk for cardiovascular events
Johann Christoph Geller; Sven Cassens; Mathias Brosz; Ulrich Keil; Johannes Bernarding; Siegfried Kropf; Ralph A. Bierwirth; Bernhard Lippmann-Grob; Heinz-Peter Schultheiss; Klaus Schluter; Klaus Pels
A Randomized Trial Using Computerized Decision Support to Improve Treatment of Major Depression in Primary Care
OBJECTIVE To examine whether feedback and treatment advice for depression presented to primary care physicians (PCPs) via an electronic medical record (EMR) system can potentially improve clinical outcomes and care processes for patients with major depression. DESIGN Randomized controlled trial. SETTING Academically affiliated primary care practice in Pittsburgh, PA. PATIENTS Two hundred primary care patients with major depression on the Primary Care Evaluation of Mental Disorders (PRIME-MD) and who met all protocol-eligibility criteria. INTERVENTION PCPs were randomly assigned to 1 of 3 levels of exposure to EMR feedback of guideline-based treatment advice for depression: �active care� (AC), �passive care� (PC), or �usual care� (UC). MEASUREMENTS AND MAIN RESULTS Patients' 3- and 6-month Hamilton Rating Scale for Depression (HRS-D) score and chart review of PCP reports of depression care in the 6 months following the depression diagnosis. Only 22% of patients recovered from their depressive episode at 6 months (HRS-D ?7). Patients' mean HRS-D score decreased regardless of their PCPs' guideline-exposure condition (20.4 to 14.2 from baseline to 6-month follow-up; P < .001). However, neither continuous (HRS-D ?7: 22% AC, 23% PC, 22% UC; P = .8) nor categorical measures of recovery (P = .2) differed by EMR exposure condition upon follow-up. Care processes for depression were also similar by PCP assignment despite exposure to repeated reminders of the depression diagnosis and treatment advice (e.g., depression mentioned in ?3 contacts with usual PCP at 6 months: 31% AC, 31% PC, 18% UC; P = .09 and antidepressant medication suggested/prescribed or baseline regimen modified at 6 months: 59% AC, 57% PC, 52% UC; P = .3). CONCLUSIONS Screening for major depression, electronically informing PCPs of the diagnosis, and then exposing them to evidence-based treatment recommendations for depression via EMR has little differential impact on patients' 3- or 6-month clinical outcomes or on process measures consistent with high-quality depression care.
Rollman, Bruce L; Hanusa, Barbara H; Lowe, Henry J; Gilbert, Trae; Kapoor, Wishwa N; Schulberg, Herbert C
System, apparatuses and methods to increase supply of specialty care surgical-medical treatments
US Patent & Trademark Office Database
System, apparatuses and methods for treating specialty care surgical-medical patients (10) who are medically-stable. A specialty care surgical-medical hospital-clinic (40) is sited on a quasi-sovereign geographic area, including federally-recognized American Indian/Alaskan Native tribal nations. Surgical-medical treatments by provider group (42) who are citizens of countries worldwide. Transportation (30) of patients to hospital-clinic (40) by non-emergency vehicles. Treatment of patients (10) maximized via surgical-medical expertise from other hospital-clinics (60) provided via information technology systems (50) connected by global wide-area network linkages (62).
Increasing Hepatitis C treatment uptake among HIV-infected patients using an HIV primary care model
Background Access to Hepatitis C (HCV) care is low among HIV-infected individuals, highlighting the need for new models to deliver care for this population. Methods Retrospective cohort analysis that compared the number of HIV patients who initiated HCV therapy: hepatology (2005�2008) vs. HIV primary care model (2008�2011). Logistic-regression modeling was used to ascertain factors associated with HCV therapy initiation and achievement of sustained viral response (SVR). Results Of 196 and 163 patients that were enrolled in the HIV primary care and hepatology models, 48 and 26 were treated for HCV, respectively (p?=?0.043). The HIV/HCV-patient referral rate did not differ during the two study periods (0.10 vs. 0.12/patient-yr, p?=?0.18). In unadjusted analysis, predictors (p?0.05) of HCV treatment initiation included referral to the HIV primary care model (OR: 1.7), a CD4+ count ?400/mm3 (OR: 1.8) and alanine aminotranferase level ?63U/L (OR: 1.9). Prior psychiatric medication use correlated negatively with HCV treatment initiation (OR: 0.6, p?=?0.045). In adjusted analysis the strongest predictor of HCV treatment initiation was CD4+ count (?400/mm3, OR: 2.1, p?=?0.01). There was no significant difference in either clinic model (primary care vs. hepatology) in the rates of treatment discontinuation due to adverse events (29% vs. 16%), loss to follow-up (8 vs. 8%), or HCV SVR (44 vs. 35%). Conclusions Using a HIV primary care model increased the number of HIV patients who initiate HCV therapy with comparable outcomes to a hepatology model.
Ertapenem versus cefepime for initial empirical treatment of pneumonia acquired in skilled-care facilities or in hospitals outside the intensive care unit
The study presented here compared the efficacy and safety of ertapenem and cefepime as initial treatment for adults with pneumonia acquired in skilled-care facilities or in hospital environments outside the intensive care unit (ICU). Non-ventilated patients developing pneumonia in hospital environments outside the ICU, in nursing homes, or in other skilled-care facilities were enrolled in this double-blind non-inferiority study, stratified
S. V. Yakovlev; L. S. Stratchounski; G. L. Woods; B. Adeyi; K. A. McCarroll; J. A. Ginanni; I. R. Friedland; C. A. Wood; M. J. DiNubile
Determinants of engagement in HIV treatment and care among Zambians new to antiretroviral therapy.
This pilot study assessed the determinants of engagement in HIV care among Zambian patients new to antiretroviral (ARV) therapy, and the effect of an intervention to increase medication adherence. Participants (n = 160) were randomized to a 3-month group or individual intervention utilizing a crossover design. Psychophysiological (depression, cognitive functioning, health status), social (social support, disclosure, stigma), structural factors (health care access, patient-provider communication), and treatment engagement (adherence to clinic visits and medication) were assessed. Participants initially receiving the group intervention improved their adherence, but gains were not maintained following crossover to the individual intervention. Increased social support and patient-provider communication and decreased concern about HIV medications predicted increased clinic attendance across both arms. Results suggest that early participation in a group intervention may promote increased adherence among patients new to ARV therapy, but long-term engagement in care may be sustained by both one-on-one and group interventions by health care staff. PMID:23009738
Jones, Deborah L; Zulu, Isaac; Vamos, Szonja; Cook, Ryan; Chitalu, Ndashi; Weiss, Stephen M
When depression complicates childbearing: guidelines for screening and treatment during antenatal and postpartum obstetric care.
Prevalence studies show that 1 in 5 women experience an episode of major depressive disorder during their lifetime. The peripartum period is a prime time for symptom exacerbation and relapse of depressive episodes. Health care providers, specifically those in obstetric care, should be aware of: (1) the frequency of depression in pregnant and postpartum women; (2) signs, symptoms, and appropriate screening methods; and (3) the health risks for the mother and growing fetus if depression is undetected or untreated. Because management of depressed peripartum women also includes care of a growing fetus or breastfeeding infant, treatment may be complex and requires input from a multidisciplinary team, including an obstetrician, psychiatrist, and pediatrician, to provide optimal care. PMID:19944300
Muzik, Maria; Marcus, Sheila M; Heringhausen, Julie E; Flynn, Heather
Assessing quality of nursing care as a confounding variable in an outcome study on neurodevelopmental treatment.
When planning a study measuring the effects of a neurodevelopmental treatment (NDT), we were confronted with the methodological problem that while measuring the effects of NDT, a rival hypothesis is that the decision to implement the NDT might be related to the quality of nursing care. Therefore, we measured the quality of nursing care as a possible confounding variable in relation to this outcome study. The quality of nursing care was measured on 12 wards participating in the experimental and control groups of the outcome study. Data were collected from 125 patients and 71 nurses and patients' records. The findings showed no significant differences in the quality of nursing care between the 2 groups of wards (P = .49). This method may be useful to other researchers conducting outcome research and who are confronted with a similar methodological problem. PMID:17873736
Hafsteinsd�ttir, Th�ra B; Kruitwagen, Cas; Strijker, Karin; van der Weide, Lies; Grypdonck, Maria H F
A Primary Care Focus on the Treatment of Patients With Major Depressive Disorder
Major depressive disorder (MDD) is a common psychiatric illness affecting nearly 20% of adults in the United States at least once during their lifetime. MDD is frequently diagnosed and treated in the primary care setting. Management of the disease may be complicated by patients and family members feeling stigmatized by the diagnosis and not understanding that depression is a treatable medical illness, which, in turn, fosters low rates of adherence to medication schedules. Incomplete or delayed response to treatment, adverse events associated with antidepressants, and medical or psychiatric comorbidities also interfere with optimal depression management. This paper presents an overview of diagnostic and treatment guidelines for MDD and focuses on challenges encountered by primary care physicians. The role of antidepressant medications, psychotherapy, and nonpharmacologic interventions for the treatment of patients with MDD is described, and factors influencing treatment selection, such as adverse event profiles and patient characteristics are examined.
Weihs, Karen; Wert, Jonathan M
A meta-analysis of the efficacy of fibromyalgia treatment according to level of care
Introduction The aim of this paper was to compare the efficacy of the treatments for fibromyalgia currently available in both primary care and specialised settings. Methods Published reports of randomised controlled trials (RCTs) researching pharmacological and non-pharmacological treatments in patients with fibromyalgia were found in the MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and PsychInfo databases. The most recent electronic search was undertaken in June 2006. Results We identified a total of 594 articles. Based on titles and abstracts, 102 full articles were retrieved, 33 of which met the inclusion criteria. These RCTs assessed 120 treatment interventions in 7789 patients diagnosed with primary fibromyalgia. Of them, 4505 (57.8%) were included in the primary care group of our study and 3284 (42.2%) in the specialised intervention group. The sample was mostly made up of middle-aged women, who have had fibromyalgia for a mean period of 6 to 10 years. The mean effect size of the efficacy of the 120 treatment interventions in patients with fibromyalgia compared with controls was 0.49 (95% confidence interval [CI] = 0.39 to 0.58; p < 0.001). In the primary care group it was 0.46 (95% CI = 0.33 to 0.58) while in specialised care it was 0.53 (95% CI = 0.38 to 0.69), with no statistical significance in the differences. We analysed the efficacy of treatments by comparing primary and specialised care in the different fibromyalgia groups and there were no significant differences. The variables of the studies that affected the improvements in the efficacy of fibromyalgia treatment were low quality of the studies and a shorter duration of treatment. However, both factors were biased by the heterogeneity of the studies. Other variables that also improved outcome and were not biased by the heterogeneity of the studies, were younger age of the patients and shorter duration of the disorder. On the contrary, gender and type of treatment (pharmacological vs. psychological) did not affect outcome. Conclusion Based on this meta-analysis and despite the heterogeneity of specialised care studies and of the other limitations described in this article, treating fibromyalgia in specialised care offers no clear advantages.
Garcia-Campayo, Javier; Magdalena, Jesus; Magallon, Rosa; Fernandez-Garcia, Esther; Salas, Montserrat; Andres, Eva
The Associations between Structural Treatment Characteristics and Post-Treatment Functioning in Compulsory Residential Youth Care
ERIC Educational Resources Information Center
Background: In 2005 a new compulsory residential treatment program was developed for adolescents in need for protection against themselves or their environment. Objective: The aim of the present study was to examine the association of structural treatment characteristics of this new residential treatment program (i.e., duration of treatment,�
Nijhof, Karin S.; Vermulst, Ad A.; Veerman, Jan W.; van Dam, Coleta; Engels, Rutger C. M. E.; Scholte, Ron H. J.
A new interdisciplinary treatment strategy versus usual medical care for the treatment of subacromial impingement syndrome: a randomized controlled trial
Background Subacromial impingement syndrome (SIS) is the most frequently recorded shoulder disorder. When conservative treatment of SIS fails, a subacromial decompression is warranted. However, the best moment of referral for surgery is not well defined. Both early and late referrals have disadvantages � unnecessary operations and smaller improvements in shoulder function, respectively. This paper describes the design of a new interdisciplinary treatment strategy for SIS (TRANSIT), which comprises rules to treat SIS in primary care and a well-defined moment of referral for surgery. Methods/Design The effectiveness of an arthroscopic subacromial decompression versus usual medical care will be evaluated in a randomized controlled trial (RCT). Patients are eligible for inclusion when experiencing a recurrence of SIS within one year after a first episode of SIS which was successfully treated with a subacromial corticosteroid injection. After inclusion they will receive injection treatment again by their general practitioner. When, after this treatment, there is a second recurrence within a year post-injection, the participants will be randomized to either an arthroscopic subacromial decompression (intervention group) or continuation of usual medical care (control group). The latter will be performed by a general practitioner according to the Dutch National Guidelines for Shoulder Problems. At inclusion, at randomization and three, six and 12 months post-randomization an outcome assessment will take place. The primary outcome measure is the patient-reported Shoulder Disability Questionnaire. The secondary outcome measures include both disease-specific and generic measures, and an economic evaluation. Treatment effects will be compared for all measurement points by using a GLM repeated measures analyses. Discussion The rationale and design of an RCT comparing arthroscopic subacromial decompression with usual medical care for subacromial impingement syndrome are presented. The results of this study will improve insight into the best moment of referral for surgery for SIS.
Dorrestijn, Oscar; Stevens, Martin; Diercks, Ron L; van der Meer, Klaas; Winters, Jan C
Dental case manager encounters: the association with retention in dental care and treatment plan completion.
Little is known about dental case managers as few programs have been scientifically evaluated. The goal of this study was to explore the impact of dental case manager on retention in dental care and completion of treatment plans, while specifically exploring the number of dental case manager encounters. Fourteen programs enrolled people with HIV/AIDS (PLWHA) in dental care and a longitudinal study between 2007 and 2009. The 758 participants had a total of 2715 encounters with a dental case manager over twelve months: 29% had a single encounter; 21% had two; 27% had 3-4 and; 23% had 5-29 encounters. Adjusting for baseline characteristics, participants receiving more encounters were significantly more likely to complete their Phase 1 treatment plan, be retained in dental care, and experience improvements in overall oral health status. Organizations considering efforts to improve the oral health of vulnerable, hard-to-engage populations should consider these findings when planning interventions. PMID:23451927
Lemay, Celeste A; Tobias, Carol; Umez-Eronini, Amarachi A; Brown, Carolyn; McCluskey, Amanda; Fox, Jane E; Bednarsh, Helene; Cabral, Howard J
Algorithms for the diagnosis and treatment of restless legs syndrome in primary care
Background Restless legs syndrome (RLS) is a neurological disorder with a lifetime prevalence of 3-10%. in European studies. However, the diagnosis of RLS in primary care remains low and mistreatment is common. Methods The current article reports on the considerations of RLS diagnosis and management that were made during a European Restless Legs Syndrome Study Group (EURLSSG)-sponsored task force consisting of experts and primary care practioners. The task force sought to develop a better understanding of barriers to diagnosis in primary care practice and overcome these barriers with diagnostic and treatment algorithms. Results The barriers to diagnosis identified by the task force include the presentation of symptoms, the language used to describe them, the actual term "restless legs syndrome" and difficulties in the differential diagnosis of RLS. Conclusion The EURLSSG task force reached a consensus and agreed on the diagnostic and treatment algorithms published here.
Patterns of Geographic Mobility Predict Barriers to Engagement in HIV Care and Antiretroviral Treatment Adherence.
Abstract Migration and geographic mobility increase risk for HIV infection and may influence engagement in HIV care and adherence to antiretroviral therapy. Our goal is to use the migration-linked communities of Santo Domingo, Dominican Republic, and New York City, New York, to determine the impact of geographic mobility on HIV care engagement and adherence to treatment. In-depth interviews were conducted with HIV+Dominicans receiving antiretroviral therapy, reporting travel or migration in the past 6 months and key informants (n=45). Mobility maps, visual representations of individual migration histories, including lifetime residence(s) and all trips over the past 2 years, were generated for all HIV+ Dominicans. Data from interviews and field observation were iteratively reviewed for themes. Mobility mapping revealed five distinct mobility patterns: travel for care, work-related travel, transnational travel (nuclear family at both sites), frequent long-stay travel, and vacation. Mobility patterns, including distance, duration, and complexity, varied by motivation for travel. There were two dominant barriers to care. First, a fear of HIV-related stigma at the destination led to delays seeking care and poor adherence. Second, longer trips led to treatment interruptions due to limited medication supply (30-day maximum dictated by programs or insurers). There was a notable discordance between what patients and providers perceived as mobility-induced barriers to care and the most common barriers found in the analysis. Interventions to improve HIV care for mobile populations should consider motivation for travel and address structural barriers to engagement in care and adherence. PMID:24839872
Taylor, Barbara S; Reyes, Emily; Levine, Elizabeth A; Khan, Shah Z; Gardu�o, L Sergio; Donastorg, Yeycy; Hammer, Scott M; Brudney, Karen; Hirsch, Jennifer S
Developing Treatment Plan Support in Outpatient Health Care Delivery with Decision Trees Technique
\\u000a This paper presents treatment plan support (TPS) development with the aim to support treatment decision making for physicians\\u000a during outpatient-care giving to patients. Evidence-based clinical data from system database was used. The TPS predictive\\u000a modeling was generated using decision trees technique, which incorporated predictor variables: patient�s age, gender, racial,\\u000a marital status, occupation, visit complaint, clinical diagnosis and final diagnosed diseases;
Shahriyah Nyak Saad Ali; Ahmad Mahir Razali; Azuraliza Abu Bakar; Nur Riza Suradi
Extended-release naltrexone for treatment of alcohol dependence in primary care
The feasibility of using extended-release injectable naltrexone (XR-NTX) to treat alcohol dependence in routine primary care settings is unknown. An open-label, observational cohort study evaluated 3-month treatment retention, patient satisfaction, and alcohol use among alcohol-dependent patients in two urban public hospital medical clinics. Adults seeking treatment were offered monthly medical management (MM) and three XR-NTX injections (380 mg, intramuscular). Physician-delivered
Joshua D. Lee; Ellie Grossman; Danae DiRocco; Andrea Truncali; Kathleen Hanley; David Stevens; John Rotrosen; Marc N. Gourevitch
Palliative care is treatment of the discomfort, symptoms, and stress of serious illness. It provides relief from distressing symptoms ... of the medical treatments you're receiving. Hospice care, care at the end of life, always includes ...
Aggressive Adolescents in Residential Care: A Selective Review of Treatment Requirements and Models
ERIC Educational Resources Information Center
This article presents a selective inventory of treatment methods of aggressive behavior. Special attention is paid to types of intervention that, according to research, are frequently used in Dutch residential youth care. These methods are based on (1) principles of (cognitive) behavior management and control, (2) the social competence model, and�
Knorth, Erik J.; Klomp, Martin; Van den Bergh, Peter M.; Noom, Marc J.
Patient-Centered Cancer Treatment Planning: Improving the Quality of Oncology Care. Workshop Summary
National Technical Information Service (NTIS)
Each year about 1.5 million people are diagnosed with cancer in the United States (ACS, 2010), and must then decide on a course of care. Cancer treatment often involves multiple options and specialties; it can be toxic, costly, intense, and protracted and...
E. Balogh M. Patlak S. J. Nass
A Systematic Review of Depression Treatments in Primary Care for Latino Adults
ERIC Educational Resources Information Center
Objective: A systematic literature review of randomized clinical trials (RCTs) assessing depression treatments in primary care for Latinos is conducted. The authors rate the methodological quality of studies, examine cultural and linguistic adaptations, summarize clinical outcomes and cost-effectiveness findings, and draw conclusions for improving�
Cabassa, Leopoldo J.; Hansen, Marissa C.
Compassion Fatigue Risk and Self-Care Practices among Residential Treatment Center Childcare Workers
ERIC Educational Resources Information Center
Exploration of the presence of risk for compassion fatigue among residential childcare workers (RCW) at residential treatment facilities and the relationship between self-care practices and compassion fatigue were explored. Using the Professional Quality of Life Survey (ProQOL-R III) to assess compassion fatigue, burnout, and compassion�
Eastwood, Callum D.; Ecklund, Kathryn
Assessing Relationship Quality in Mandated Community Treatment: Blending Care with Control
ERIC Educational Resources Information Center
Traditional measures of the therapeutic alliance do not capture the dual roles inherent in relationships with involuntary clients. Providers not only care for, but also have control over, involuntary clients. In 2 studies of probationers mandated to psychiatric treatment (n = 90; n = 322), the authors developed and validated the revised Dual-Role�
Skeem, Jennifer L.; Louden, Jennifer Eno; Polaschek, Devon; Camp, Jacqueline
Primary care: constipation and encopresis treatment strategies and reasons to refer.
The purpose of the study was to assess constipation and encopresis treatment strategies of primary care providers and determine reasons to refer to a pediatric gastroenterology specialist. A closed-ended questionnaire was mailed to a convenience sampling of 237 pediatric primary care providers. Ninety-one questionnaires were returned with a 38% response rate: 74 (81%) pediatricians and 17 (19%) nurse practitioners. The majority of responders recommended pharmacologic treatment and diet changes. Many providers (73%) estimated a 75%-100% success rate when managing constipation, whereas 19% providers estimated a greater than 80% success rate with encopresis patients. The number one reason to refer was unresponsiveness to treatment (71%), followed by parents want a second opinion (15%), rule out organic cause (9%), and management is too time-consuming (5%). Both primary care providers and pediatric gastroenterologists use medication strategies, but diet recommendations are not the same. Unresponsiveness to treatment is the main reason for referral. If better management can occur in the primary care setting, costly specialty services may be avoided and possibly reduce healthcare costs. PMID:20890159
Philichi, Lisa; Yuwono, Melawati
Staff Group Unanimity in the Care of Juveniles in Institutional Treatment: Routines, Rituals, and Relationships
ERIC Educational Resources Information Center
One prerequisite for effective institutional care is that staff agree on how to deliver treatment and have a unified view of how to achieve change--in other words, to have staff group unanimity (SGU). This study used the Correctional Program Assessment Inventory (CPAI) 2000, interviews with key staff, and observations of daily activities to�
Ahonen, Lia; Degner, Jurgen
Multidimensional Treatment Foster CareA Program for Intensive Parenting, Family Support, and Skill Building
The goals, objectives, and philosophy of Multidimensional Treatment Foster Care (MTFC) are outlined in this article. Three specific mechanisms of the MTFC approach known to reduce conflict in the therapeutic milieu and to contribute to successful outcomes for youth and their families are described: a proactive approach to reducing problem behavior, the creation and maintenance of a consistent and reinforcing
Philip A. Fisher; Patricia Chamberlain
Community Treatment Orders: Relationship to Clinical Care, Medication Compliance, Behavioural Disturbance and Readmission
Objective: The objective of this study was to investigate the readmission rate, and the level of patient disturbance and community care associated with readmission following Community Treatment Orders (CTOs) in New South Wales, Australia.Method: The readmission rates of all patients given CTOs within a 4-year period and a matched comparison group were investigated. The following factors were compared before, during
Kevin Vaughan; Neil McConaghy; Cherry Wolf; Craig Myhr; Terry Black
Community Treatment Orders: relationship to clinical care, medication compliance, behavioural disturbance and readmission
Objective: The objective of this study was to investigate the readmission rate, and the level of patient disturbance and community care associated with readmission following Community Treatment Orders (CTOs) in New South Wales, Australia. Method: The readmission rates of all patients given CTOs within a 4-year period and a matched comparison group were investigated. The following factors were com- pared
Kevin Vaughan; Neil McConaghy; Cherry Wolf; Craig Myhr; Terry Black
Behavioral treatment of insomnia: a proposal for a stepped-care approach to promote public health
Chronic insomnia is a highly prevalent condition that has psychological and medical consequences for those who suffer from it and financial consequences for both the individual and society. In spite of the fact that nonpharmacologic treatment methods have been developed and shown to be as or more effective than medication for chronic insomnia, these methods remain greatly underutilized due to an absence of properly trained therapists and a general failure in dissemination. A stepped-care model implemented in a primary-care setting offers a public health solution to the problem of treatment accessibility and delivery of behavioral treatments for insomnia. Such a model would provide graduated levels of cognitive behavioral intervention, with corresponding increases in intensity and cost, including self-help, manualized group treatment, brief individual treatment, and finally, individualized behavioral treatment provided by a specialist. To provide such a systematic approach, future research would need to confirm several aspects of the model, and a cadre of professionals would need to be trained to administer manualized care in both group and individualized formats.
Mack, Laurin J; Rybarczyk, Bruce D
The Influence of Structured Information and Monitoring on the Outcome of Asthma Treatment in Primary Care: A Cluster Randomized Study
Background: In clinical trials of asthma, the outcomes are often good, but when the same treatment regimens are implemented in primary care, equally good results are not obtained. Objective: To investigate if addition of structured patient information and monitoring by an asthma diary in primary care improves asthma control. Methods: 141 patients from 19 primary care centres were studied. The
Mika Nokela; Marianne Heibert Arnlind; Per-Olof Ehrs; Ingvar Krakau; Lennart Forslund; Eva Wikstr�m Jonsson
Perspectives of Quality Care in Cancer Treatment: A Review of the Literature
Background Approximately 1.7 million Americans are diagnosed with cancer annually. There is an increasing demand for high-quality cancer care; however, what constitutes quality care is not well defined. There remains a gap in our knowledge regarding the current perceptions of what defines quality care. Objective To review the current understanding and perspectives of key stakeholders regarding quality cancer care for adult patients with cancer who are receiving chemotherapy-based treatment regimens. Methods This systematic qualitative literature review involved a search of MEDLINE and PubMed databases for articles that were published between January 2009 and May 2013 using a predefined search strategy with specific Medical Subject Headings terms encompassing 3 core concepts�cancer, chemotherapy, and quality of healthcare. Articles were eligible to be included if they focused on adult cancers, discussed quality indicators of cancer care or quality of care in the article's body, discussed treating cancer with chemotherapy, were conducted in the United States and with US respondents, and reported data about cancer quality that were obtained directly from stakeholders (eg, patients, caregivers, providers, payers, other healthcare professionals). Thematic analyses were conducted to assess the perspectives and the intersection of quality care issues from each stakeholder group that was identified, including patients, providers, and thought leaders. Results The search strategy identified 542 articles that were reviewed for eligibility. Of these articles, 15 were eligible for inclusion in the study and reported perspectives from a total of 4934 participants. Patients with cancer, as well as providers, noted information needs, psychosocial support, responsibility for care, and coordination of care as important aspects of quality care. Providers also reported the importance of equity in cancer care and reimbursement concerns, whereas patients with cancer considered the timeliness of care an important factor. The perspectives of thought leaders focused on barriers to and facilitators of quality care. Conclusion Thematic elements related to cancer quality were relatively consistent between patients and providers; no additional information was found regarding payer perspectives. The perspectives of these groups are important to consider as quality initiatives are being developed.
Hess, Lisa M.; Pohl, Gerhardt
Treatment of Pancreatic and Periampullary Cancers at a Community Hospital: Successful Application of Tertiary Care Treatment Standards
Background. The treatment of pancreatic cancer and other periampullary neoplasms is complex and challenging. Major high-volume cancer centers can provide excellent multidisciplinary care of these patients but almost two-thirds of pancreatic cancer patients are treated at low volume centers. There is very little published data from low volume community cancer programs in regards to the treatment of periampullary cancer. In this study, a review of comprehensive periampullary cancer care at two low volume hospitals with comparison to national standards is presented. Methods. This is a retrospective review of 70 consecutive patients with periampullary neoplasms who underwent surgery over a 5-year period (2006�2010) at two community hospitals. Results. There were 51 successful resections of 70 explorations (73%) including 34 Whipple procedures. Mortality rate was 2.9%. Comparison of these patients to national standards was made in terms of operative mortality, resectability rate, administration of adjuvant therapy, clinical trial participation and overall survival. The results in these patients were comparable to national standards. Conclusions. With adequate commitment of resources and experienced surgical and oncologic practitioners, community cancer centers can meet national tertiary care standards in terms of pancreatic and periampullary cancer care.
Moesinger, Robert C.; Davis, Jan W.; Hill, Britani; Johnston, W. Cory; Gray, Carl; Johnson, Harold; Ingersoll, Leslye; Whipple, Gary; Reilly, Mark; Harris, Robert; Hansen, Vincent
Concomitant Use of Midazolam and Buprenorphine and its Implications Among Drug Users in Singapore
Introduction: The aim of this study was to determine the prevalence and characteristics of benzodiazepine (BZD) abuse among intravenous opioid users in Singapore. Materials and Methods: Eligibility criteria for inclusion in this study were all intravenous buprenorphine abusers, who presented to the Community Addictions Management Programme (CAMP) over a 1-year period from February 2005 to January 2006. One hundred and
Wei-Ling Ng; Subramaniam Mythily; Guo Song; Yiong-Huak Chan; Munidasa Winslow
Supportive care after curative treatment for breast cancer (survivorship care): resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement.
Breast cancer survivors may experience long-term treatment complications, must live with the risk of cancer recurrence, and often experience psychosocial complications that require supportive care services. In low- and middle-income settings, supportive care services are frequently limited, and program development for survivorship care and long-term follow-up has not been well addressed. As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert panel identified nine key resources recommended for appropriate survivorship care, and developed resource-stratified recommendations to illustrate how health systems can provide supportive care services for breast cancer survivors after curative treatment, using available resources. Key recommendations include health professional education that focuses on the management of physical and psychosocial long-term treatment complications. Patient education can help survivors transition from a provider-intense cancer treatment program to a post-treatment provider partnership and self-management program, and should include: education on recognizing disease recurrence or metastases; management of treatment-related sequelae, and psychosocial complications; and the importance of maintaining a healthy lifestyle. Increasing community awareness of survivorship issues was also identified as an important part of supportive care programs. Other recommendations include screening and management of psychosocial distress; management of long-term treatment-related complications including lymphedema, fatigue, insomnia, pain, and women's health issues; and monitoring survivors for recurrences or development of second primary malignancies. Where possible, breast cancer survivors should implement healthy lifestyle modifications, including physical activity, and maintain a healthy weight. Health professionals should provide well-documented patient care records that can follow a patient as they transition from active treatment to follow-up care. PMID:24007941
Ganz, Patricia A; Yip, Cheng Har; Gralow, Julie R; Distelhorst, Sandra R; Albain, Kathy S; Andersen, Barbara L; Bevilacqua, Jose Luiz B; de Azambuja, Evandro; El Saghir, Nagi S; Kaur, Ranjit; McTiernan, Anne; Partridge, Ann H; Rowland, Julia H; Singh-Carlson, Savitri; Vargo, Mary M; Thompson, Beti; Anderson, Benjamin O
Child Care in Outpatient Substance Abuse Treatment Facilities for Women: Findings from the 2008 National Survey of Substance Abuse Treatment Services
Mothers with substance use disorders who lack access to child care are often unable to enter or remain in substance abuse\\u000a treatment. This study examined the availability of child care in outpatient substance abuse treatment facilities and whether\\u000a or not certain facility characteristics were associated with the availability of child care. Using data from the 2008 National\\u000a Survey of Substance
Jonathan David Brown; Sonya Vartivarian; Cathie E. Alderks
Impact of advances in diabetes care on dental treatment of the diabetic patient.
In medicine and dentistry, studies are published periodically that have a potentially wide-ranging impact on patient health and management. One such study is the Diabetes Control and Complications Trial (DCCT), which offers new hope for millions of individuals with diabetes and has begun to significantly alter medical management of these patients. Advances in the medical treatment of diabetes require a heightened awareness by dental practitioners of the various treatment regimens of their patients with diabetes, especially because of potential complications associated with diabetes care. Intensive medical treatment with oral agents and exogenous insulin injection promises to decrease the long-term risks of major complications of diabetes, but these treatments increase the risk of medical emergencies, especially hypoglycemia. This article reviews the findings of the DCCT, diabetes treatment regimens that might be encountered in a dental practice, and potential alterations to dental treatment protocols. PMID:9533351
Mealey, B L
Relationships between stigma, depression, and treatment in white and African American primary care patients.
Although many depressed patients are treated in primary care, depression in these settings has been underdetected and undertreated, which may be influenced by mental health beliefs such as stigma. This study examined the relationships among depression, mental health stigma, and treatment in African American and white primary care patients. Data were collected at 3 primary care settings from 1103 patients who completed surveys measuring depression, stigma, and treatment use. Overall, African American patients reported greater mental health stigma than whites. African American women reported greater stigma than white women. White patients were found to be more likely to use depression treatment than African American patients. Multivariate analyses showed that greater depression severity fully mediated the relationship between stigma and treatment use, and that patients with the highest depression scores had significantly higher stigma scores as well. These results suggest that greater severity of depressive symptoms may override stigma and other beliefs about mental health in determining treatment use, but may be important to address for patients with more moderate levels of symptomatology. PMID:19525740
Menke, Rena; Flynn, Heather
Scaling up antiretroviral treatment and improving patient retention in care: lessons from Ethiopia, 2005-2013
Background Antiretroviral treatment (ART) was provided to more than nine million people by the end of 2012. Although ART programs in resource-limited settings have expanded treatment, inadequate retention in care has been a challenge. Ethiopia has been scaling up ART and improving retention (defined as continuous engagement of patients in care) in care. We aimed to analyze the ART program in Ethiopia. Methods A mix of quantitative and qualitative methods was used. Routine ART program data was used to study ART scale up and patient retention in care. In-depth interviews and focus group discussions were conducted with program managers. Results The number of people receiving ART in Ethiopia increased from less than 9,000 in 2005 to more than 439, 000 in 2013. Initially, the public health approach, health system strengthening, community mobilization and provision of care and support services allowed scaling up of ART services. While ART was being scaled up, retention was recognized to be insufficient. To improve retention, a second wave of interventions, related to programmatic, structural, socio-cultural, and patient information systems, have been implemented. Retention rate increased from 77% in 2004/5 to 92% in 2012/13. Conclusion Ethiopia has been able to scale up ART and improve retention in care in spite of its limited resources. This has been possible due to interventions by the ART program, supported by health systems strengthening, community-based organizations and the communities themselves. ART programs in resource-limited settings need to put in place similar measures to scale up ART and retain patients in care.
Effects of care pathways on the in-hospital treatment of heart failure: a systematic review
Background Care pathways have become a popular tool to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. We performed a disease specific systematic review to determine how care pathways in the hospital treatment of heart failure affect in-hospital mortality, length of in-hospital stay, readmission rate and hospitalisation cost when compared with standard care. Methods Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched from 1985 to 2010. Each study was assessed independently by two reviewers. Methodological quality of the included studies was assed using the Jadad methodological approach for randomised controlled trials, controlled clinical trials and the New Castle Ottawa Scale for case�control studies, cohort studies and time interrupted series. Results Seven studies met the study inclusion criteria and were included in the systematic review with a total sample of 3,690 patients. The combined overall results showed that care pathways have a significant positive effect on mortality and readmission rate. A shorter length of hospital stay was also observed compared with the standard care group. No significant difference was found in the hospitalisation costs. More positive results were observed in controlled trials compared to randomized controlled trials. Conclusion By combining all possible results, it can be concluded that care pathways for treatment of heart failure decrease mortality rates and length of hospital stay, but no statistically significant difference was observed in the readmission rates and hospitalisation costs. However, one should be cautious with overall conclusions: what works for one organization may not work for another because of the subtle differences in processes and bottlenecks.
House calls revisited: Leveraging technology to overcome obstacles to psychiatric care and improve treatment outcomes
Despite an increasing number of military service members in need of mental health treatment following deployment to Iraq and Afghanistan, numerous psychological and practical barriers limit access to care. Perceived stigma about admitting psychological difficulties as well as frequent long distances to treatment facilities reduce many veterans' willingness and ability to receive care. Telemedicine and virtual human technologies offer a unique potential to expand services to those in greatest need. Telemedicine-based treatment has been used to address multiple psychiatric disorders, including posttraumatic stress disorder, depression, and substance use, as well as to provide suicide risk assessment and intervention. Clinician education and training has also been enhanced and expanded through the use of distance technologies, with trainees practicing clinical skills with virtual patients and supervisors connecting with clinicians via videoconferencing. The use of these innovative and creative vehicles offer a significant and as yet unfulfilled promise to expand delivery of high quality psychological therapies, regardless of clinician and patient location.
Olden, Megan; Cukor, Judith; Rizzo, Albert "Skip"; Rothbaum, Barbara; Difede, JoAnn
Pharmacokinetics of buprenorphine following intravenous and buccal administration in cats, and effects on thermal threshold.
This study reports the pharmacokinetics of buprenorphine, following i.v. and buccal administration, and the relationship between buprenorphine concentration and its effect on thermal threshold. Buprenorphine (20�?g/kg) was administered intravenously or buccally to six cats. Thermal threshold was determined, and arterial blood sampled prior to, and at various times up to 24�h following drug administration. Plasma buprenorphine concentration was determined using liquid chromatography/mass spectrometry. Compartment models were fitted to the time-concentration data. Pharmacokinetic/pharmacodynamic models were fitted to the concentration-thermal threshold data. Thermal threshold was significantly higher than baseline 44�min after buccal administration, and 7, 24, and 104�min after i.v. administration. A two- and three-compartment model best fitted the data following buccal and i.v. administration, respectively. Following i.v. administration, mean���SD volume of distribution at steady-state (L/kg), clearance (mL�min/kg), and terminal half-life (h) were 11.6���8.5, 23.8���3.5, and 9.8���3.5. Following buccal administration, absorption half-life was 23.7���9.1�min, and terminal half-life was 8.9���4.9�h. An effect-compartment model with a simple effect maximum model best predicted the time-course of the effect of buprenorphine on thermal threshold. Median (range) ke0 and EC50 were 0.003 (0.002-0.018)/min and 0.599 (0.073-1.628) ng/mL (i.v.), and 0.017 (0.002-0.023)/min and 0.429 (0.144-0.556) ng/mL (buccal). PMID:24862514
Hedges, A R; Pypendop, B H; Shilo-Benjamini, Y; Stanley, S D; Ilkiw, J E
The effects of prenatal exposure to buprenorphine or methadone on infant visual evoked potentials.
This study compared the neurological development of 4 month old infants exposed to buprenorphine or methadone during pregnancy to that of a control group of non-exposed infants. Participants were 30 buprenorphine-maintained women, 22 methadone-maintained women and 33 non opioid-dependent controls, and their infants. Women were enrolled during pregnancy as part of an open-label non-randomised flexible-dosing longitudinal study. Groups were matched for maternal age, parity, gravida, and tobacco and alcohol use. Infant neurological development was assessed by measuring latency of pattern reversal visual evoked potentials (VEP). One-way between groups analyses of variance (ANOVA) were conducted to test the statistical significance of differences between the mean latencies of the peak response to two different sized checkerboard patterns (48' and 69' of retinal arc). Infants prenatally exposed to methadone had significantly prolonged latencies, compared with infants in the control group and infants prenatally exposed to buprenorphine, in response to checks of 48' and 69'. VEP latencies of infants prenatally exposed to buprenorphine did not differ significantly from controls for either check size. After adjustment for covariates, prenatal exposure to methadone remained a significant predictor of VEP response to checks of 48', but not 69'. Maternal self-reported used of marijuana during pregnancy made a significant unique contribution to the variance in P1 latencies for both check sizes. Data from this controlled, non-randomised study suggest that buprenorphine may confer an advantage over methadone as a maintenance drug during pregnancy in terms of infant neural development at 4 months of age. PMID:19751825
Whitham, Justine N; Spurrier, Nicola J; Sawyer, Michael G; Baghurst, Peter A; Taplin, John E; White, Jason M; Gordon, Andrea L
[Patient-controlled analgesia with epidural pethidine or buprenorphine plus bupivacaine for postoperative analgesia].
We evaluated the efficacy of epidural patient-controlled analgesia (PCA) with pethidine or buprenorphine plus 0.25% bupivacaine for postoperative analgesia after laparotomy with a midline incision under general anesthesia. Twenty patients were randomly allocated to two groups. In one group (PCEA-P group; n = 10), epidural pethidine plus 0.25% bupivacaine by PCA with 5 mg of pethidine and 2.5 ml of 0.25% bupivacaine bolus with a lockout interval of 20 min was added to a continuous epidural infusion of 0.25% bupivacaine (2 ml.h-1) plus pethidine (100 mg.24h-1) for 72 h. In the other group (PCEA-B group; n = 10), epidural buprenorphine plus 0.25% bupivacaine by PCA with 0.03 mg of buprenorphine and 2.5 ml of 0.25% bupivacaine bolus with a lockout interval of 20 min was added to a continuous epidural infusion of 0.25% bupivacaine (2 ml.h-1) and buprenorphine (0.6 mg.24 h-1) for 72 h. Analgesia was evaluated by 100 mm visual analog scale and verbal descriptor scale. In PCEA-B group, 90% of the patients did not complain of pain at rest, and in PCEA-P group, all the patients did not complain of pain at rest for 72 h. There were no significantly different analgesic effects between PCEA-P and PCEA-B for 48 h. The average doses of epidural PCA were 1.9 mg.kg-1.24 h-1 of pethidine, and 0.012 mg.kg-1.24 h-1 of buprenorphine, respectively. We conclude that PCEA-P and PCEA-B were effective for postoperative pain to the same degree for the first 48 h, but PCEA-P was superior to PCEA-B for the last 24 h. PMID:8254871
Mitsuhata, H; Hirabayashi, Y; Saitoh, K; Horiguchi, Y; Togashi, H; Shimizu, R; Hasegawa, J; Matsumoto, S
Culture is treatment: considering pedagogy in the care of Aboriginal people.
This article presents an overview of culture as treatment, by recognizing the impact that culture has on treatment along with the specific rituals, customs, and meanings related to healing. Attention must be given to the Aboriginal heritage, including various concepts of metaphysics, spirituality, medicines, government, oral history, and language. A pedagogical underpinning of illness and healing is better cared for through cultural messaging and learning that is related to the complex historical legacy of Aboriginal societies, and therefore, culture provides important diverse contributions to current treatment and wellness programs. PMID:20506971
Green, Brenda L
Head and neck cancer: historical evolution of treatment and patient self-care requirements.
The purpose of this literature review is to explore the historical progression of treatment and its impact on care requisites in patients with head and neck cancer. Head and neck cancers are some of the most visible types of cancer. Patients often experience difficulties in self-care because of problems adapting to and coping with the diagnosis and disease management. Evaluation of the literature from the 1960s to present indicated a shift from coping with disfigurement to focusing on dysfunction and rehabilitative self-care. The process of assisting patients with self-care activities occurs from the time of diagnosis through post-treatment and beyond. Adapting to and coping with changes in physical appearance and function begins with the cognitive decision to initiate treatment modalities specific to the cancer site. Current knowledge of the manifestations of head and neck cancer provides the healthcare team with a better understanding of the disease trajectory and how best to assist patients in adapting to and coping with changes affecting their quality of life. PMID:24305487
Sobecki-Ryniak, Diane; Krouse, Helene J
[Prevention and treatment of mental disorders in the workplace: staged spectrum of care].
Mental disorders connected with work stress are of growing importance for the health care system. Following a heated debate on burnout in Germany, at present various approaches on how to prevent the development of burnout syndromes, how to ensure a need adapted treatment for employees with a manifest disorder and how the process of returning to work already addresses aspects of secondary prevention are under discussion. This leads to different fields of activities for company health management and the health care system and structural improvements are essential. PMID:24190031
Berger, M; Gravert, C; Schneller, C; Maier, W
Prevention and screening, brief intervention, and referral to treatment for substance use in primary care.
Substance use and related disorders are among the leading causes of preventable injury and illness, chronic health conditions, medical complications, disability, increased suffering, and premature death. Primary care clinicians can help patients avoid, reduce, or eliminate high-risk behaviors and negative consequences associated with substance use by integrating prevention and screening, brief intervention, and referral to treatment into their clinical practices. This article provides the necessary information, evidence-based recommendations, and readily available resources to help address substance use and related disorders in primary care, with special emphasis on the use of tobacco, alcohol, cannabis, and nonmedical prescription opioid medications. PMID:24830605
Strobbe, Stephen
Advancing Alzheimer's disease diagnosis, treatment, and care: recommendations from the Ware Invitational Summit.
To address the pending public health crisis due to Alzheimer's disease (AD) and related neurodegenerative disorders, the Marian S. Ware Alzheimer Program at the University of Pennsylvania held a meeting entitled "State of the Science Conference on the Advancement of Alzheimer's Diagnosis, Treatment and Care," on June 21-22, 2012. The meeting comprised four workgroups focusing on Biomarkers; Clinical Care and Health Services Research; Drug Development; and Health Economics, Policy, and Ethics. The workgroups shared, discussed, and compiled an integrated set of priorities, recommendations, and action plans, which are presented in this article. PMID:22959699
Naylor, Mary D; Karlawish, Jason H; Arnold, Steven E; Khachaturian, Ara S; Khachaturian, Zaven S; Lee, Virginia M-Y; Baumgart, Matthew; Banerjee, Sube; Beck, Cornelia; Blennow, Kaj; Brookmeyer, Ron; Brunden, Kurt R; Buckwalter, Kathleen C; Comer, Meryl; Covinsky, Kenneth; Feinberg, Lynn Friss; Frisoni, Giovanni; Green, Colin; Guimaraes, Renato Maia; Gwyther, Lisa P; Hefti, Franz F; Hutton, Michael; Kawas, Claudia; Kent, David M; Kuller, Lewis; Langa, Kenneth M; Mahley, Robert W; Maslow, Katie; Masters, Colin L; Meier, Diane E; Neumann, Peter J; Paul, Steven M; Petersen, Ronald C; Sager, Mark A; Sano, Mary; Schenk, Dale; Soares, Holly; Sperling, Reisa A; Stahl, Sidney M; van Deerlin, Vivianna; Stern, Yaakov; Weir, David; Wolk, David A; Trojanowski, John Q
Roles of ?-opioid receptors and nociceptin/orphanin FQ peptide receptors in buprenorphine-induced physiological responses in primates.
Buprenorphine is known as a ?-opioid peptide (MOP) receptor agonist, but its antinociception is compromised by the activation of nociceptin/orphanin FQ peptide (NOP) receptors in rodents. The aim of this study was to investigate the roles of MOP and NOP receptors in regulating buprenorphine-induced physiological responses in primates (rhesus monkeys). The effects of MOP antagonist (naltrexone), NOP antagonist [(�)-1-[(3R*,4R*)-1-(cyclooctylmethyl)-3-(hydroxymethyl)-4-piperidinyl]-3-ethyl-1,3-dihydro-2H-benzimidazol-2-one (J-113397)], and NOP agonists [(1S,3aS)-8-(2,3,3a,4,5,6-hexahydro-1H-phenalen-1-yl)-1-phenyl-1,3,8-triaza-spiro[4.5] decan-4-one (Ro 64-6198) and 3-endo-8-[bis(2-methylphenyl)methyl]-3-phenyl-8-azabicyclo[3.2.1]octan-3-ol (SCH 221510)] on buprenorphine were studied in three functional assays for measuring analgesia, respiratory depression, and itch in primates. Over the dose range of 0.01 to 0.1 mg/kg, buprenorphine dose-dependently produced antinociception, respiratory depression, and itch/scratching responses, and there was a ceiling effect at higher doses (0.1-1 mg/kg). Naltrexone (0.03 mg/kg) produced similar degrees of rightward shifts of buprenorphine's dose-response curves for all three endpoints. Mean pK(B) values of naltrexone (8.1-8.3) confirmed that MOP receptors mediated mainly buprenorphine-induced antinociception, respiratory depression, and itch/scratching. In contrast, J-113397 (0.1 mg/kg) did not change buprenorphine-induced physiological responses, indicating that there were no functional NOP receptors in buprenorphine-induced effects. More importantly, both NOP agonists, Ro 64-6198 and SCH 221510, enhanced buprenorphine-induced antinociception without respiratory depression and itch/ scratching. The dose-addition analysis revealed that buprenorphine in combination with the NOP agonist synergistically produced antinociceptive effects. These findings provided functional evidence that the activation of NOP receptors did not attenuate buprenorphine-induced antinociception in primates; instead, the coactivation of MOP and NOP receptors produced synergistic antinociception without other side effects. This study strongly supports the therapeutic potential of mixed MOP/NOP agonists as innovative analgesics. PMID:22743574
Cremeans, Colette M; Gruley, Erin; Kyle, Donald J; Ko, Mei-Chuan
Roles of ?-Opioid Receptors and Nociceptin/Orphanin FQ Peptide Receptors in Buprenorphine-Induced Physiological Responses in Primates
Buprenorphine is known as a ?-opioid peptide (MOP) receptor agonist, but its antinociception is compromised by the activation of nociceptin/orphanin FQ peptide (NOP) receptors in rodents. The aim of this study was to investigate the roles of MOP and NOP receptors in regulating buprenorphine-induced physiological responses in primates (rhesus monkeys). The