Opiate Treatment with Agonists Including Methadone, Buprenorphine, and Suboxone

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41. Methadone - 3-12-10

An editorial in the March 8, 2000, edition of The Journal of the American Medical Association states that following the Scottish example and allowing primary care physicians to dispense methadone "can provide a 3- to 5-fold increase in access. It can also reduce the cost per patient, although added access will clearly increase short-term substance abuse treatment costs while reducing long-term costs associated with overdose emergencies, HIV infection, and crime."

Rounsaville, Bruce J., MD, and Kosten, Thomas R., MD, "Treatment for Opioid Dependence: Quality and Access", Journal of the American Medical Association, (Chicago, IL: American Medical Association, March 8, 2000), Vol. 283, No. 10, p. 1338.
http://www.doctordeluca.com/Li...

42. OST and Patient Retention

The New England Journal of Medicine published a study comparing methadone with LAAM and buprenorphine. The authors concluded that "Levomethadyl acetate, buprenorphine, and high-dose methadone were all effective in treating opioid dependence and were were superior on multiple measures to low-dose methadone. The percentage of patients retained at 17 weeks compared favorably with rates reported elsewhere for these medications."

Johnson, Rolley E., Pharm. D., Mary Ann Chutuape, PhD, Eric C. Strain, MD, Sharon L. Walsh, PhD, Maxine L. Stitzer, PhD, and George E. Bigelow, PhD, "A Comparison of Levomethadyl Acetate, Buprenorphine, and Methadone for Opioid Dependence," New England Journal of Medicine (Boston, MA: Massachusetts Medical Society, Nov. 2, 2000), Vol. 343, No. 18, p. 1295.
http://content.nejm.org/cgi/re...

43. Risk of Death and Other Adverse Events from Anesthesia-Assisted Rapid Opioid Detoxification (AAROD)

"Government agencies and professional societies,* including the American Society of Addiction Medicine, have recommended against using AAROD in clinical settings (9). There is insufficient knowledge regarding how widely AAROD is used in the United States and the frequency of AAROD-associated adverse events in community practice settings. At least seven deaths occurred following AAROD among 2,350 procedures performed in one practice during 1995–1999.†
"The New York City clinic investigation revealed that AAROD was performed on 75 patients during January–September 2012 and was associated with two deaths and five additional adverse events requiring hospitalization, a serious adverse event rate of 9.3%. No standard protocol exists for AAROD; however, the clinic’s practice was consistent with AAROD use described elsewhere (7). All events occurred after and in close temporal proximity to AAROD. Although a common mechanism linking these events to AAROD is not evident, the events are consistent with previously proposed mechanisms of AAROD-associated adverse events, including electrolyte disturbance, catecholamine release, altered cardiopulmonary functioning, acute lung injury, and other physiologic effects associated with administration of high doses of opioid antagonists under general anesthesia (10). Given the ongoing epidemic of prescription opioid dependence, further increases in the demand for substance use disorder services are to be expected. AAROD has substantial risks, including a risk for death, and little to no evidence to support its use. Safe, evidence-based treatments of opioid dependence (e.g., MAT [Medication-Assisted Treatment]) exist and are preferred (2)."


* Additional information available at http://www.nice.org.uk/. Care Med 2000;28:969–76.
† Additional information available at http://njlaw.rutgers.edu/colle....

"Deaths and Severe Adverse Events Associated With Anesthesia-Assisted Rapid Opioid Detoxification - New York City, 2012," Mortality and Morbidity Weekly Report (Atlanta, GA: Centers for Disease Control, Sept. 27, 2013), Vol. 62, No. 38, p. 780.
http://www.cdc.gov/...
http://www.cdc.gov/mmwr/pdf/wk...

44. Feasibility of OBOT

Office-Based Opioid Substitution Treatment (OBOT)

"This study has implications for future treatment of opioid dependence. First, the results support the feasibility of transferring stable patients from NTPs to the offices of trained primary care physicians and extends prior research in this field. These findings, along with recent trials demonstrating the effectiveness of buprenorphine for untreated opioid-dependent patients in primary care settings, offer encouragement regarding the use of primary care offices to help expand access to treatment for opioid dependence."

Fiellin, David A., MD, Patrick G. O'Connor, MD, MPH, Marek Chawarski, PhD, Juliana P. Pakes, MEd, Michael V. Pantalon, PhD, and Richard S. Schottenfeld, MD, "Methadone Maintenance in Primary Care: A Randomized Controlled Trial," Journal of the American Medical Association (Chicago, IL: American Medical Association, Oct. 10, 2001), Vol. 286, No. 14, p. 1730.
http://jama.jamanetwork.com/ar...

45. Feasibility of OBOT

"Our results demonstrate that methadone maintenance using weekly physician office-based dispensing is feasible, that treatment retention and patient and clinician satisfaction are high, and that illicit drug use does not differ significantly compared with continued treatment in an NTP [narcotic treatment program]. Stable patients demonstrated high functional status and low levels of health and social service use on transfer from an NTP to office-based care. The high level of patient and clinician satisfaction with office-based care and the outcomes observed with office-based treatment run counter to concerns regarding the potential quality of this type of care and the ability to identify a group of physicians interested in providing treatment for opioid-dependent patients."

Fiellin, David A., MD, Patrick G. O'Connor, MD, MPH, Marek Chawarski, PhD, Juliana P. Pakes, MEd, Michael V. Pantalon, PhD, and Richard S. Schottenfeld, MD, "Methadone Maintenance in Primary Care: A Randomized Controlled Trial," Journal of the American Medical Association (Chicago, IL: American Medical Association, Oct. 10, 2001), Vol. 286, No. 14, p. 1729.
http://jama.jamanetwork.com/ar...

46. Benefits from OBOT

"Office-based methadone maintenance administered by appropriately trained primary care and specialist physicians has the potential to provide an alternative for selected patients to the current narcotic treatment system that would allow for greater physician involvement and perhaps increased quality of care. Potential benefits from this type of care include increased attention to comorbid medical and psychiatric conditions, decreased stigma associated with the diagnosis and treatment, decreased contact with active heroin users, and increased access to treatment. These benefits may increase patient satisfaction and enhance clinical outcomes."

Fiellin, David A., MD, Patrick G. O'Connor, MD, MPH, Marek Chawarski, PhD, Juliana P. Pakes, MEd, Michael V. Pantalon, PhD, and Richard S. Schottenfeld, MD, "Methadone Maintenance in Primary Care: A Randomized Controlled Trial," Journal of the American Medical Association (Chicago, IL: American Medical Association, Oct. 10, 2001), Vol. 286, No. 14, p. 1725.
http://jama.jamanetwork.com/ar...

47. Effectiveness of OBOT

Researchers from Yale University "investigated the use of counseling and different frequencies of medication dispensing in primary care treatment with buprenorphine-naloxone. Neither the primary outcomes (the frequency of illicit opioid use, the percentage of opioid-negative urine specimens, and the maximum number of consecutive weeks of abstinence from illicit opioids) nor the proportion of patients who completed the study differed significantly among the three groups. Specifically, outcomes among patients receiving brief counseling combined with once-weekly medication dispensing did not differ significantly from outcomes among patients receiving either extended counseling or thrice-weekly medication dispensing did not differ significantly from outcomes among patients receiving either extended counseling or thrice-weekly medication dispensing. Patient satisfaction was significantly higher with once-weekly than with thrice-weekly medication dispensing, although because of the large number of statistical tests conducted, this may represent a chance finding."

Fiellin, David A., MD, Michael V. Pantalon, PhD, Marek C. Chawarski, PhD, Brent A. Moore, PhD, Lynn E. Sullivan, MD, Patrick G. O'Connor, MD, MPH, and Richard S. Schottenfeld, MD, "Counseling plus Buprenorphine-Naloxone Maintenance Therapy for Opioid Dependence," New England Journal of Medicine Vol. 355, No. 4, July 27, 2006, pp. 370-371.
http://content.nejm.org/cgi/re...

48. Effectiveness of Office-Based Buprenorphine Treatment

"Consistent with the findings of previous research with buprenorphine,1-4 the frequency of illicit opioid use decreased significantly from baseline to induction and was lowest during maintenance for all three groups. The mean percentages of patients who completed the 24-week study, which ranged between 39 and 48 percent, were similar to those found in previous studies, including one conducted in an office-based setting.1-4 Therefore, the majority of patients who entered this study either left treatment or were considered appropriate for transfer to a more structured treatment setting with methadone. Nonetheless, although we did not demonstrate the superiority of extended counseling or thrice-weekly medication dispensing over the relatively limited nurse-administered counseling and once-weekly dispensing, our findings support the feasibility of buprenorphine–naloxone maintenance in primary care.10,13,21"

Fiellin, David A., MD, Michael V. Pantalon, PhD, Marek C. Chawarski, PhD, Brent A. Moore, PhD, Lynn E. Sullivan, MD, Patrick G. O'Connor, MD, MPH, and Richard S. Schottenfeld, MD, "Counseling plus Buprenorphine-Naloxone Maintenance Therapy for Opioid Dependence," New England Journal of Medicine Vol. 355, No. 4, July 27, 2006, p. 371.
http://content.nejm.org/cgi/re...

49. Methadone vs. Buprenorphine Treatment

"Opioid dependence and addiction, whether to heroin or prescription pain relievers, is a serious, life-threatening medical condition. Methadone and buprenorphine are medications that permit addicted individuals to function normally within their families, jobs, and communities. While treatment with methadone is more established, it requires daily visits to an OTP. Not all individuals who could benefit from methadone treatment live within easy travelling distance of an OTP. Furthermore, the requirement for daily visits can interfere with jobs and other important activities. The introduction of buprenorphine for the treatment of opioid dependence has provided an alternative to methadone treatment for some opioid dependent persons; however, buprenorphine may not be appropriate for all opioid-addicted persons. The dramatic increase in the number of clients receiving buprenorphine through treatment facilities is an indication of the demand for safe and effective medications for the treatment of opioid addiction in the context of a broader treatment program."

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (April 23, 2013). The N-SSATS Report: Trends in the Use of Methadone and Buprenorphine at Substance Abuse Treatment Facilities: 2003 to 2011. Rockville, MD, p. 2.
http://www.samhsa.gov/data/2k1...

50. Frequency of Dosing with Buprenorphine

The New England Journal of Medicine published a study comparing methadone with LAAM [levomethadyl acetate] and buprenorphine. According to the report, "Most of the development and evaluation research on buprenorphine has been based on daily doses. Our study used thrice-weekly doses and found that outcomes were approximately equivalent to those with either daily methadone or thrice-weekly levomethadyl acetate. Thus, thrice-weekly buprenorphine may also offer greater convenience to patients and clinic staff."

Johnson, Rolley E., Pharm. D., Mary Ann Chutuape, PhD, Eric C. Strain, MD, Sharon L. Walsh, PhD, Maxine L. Stitzer, PhD, and George E. Bigelow, PhD, "A Comparison of Levomethadyl Acetate, Buprenorphine, and Methadone for Opioid Dependence," New England Journal of Medicine (Boston, MA: Massachusetts Medical Society, Nov. 2, 2000), Vol. 343, No. 18, p. 1296.
http://content.nejm.org/cgi/re...

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