Office-based opioid dependence treatment.

Filed under: Methadone Detox

Pain Physician. 2012 Jul; 15(3 Suppl): ES231-6
Colson J, Helm Ii S, Silverman SM

Opioid misuse and abuse occurring in association with the treatment of chronic non-cancer pain are not new phenomena, but their increasing prevalence in recent years is unprecedented. Advancements in pharmaceutical technologies have provided opioid-related drugs, which lack the pure mu agonist activity characteristic of the typical opioid congeners. This absent or altered mu receptor activity imparts an opioid receptor antagonistic or partial agonistic pharmacologic action, which serves to modulate the development of opioid-induced tolerance and physical dependence and facilitate detoxification and withdrawal from opioids. Opioid antagonists and partial agonists are being used in abuse deterrent strategy regimens to prevent opioid tolerance and the development of dependence, as well as in the management of opioid detoxification and treatment of withdrawal. The specific opioid antagonists and partial agonists used in these various therapeutic modalities will be the focus of this review.Evaluate the comparative therapeutic utility of opioid antagonists and partial agonists in preventing the development of opioid tolerance and treating opioid dependence, detoxification, and withdrawal. A primary focus is the use of opioid antagonists and partial agonists within an office-based practice.A narrative review of the current literature involving the therapeutic use of opioid antagonists and partial agonists in the management of opioid tolerance, dependence, detoxification, and withdrawal. A computerized literature search in the PubMed, EMBASE, BioMed, and Cochrane Library review databases from 2008 through 2010 was performed. This search included systematic and narrative reviews, prospective and retrospective studies, as well as cross-references from bibliographies of notable primary and review articles and abstracts from scientific meetings. US Food and Drug Administration records and pharmaceutical manufacturers’ product literature were also used in the search.Opioid dependency, whether it results from the misuse or abuse of prescription or street drugs, continues to be a significant public health issue. Passage of DATA 2000 and US Food and Drug Administration approval of buprenorphine and buprenorphine/ naloxone has revolutionized opioid dependence therapy. The traditional addiction medicine therapy regimen of methadone maintenance, with its inherent legal limitations and restrictions, has been challenged by an office-based dependence practice with buprenorphine serving as a prominent therapeutic tool.
Source

American Society of Interventional Pain Physicians (ASIPP) Guidelines for Responsible Opioid Prescribing in Chronic Non-Cancer Pain: Part 2 – Guidance.

Filed under: Methadone Detox

Pain Physician. 2012 Jul; 15(3 Suppl): S67-S116
Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, Brown KR, Bruel BM, Bryce DA, Burks PA, Burton AW, Calodney AK, Caraway DL, Cash KA, Christo PJ, Damron KS, Datta S, Deer TR, Diwan S, Eriator I, Falco FJ, Fellows B, Geffert S, Gharibo CG, Glaser SE, Grider JS, Hameed H, Hameed M, Hansen H, Harned ME, Hayek SM, Helm Ii S, Hirsch JA, Janata JW, Kaye AD, Kaye AM, Kloth DS, Koyyalagunta D, Lee M, Malla Y, Manchikanti KN, McManus CD, Pampati V, Parr AT, Pasupuleti R, Patel VB, Sehgal N, Silverman SM, Singh V, Smith HS, Snook LT, Solanki DR, Tracy DH, Vallejo R, Wargo BW

RESULTS: Part 2 of the guidelines on responsible opioid prescribing provides the following recommendations for initiating and maintaining chronic opioid therapy of 90 days or longer. 1.  A)  Comprehensive assessment and documentation is recommended before initiating opioid therapy, including documentation of comprehensive history, general medical condition, psychosocial history, psychiatric status, and substance use history. (Evidence: good)  B)  Despite limited evidence for reliability and accuracy, screening for opioid use is recommended, as it will identify opioid abusers and reduce opioid abuse. (Evidence: limited)  C)  Prescription monitoring programs must be implemented, as they provide data on patterns of prescription usage, reduce prescription drug abuse or doctor shopping. (Evidence: good to fair)  D)  Urine drug testing (UDT) must be implemented from initiation along with subsequent adherence monitoring to decrease prescription drug abuse or illicit drug use when patients are in chronic pain management therapy. (Evidence: good) 2.  A)  Establish appropriate physical diagnosis and psychological diagnosis if available prior to initiating opioid therapy. (Evidence: good)  B)  Caution must be exercised in ordering various imaging and other evaluations, interpretation and communication with the patient, to avoid increased fear, activity restriction, requests for increased opioids, and maladaptive behaviors. (Evidence: good)  C)  Stratify patients into one of the 3 risk categories – low, medium, or high risk.  D)  A pain management consultation, may assist non-pain physicians, if high-dose opioid therapy is utilized. (Evidence: fair) 3.  Essential to establish medical necessity prior to initiation or maintenance of opioid therapy. (Evidence: good) 4.  Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. (Evidence: good) 5.  A)  Long-acting opioids in high doses are recommended only in specific circumstances with severe intractable pain that is not amenable to short-acting or moderate doses of long-acting opioids, as there is no significant difference between long-acting and short-acting opioids for their effectiveness or adverse effects. (Evidence: fair)  B)  The relative and absolute contraindications to opioid use in chronic non-cancer pain must be evaluated including respiratory instability, acute psychiatric instability, uncontrolled suicide risk, active or history of alcohol or substance abuse, confirmed allergy to opioid agents, coadministration of drugs capable of inducing life-limiting drug interaction, concomitant use of benzodiazepines, active diversion of controlled substances, and concomitant use of heavy doses of central nervous system depressants. (Evidence: fair to limited)  6.  A robust agreement which is followed by all parties is essential in initiating and maintaining opioid therapy as such agreements reduce overuse, misuse, abuse, and diversion. (Evidence: fair) 7.  A)  Once medical necessity is established, opioid therapy may be initiated with low doses and short-acting drugs with appropriate monitoring to provide effective relief and avoid side effects. (Evidence: fair for short-term effectiveness, limited for long-term effectiveness)  B)  Up to 40 mg of morphine equivalent is considered as low dose, 41 to 90 mg of morphine equivalent as a moderate dose, and greater than 91 mg of morphine equivalence as high dose. (Evidence: fair)   C)  In reference to long-acting opioids, titration must be carried out with caution and overdose and misuse must be avoided. (Evidence: good) 8.  A)  Methadone is recommended for use in late stages after failure of other opioid therapy and only by clinicians with specific training in the risks and uses. (Evidence: limited)  B)  Monitoring recommendation for methadone prescription is that an electrocardiogram should be obtained prior to initiation, at 30 days and yearly thereafter. (Evidence: fair) 9.  In order to reduce prescription drug abuse and doctor shopping, adherence monitoring by UDT and PMDPs provide evidence that is essential to the identification of those patients who are non-compliant or abusing prescription drugs or illicit drugs. (Evidence: fair) 10.  Constipation must be closely monitored and a bowel regimen be initiated as soon as deemed necessary. (Evidence: good) 11.  Chronic opioid therapy may be continued, with continuous adherence monitoring, in well-selected populations, in conjunction with or after failure of other modalities of treatments with improvement in physical and functional status and minimal adverse effects. (Evidence: fair) DISCLAIMER: The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a “standard of care.”
Source

Diminished brain functional magnetic resonance imaging activation in patients on opiate maintenance despite normal spatial working memory task performance.

Filed under: Methadone Detox

Clin Neuropharmacol. 2012 Jul; 35(4): 153-60
Bach P, Vollstädt-Klein S, Frischknecht U, Hoerst M, Kiefer F, Mann K, Ende G, Hermann D

Despite the beneficial impact on the reduction of addictive behavior, opiate maintenance therapy has been associated with negative effects on cognitive and psychomotor functioning. This may limit the outcome of behavioral strategies, rehabilitation, and reintegration into society. The objective of the study at hand was to investigate the effect of buprenorphine and methadone maintenance therapy on visuospatial working memory performance.Visuospatial working memory performance of 13 patients, receiving either methadone or buprenorphine, was investigated and compared to 13 control participants using functional magnetic resonance imaging.Altered neuronal activation was found in the patients, including brain areas associated with working memory performance and addiction. Behavioral performance on the visuospatial working memory task was similar across groups.Results indicate that there are no robust impairments of visuospatial capabilities in patients on opiate maintenance, but altered neuronal activation in working memory-related brain areas-due to chronic presence of opiates-may limit cognitive performance on complex cognitive tasks. Factors in therapeutic strategies that may support rehabilitation of patients’ cognitive performance are discussed.
Source

Client and Program Characteristics Associated with Wait Time to Substance Abuse Treatment Entry.

Filed under: Methadone Detox

Am J Drug Alcohol Abuse. 2012 Jul 11;
Andrews CM, Shin HC, Marsh JC, Cao D

Background: Wait time is among the most commonly cited barriers to access among individuals seeking entry to substance abuse treatment, yet relatively little is known about what contributes to it. Objectives: To address this gap, this study draws from a national sample of substance abuse treatment clients and programs to estimate the proportion of clients entering treatment who waited more than 1 month to receive it (outpatient, residential, or methadone) and to identify client and program characteristics associated with wait time. Methods: This study used data from the National Treatment Improvement Evaluation Study (1992-1997). The data include 2920 clients from 57 substance abuse treatment programs. Generalized linear modeling was used to identify client and program characteristics associated with wait time to treatment entry. Results: Results of modeling indicate that being African-American (OR: 1.40; CI: 1.04, 1.88), being referred by criminal justice (OR: 1.70; CI: 1.18, 2.43), and receiving methadone (OR: 3.90; CI: 1.00, 15.16) were associated with increased odds of waiting more than 1 month. Conversely, having a diagnosis of HIV/AIDS (OR: 0.38; CI: 0.19, 0.77) was associated with decreased odds of waiting for more than 1 month. Conclusion: A significant proportion of clients waited more than 1 month on enter treatment. Greater odds of such wait times were associated with being African-American, criminal justice-referred, and receiving methadone. Significance: This study is the first to use a national sample to examine the prevalence of wait time to substance abuse treatment entry and to identify client and program characteristics associated with it.
Source

Find More Methadone Detox Information…

Comments are closed.