Addressing misuse and diversion of opioid substitution medication: guidance based on systematic evidence review and real-world experience

Wright, Nat; D'Agnone, Oscar; Krajči, Peter; Littlewood, Richard; Alho, Hannu; Reimer, Jens; Roncero, Carlos; Somaini, Lorenzo; Maremmani, Icro

doi:10.1093/pubmed/fdv150

Cited by 35 publications

(19 citation statements)

References 26 publications

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“…Despite these positives, participants remained concerned about the dangers of reverting to past life styles and illicit drug use and expressed heightened anxiety over ‘ not bumping into individuals ’ and ‘ avoiding certain people ’. This finding is not uncommon in the literature where the diversion of ORT medication and its misuse is widely accepted as one of the areas that needs constant vigilance.…”

Section: Discussionsupporting

confidence: 83%

The lived experience of Australian opioid replacement therapy recipients in a community‐based program in regional Victoria

Patil

Cash

Cant

et al. 2019

Drug and Alcohol Review

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Introduction and Aims Treatment of opioid dependence through opioid replacement therapy is widely recognised as effective. Nonetheless, while there has been a community‐based program in the state of Victoria for over two decades, consumer experiences have received little attention. This study aimed to describe the experiences of opioid replacement therapy consumers living in rural and regional areas of the state. Design and Methods A qualitative design employed an interpretative phenomenological approach. Sixteen consumers were interviewed. Thematic analysis was conducted by the researchers to examine the phenomena of consumers′ experiences and findings were verified by a stakeholder group. Results Findings centred on themes of consumers′ experience of becoming recipients; consumer perceptions of pharmacists and pharmacy settings and psychosocial impacts on consumers. A majority of participants believed opioid replacement therapy brought increased normality to their life, however systemic and psychosocial barriers impacted on well‐being. The pharmacy setting itself as a public dosing space commonly provoked feelings of stigma and discrimination among consumers. Other barriers prominently reported were restrictions on number of takeaways, cost of dispensing and lack of access to medical practitioners and allied supports. Discussion and Conclusions There were psychosocial impacts on opioid replacement therapy consumers relating to financial and social burdens, stigma and discrimination. Access to medical care and a choice of pharmacy appeared to be restricted in rural regions. The findings suggest a need to address, in particular, the financial and dispensing point burdens experienced by consumers to facilitate program retention.

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Section: Discussionsupporting

confidence: 83%

The lived experience of Australian opioid replacement therapy recipients in a community‐based program in regional Victoria

Patil

Cash

Cant

et al. 2019

Drug and Alcohol Review

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“…Because there are limited data on patients stable on sublingual buprenorphine, 23 it is important to study maintenance and improvement of stability in patients who achieve good clinical response to initial buprenorphine treatment. In this study, buprenorphine implants were noninferior to sublingual buprenorphine for the primary end point of at least 4 of 6 months with no illicit opioid use by drug testing and self-report among opioid-dependent adults maintaining clinical stability with sublingual buprenorphine.…”

Section: Discussionmentioning

confidence: 99%

“…24 An implantable buprenorphine delivery system reduces adherence issues and may improve efficacy. Furthermore, buprenorphine implants may reduce the need for sublingual buprenorphine, decreasing its availability for diversion, misuse, 23 and harms such as accidental pediatric exposure. 25 This study demonstrated the efficacy of buprenorphine implants in treatment of patients maintaining clinical stability with sublingual buprenorphine in comparison with an active control; preliminary evidence of efficacy relative to placebo was previously demonstrated by reducing opioid use in patients initiating buprenorphine treatment in double-blind, phase 3, placebocontrolled trials.…”

Section: Discussionmentioning

confidence: 99%

Effect of Buprenorphine Implants on Illicit Opioid Use Among Abstinent Adults With Opioid Dependence Treated With Sublingual Buprenorphine

Rosenthal

Lofwall

Kim³

et al. 2016

JAMA

101

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OBJECTIVE To determine whether 6-month buprenorphine implants are noninferior to daily sublingual buprenorphine as maintenance treatment for opioid-dependent patients with stable abstinence. DESIGN, SETTING, AND PARTICIPANTS Outpatient, randomized, active-controlled, 24-week, double-blind, double-dummy study conducted at 21 US sites from June 26, 2014, through May 18, 2015. Outpatients were prescribed daily sublingual buprenorphine for 6 months or more, were abstinent while taking 8 mg/d or less of sublingual buprenorphine for 90 days or longer, and were determined to be clinically stable by their physician. INTERVENTIONS Participants were randomized to receive sublingual buprenorphine plus 4 placebo implants or sublingual placebo plus four 80-mg buprenorphine hydrochloride implants (expected efficacy, 24 weeks). MAIN OUTCOME MEASURE The primary end point was between-group difference in proportion of responders (Ն4 of 6 months without opioid-positive urine test result [monthly and 4 times randomly] and self-report). The noninferiority established for the lower bound of the 95% confidence interval was greater than −0.20 (P < .025). Secondary end points included cumulative percentage of negative opioid urine results, abstinence, and time to first illicit opioid use. Safety was assessed by adverse event reporting. RESULTS Of 177 participants (mean age, 39 years; 40.9% female), 90 were randomized to sublingual buprenorphine with placebo implants and 87 to buprenorphine implants with sublingual placebo; 165 of 177 (93.2%) completed the trial. Eighty-one of 84 (96.4%) receiving buprenorphine implants and 78 of 89 (87.6%) receiving sublingual buprenorphine were responders, an 8.8% difference (1-sided 97.5% CI, 0.009 to ϱ; P < .001 for noninferiority). Over 6 months, 72 of 84 (85.7%) receiving buprenorphine implants and 64 of 89 (71.9%) receiving sublingual buprenorphine maintained opioid abstinence (hazard ratio, 13.8; 95% CI, 0.018-0.258; P = .03). Non-implant-related and implant-related adverse events occurred in 48.3% and 23% of the buprenorphine implant group and in 52.8% and 13.5% of participants in the sublingual buprenorphine group, respectively. CONCLUSIONS AND RELEVANCE Among adults with opioid dependence maintaining abstinence with a stable dose of sublingual buprenorphine, the use of buprenorphine implants compared with continued sublingual buprenorphine did not result in an inferior likelihood of remaining a responder. However, the study population had an exceptionally high response rate in the control group, and further studies are needed in broader populations to assess the efficacy in other settings.

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“…Following the latest evidence about using more frequent urine testing would allow for a more objective evaluation of the retention in the program and provide better outcomes on sustaining opioid-free urinalysis [ 36 ]. Further evaluations of the effectiveness of OAT countries are warranted to monitor the potential adverse effects associated with buprenorphine misuse in MENA [ 1 , 37 ]. The encouraging results of the evaluation of the first pilot OAT program in Lebanon support expanding the access to buprenorphine in Lebanon and other MENA countries in order to treat individuals with opioid use disorder.…”

Section: Discussionmentioning

confidence: 99%

Opiate agonist treatment to improve health of individuals with opioid use disorder in Lebanon

2017

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BackgroundOpioid agonist therapy has been widely used to reduce harms among individuals with opioid use disorder but its effectiveness has not been evaluated in the Middle East North African (MENA) region. This study aims to evaluate the effectiveness of a program using opioid agonist therapy in combination with psychosocial support on improving psychological and social well-being, reducing arrest, and reducing risky behavior in individuals with opioid use disorder in Lebanon.MethodsA one-group pre-test post-test design study was performed at SKOUN Lebanese Addiction Centre between January 2013 and December 2014. Eighty-six out of 181 patients agreed to participate and completed the 3-month assessment and 38 concluded the 12-month assessment. Psychological (depression and anxiety, quality of life), substance dependence/abuse, behavioral (injecting behavior, sharing needles and paraphernalia), and social outcomes were evaluated at baseline, 3, and 12 months post-treatment.ResultsRemarkable statistical significance improvements were observed 3 months after treatment in most outcome variables including quality of life, anxiety, substance dependence, overdose, employment, and injecting behavior. Improvements were sustained 12 months after treatment.ConclusionResults support expanding the access to opioid agonist therapy in other MENA countries to treat substance dependence and reduce harms among individuals with opioid use disorder.

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Addressing misuse and diversion of opioid substitution medication: guidance based on systematic evidence review and real-world experience

Cited by 35 publications

References 26 publications

The lived experience of Australian opioid replacement therapy recipients in a community‐based program in regional Victoria

The lived experience of Australian opioid replacement therapy recipients in a community‐based program in regional Victoria

Effect of Buprenorphine Implants on Illicit Opioid Use Among Abstinent Adults With Opioid Dependence Treated With Sublingual Buprenorphine

Opiate agonist treatment to improve health of individuals with opioid use disorder in Lebanon

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