Deimplementation in the provision of opioid agonist treatment to achieve equity of care for people engaged in treatment: a qualitative study.

BACKGROUND: Deimplementation, the removal or reduction of potentially hazardous approaches to care, is key to progressing social equity in health. While the benefits of opioid agonist treatment (OAT) are well-evidenced, wide variability in the provision of treatment attenuates positive outcomes. During the COVID-19 pandemic, OAT services deimplemented aspects of provision which had long been central to treatment in Australia; supervised dosing, urine drug screening, and frequent in-person attendance for review. This analysis explored how providers considered social inequity in health of patients in the deimplementation of restrictive OAT provision during the COVID-19 pandemic. METHODS: Between August and December 2020, semi-structured interviews were conducted with 29 OAT providers in Australia. Codes relating to the social determinants of client retention in OAT were clustered according to how providers considered deimplementation in relation to social inequities. Normalisation Process Theory was then used to analyse the clusters in relation to how providers understood their work during the COVID-19 pandemic as responding to systemic issues that condition OAT access. RESULTS: We explored four overarching themes based on constructs from Normalisation Process Theory: adaptive execution, cognitive participation, normative restructuring, and sustainment. Accounts of adaptive execution demonstrated tensions between providers' conceptions of equity and patient autonomy. Cognitive participation and normative restructuring were integral to the workability of rapid and drastic changes within the OAT services. Key transformative actors included communities of practice and "thought leaders" who had long supported deimplementation for more humane care. At this early stage of the pandemic, providers had already begun to consider how this period could inform sustainment of deimplementation. When considering a future, post-pandemic period, several providers expressed discomfort at operating with "evidence-enough" and called for narrowly defined types of data on adverse events (e.g. overdose) and expert consensus on takeaway doses. CONCLUSIONS: The possibilities for achieving social equity in health are limited by the divergent treatment goals of providers and people receiving OAT. Sustained and equitable deimplementation of obtrusive aspects of OAT provision require co-created treatment goals, patient-centred monitoring and evaluation, and access to a supportive community of practice for providers.

Individualizing methadone treatment with split dosing: An underutilized tool.

Methadone's long half-life typically allows for once daily dosing. However, a growing body of evidence and clinical experience shows that some patients may benefit from twice-daily ("split") dosing to produce more stable symptoms and minimize side effects, independent of serum peak-to-trough levels. Concerns regarding split dosing typically center on diversion and poor adherence and must be taken seriously. However, policy changes during COVID-19 demonstrate that the rigidity historically applied to methadone may be unnecessarily stringent. Given clinical advances and policy updates, we believe clinicians should weigh the risks and benefits of this underutilized tool for select patients, as we await the evidence-based recommendations our patients deserve.

Changes to methadone maintenance therapy in the United States, Canada, and Australia during the COVID-19 pandemic: A narrative review.

INTRODUCTION: In response to the COVID-19 pandemic, countries across the world made adaptations to policies regulating the provision of methadone maintenance therapy (MMT) to facilitate social distancing for health care providers and people in treatment. Many countries issued guidance about increasing take-home methadone doses after the onset of the pandemic. METHODS: In this review, we compare the regulation of MMT prior to the pandemic in the United States, Canada, and Australia, analyze changes to treatment policy in the context of COVID-19, and review emerging data on treatment outcomes. RESULTS: The United States only permits the prescription and disbursement of methadone for MMT treatment at federally designated opioid treatment programs (OTPs). Conversely, Australia and Canada operate on a community pharmacy-based distribution model, where patients can access methadone doses either in participating pharmacies or in some methadone clinics. CONCLUSION: Given reports of similar treatment outcomes and increased patient satisfaction since the pandemic-related policy changes, some changes including increased receipt of take-home doses should be considered for incorporation into post-pandemic treatment policies and regulations.

Impacts of the COVID-19 pandemic on enrollment in medications for opioid use disorder (MOUD) in Vancouver, Canada: An interrupted time series analysis.

BACKGROUND: In anticipation of COVID-19 related disruptions to opioid use disorder (OUD) care, new provincial and federal guidance for the management of OUD and risk mitigation guidance (RMG) for prescription of pharmaceutical opioids were introduced in British Columbia, Canada, in March 2020. This study evaluated the combined impacts of the COVID-19 pandemic and counteracting OUD policies on enrollment in medications for OUD (MOUD). METHODS: Using data from three cohorts of people with presumed OUD in Vancouver, we conducted an interrupted time series analysis to estimate the combined effects impact of the COVID-19 pandemic and counteracting OUD policies on the prevalence of enrollment in MOUD overall, as well as in individual MOUDs (methadone, buprenorphine/naloxone, slow-release oral morphine) between November 2018 and November 2021, controlling for pre-existing trends. In sub-analysis we considered RMG opioids together with MOUD. RESULTS: We included 760 participants with presumed OUD. In the post-COVID-19 period, MOUD and slow-release oral morphine prevalence rates showed an estimated immediate increase in level (+7.6%, 95% CI: 0.6%, 14.6% and 1.8%, 95% CI: 0.3%, 3.3%, respectively), followed by a decline in the monthly trend (-0.8% per month, 95% CI: -1.4%, -0.2% and -0.2% per month, 95% CI: -0.4, -0.1, respectively). There were no significant changes in the prevalence trends of enrollment in methadone, buprenorphine/naloxone, or when RMG opioids were considered together with MOUD. CONCLUSIONS: Despite immediate improvements in MOUD enrollment in the post-COVID-19 period, this beneficial trend reversed over time. RMG opioids appeared to have provided additional benefits to sustain retention in OUD care.

SARS-CoV-2 INFECTION AMONG PERSONS WHO INJECT DRUGS AND THEIR PARTNERS IN KENYA

Background: Despite increased social vulnerability and barriers to care, there has been a paucity of data on SARS-CoV-2 incidence among key populations in sub-Saharan Africa. We seek to characterize active infections and define transmission dynamics of SARS-CoV-2 among people who inject drugs (PWID) and their sexual and injecting partners from Nairobi and the coastal region in Kenya. Method(s): This was a nested cross-sectional study of SARS-CoV-2 infection from April to July 2021 within a cohort study of assisted partner services for PWID in Kenya. A total of 1000 PWID and their partners (500 living with and 500 living without HIV) were recruited for SARS-CoV-2 antibody testing, of whom 440 were randomly selected to provide self-collected nasal swabs for real-time PCR testing. Whole genome sequencing (WGS) was completed on a limited subset of samples (N=23) with cycle threshold values 32.0. Phylogenetic tree construction and analysis was performed using the Nextstrain pipeline and compared with publicly available SARS-CoV-2 sequences from GenBank. Result(s): A total of 438 (99.5%) participants provided samples for SARS-CoV-2 PCR testing. Median age was 37 (IQR 32-42);128 (29.2%) were female;and 222 (50.7%) were living with HIV. The overall prevalence of SARS-CoV-2 infection identified by RT-PCR was 86 (19.6%). In univariate analyses, there was no increased relative risk of SARSCoV- 2 infection related to positive HIV status, frequenting an injection den, methadone treatment, unstable housing, report of any high-risk exposure, or having a sexual or injecting partner diagnosed with COVID-19 or who died from COVID-19 or flu-like illness. Eight samples were successfully sequenced via WGS and classified as WHO variants of concern: 3 Delta, 3 Alpha, and 2 Beta. Seven were classified into clades predominantly circulating in Kenya during 2021. Notably, two sequences were identical and matched identically to another Kenyan sequence, which is consistent with, though not indictive of, a transmission linkage. Conclusion(s): Overall, the risk of SARS-CoV-2 infection in this population of PWID and their partners was not significantly associated with risk factors related to injection drug use. At a genomic level, the SARS-CoV-2 strains in this study were consistent with contemporary Kenyan lineages circulating during the time and not unique to PWID. Prevention efforts, therefore, must also focus on marginalized groups for control given the substantial amount of mixing that likely occurs between populations.

Optimizing Medication Treatment of Opioid Use Disorder During COVID-19 (SARS-CoV-2)

The COVID-19 health crisis joined, rather than supplanted, the opioid crisis as the most acutely pressing threats to US public health. In the setting of COVID-19, opioid use disorder treatment paradigms are being disrupted, including the fact that methadone clinics are scrambling to give "take-home"doses where they would typically not. The rapid transition away from in-person examination, dosing and group therapy in an era of social isolation calls for adjustments to clinical practice, including emphasizing patient-provider communication, favoring new inductees on buprenorphine and leveraging technology to optimize safety of medication treatment. Copyright © 2020 American Society of Addiction Medicine.

Opioid Policy Changes During the COVID-19 Pandemic - and Beyond

The United States is currently in the midst of 2 public health emergencies: COVID-19 and the ongoing opioid crisis. In an attempt to reduce preventable harm to individuals with opioid use disorder (OUD), federal, state, and local governments have temporarily modified law and policy to increase access to OUD treatment and divert some individuals at high risk away from the correctional system. In this Commentary, we briefly describe how people with OUD are at increased risk for COVID-19, discuss existing policy barriers to evidence-based prevention and treatment for individuals with OUD, explain the temporary rollbacks of those barriers, and argue that these changes should be made permanent. We also suggest several additional steps that federal and state governments can urgently take to reduce barriers to care for individuals with OUD, both during the current crisis and beyond. Copyright © 2020 American Society of Addiction Medicine.

It's Not Always Just a Rash

[...]it may have been difficult to get him admitted since it is not our current practice to admit patients with mild COVID-19 infections. [...]our financial incentives are to see many patients each shift, which does not always leave time to care for more socially challenging cases. Burnout is rising in the field of emergency medicine, and I think a part of that burnout can be attributed to the uphill battle that providers are fighting daily to care for patients that our health system leaves behind.

Conference Proceedings 33rd AAAP Annual Meeting and Scientific Symposium

The proceedings contain 20 papers. The topics discussed include: the effect of specialty addiction consultation on prescribing medication for opioid use disorder (MOUD) during general hospital admission;mindfulness-based interventions for adolescent drug and alcohol use: a systematic review and meta-analysis;early changes in irritability predict longer-term abstinence from drug use in adults with stimulant use disorder: findings from the stride study;carfentanil, a highly potent opioid responding to high doses of naloxone, what can help?;an inpatient protocol for managing methamphetamine withdrawal;COVID-19 treatment outcome in a cohort of methamphetamine and cannabis users;the impact of COVID-19 on overdose risk and healthcare-seeking behaviors among hospitalized patients with opioid use disorder;and inpatient low dose transitions from full agonist opioids including methadone onto long-acting depot buprenorphine: case series from a multicenter clinical trial.

Payer Strategies to Ensure Access to Care for Individuals With Opioid Use Disorder During COVID-19

[...]increase access to care by reimbursing virtual visits. [...]leverage data to identify and intervene when patients are at risk for recurrence or overdose. In practice, expanded access to buprenorphine reduces diversion and misuse because they occur commonly among individuals seeking relief from withdrawal.2 Compared with buprenorphine monotherapy, buprenorphine-naloxone is associated with lower rates of misuse.2 Mark et al demonstrate that among Medicare beneficiaries, removal of prior authorization for buprenorphine-naloxone doubled treatment rates and significantly reduced emergency department (ED) visits and hospitalizations.4 Ultimately, the lifesaving benefits of expanded access to buprenorphine far outweigh the associated risks. In a time of social distancing, limited personal protective equipment, and transportation barriers, payment and delivery of telehealth is imperative to ensuring access to care. Because many patients do not have reliable access to broadband connection or smartphones, audio-only visits must be reimbursed as well.

Idiopathic anomalous congenital band causing small intestinal obstruction in a 5-month-old dog

A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.

Prevalence of COVID-19 outcomes in patients referred to opioid agonist treatment centers.

Background: Coronavirus disease (COVID-19) is a mild to severe infectious respiratory illness caused by the SARS-CoV-2 virus. Based on the numerous pieces of evidence regarding the role of opioids in immune function, viral replication, and virus-mediated pathology, we decided to assess the incidence and severity of COVID-19 outcomes in people undergoing opioid maintenance treatment. Methods: This is a prospective, descriptive, multi-center study that included 452 patients undergoing maintenance treatment in opioid agonist treatment (OAT) clinics in different cities of Iran. Demographic information, underlying disease, history of maintenance treatment, type of drug used, history of addiction, smoking, and the kind of substance abused, were recorded. A physician evaluated the COVID-19 symptoms, and the severity of the disease was defined based on the number of observed symptoms. Results: The results have not shown any significant difference in the severity of COVID-19 symptoms in different nationalities, gender, and treatment groups. Furthermore, the history of drug abuse, including time and type of abuse and smoking, has not indicated any significant association with the occurrence of symptoms. Only the severity of COVID-19 in the mentioned cities (first and second follow-up: p < 0.001) and individuals with a history of underlying disease (first follow-up: p = 0.020; second follow-up: p = 0.043) were significantly different. Conclusion: Our results have demonstrated that the severity of symptoms in people with the underlying disease was significantly higher than in others. But there is no association between sex, race, treatment groups, and abuse history with the severity of COVID-19 symptoms in methadone maintenance treatment (MMT) patients.

The Promise and Challenges of Integrating Real-World Evidence in Clinical Research

The role of real-world evidence (RWE) in regulatory, drug development, and healthcare decision-making is rapidly expanding. While RWE cannot substitute the evidence obtained from randomized controlled studies (RCTs), the two can be viewed as complementary sources with the same goal of understanding and improving patient's outcomes. However, the hopes of RWE have been tempered by several critical aspects/ challenges such as quality of data sources, potential for systematic bias, or formulating a research question using causal inference framework. In this session, we will discuss commonly encountered issues and recommend key methodological considerations and potential solutions for (1) assessing representativeness and generalizing results from experimental to non-experimental studies, (2) identifying under-represented groups in clinical trials for pharmacotherapy for opioid use disorder, (3) characterizing and increasing diversity in clinical trials, and (4) assessing biases and constructing valid ''synthetic control'' arms for (oncology) clinical trials. Each speaker will have 15-20 min each, followed by a 10-min discussion. Additional Q&A time will be allocated at the end of the session. The individual s are described in more detail below. (1) Ben Ackerman;Title: Using real-world data to assess representativeness and improve generalizations of study findings Randomized trials are considered the gold standard for estimating causal effects. Trial findings are often used to inform policy and programming efforts, yet their results may not generalize well to a relevant target population if the trial sample is not representative of the population of interest. More specifically, generalizations will be hindered if a trial is not similar to the population with respect to characteristics that moderate the treatment effect. Statistical methods have been developed to assess representativeness and improve generalizability by combining trials with data from non-experimental studies. Real-world datasets derived from electronic health records are promising resources that can supplement trial data when applying such methods. However, identifying the right real-world data source with the appropriate characteristics captured can be challenging in practice. In this talk, we will articulate a framework for combining trial and real-world data to assess representativeness and ultimately addressing concerns of generalizability. Through this framework, we will provide guidance on defining the target population of interest, identifying a suitable real-world data source describing that population, harmonizing across the data sources, and drawing meaningful comparisons between the trial and target population. This work will provide researchers with methods and tools to contextualize trial findings within the target population of interest through the use of real-world data. (2) Kara Rudolph;Title: Characterizing subgroups that are under-represented in clinical trials for pharmacotherapy for opioid use disorder The opioid epidemic in the United States is a public health emergency, exacerbated by the Covid-19 pandemic. Medications for opioid use disorder (MOUD)- injection naltrexone, buprenorphine, and methadone- are the most effective tools for improving outcomes and preventing overdose among persons with opioid use disorder (OUD), but engagement in MOUD, especially long-term engagement typically required for a successful outcome, is unacceptably low. Long-term engagement rates tend to be even lower in real-world settings-what National Institute on Drug Abuse (NIDA) has termed the research-to-practice gap. This discrepancy between trial and real-world MOUD effectiveness could be partially attributable to differences between clinical trial and real-world population characteristics (e.g. in terms of psychiatric and substance use comorbidities, previous treatment experience, and immigration status) if treatment effects are modified (increased/decreased) by some of these characteristics that also relate to trial participation. We identif and characterize clinically meaningful, interpretable subgroups of persons seeking OUD treatment in US usualcare settings who are not represented or underrepresented in MOUD trials based on multiple characteristics simultaneously. This moves us beyond existing approaches for assessing representation that have generally been limited to considering one individual-level characteristic at a time (e.g. race/ethnicity). (3) Madison Stoms;Title: Minority representation in clinical trials: generalizing trial results to diverse populations Since its origin, medical research has persistently lacked minority representation. In 2020 alone, the US Food and Drug Administration (FDA) reported that a mere 6% and 11% of clinical trial participants report Black and Hispanic race, respectively. Along with efforts to directly increase representation, via revised recruitment strategies, methods are being developed to leverage external data containing information on under-represented populations. The field from which these methods arise, real-world evidence (RWE), is rapidly emerging and aims to address clinical questions outside the scope of clinical trials. In this talk, we focus on generalizability and transportability methods, which can be used to extrapolate results from mostly racially homogeneous samples to diverse populations. We will also discuss the current state of diversity in clinical trials, important assumptions of generalizability and transportability methods, and applications relevant to increasing racial/ethnic representation. (4) Elizabeth Garrett-Mayer;Title: Leveraging RWD for new indications for FDA-approved anticancer agents: are we there yet? Vast amounts of health outcome data are available in real-world datasets (RWDs), like electronic health record databases and medical claim databases. In rare disease settings, performing randomized trials may be resource-intensive and inefficient due to accrual challenges. Efforts have been made to derive ''control arms'' from RWDs, representing a standard of care treatment arm, so all (or most) patients prospectively enrolled in a trial can be assigned to an experimental arm. Major challenges exist in ensuring that comparisons between the arms are meaningful, valid, and unbiased. This talk will discuss challenges, including potential for biases, harmonizing outcome measures, and efforts moving forward that will facilitate supplementing clinical trial data with RWD.

The Virtues of Osteopathic Manipulative Treatments in Patients with Opioid Use Disorder

As America continues to face the opioid epidemic, numerous people have made great strides in receiving formal treatment for their opioid use disorder (OUD). This research seeks to examine the effects of providing osteopathic manipulative treatment (OMT) along with traditional OUD pharmacological methods in providing results for patients. By using prior research on OMT techniques, we were able to uncover how effective OMT can be in reducing the time and discomfort associated with seeking opioid recovery. Osteopathic manipulative treatment, in combination with traditional pharmacology, was associated with reduction of somatic pain, higher success with medication-assisted treatment and lower costs. This research also highlights the importance of OMT in the era of COVID-19 social distancing, as well as special considerations when treating those with trauma histories associated with their disorder. We argue the benefit of OMT in combination with pharmacological methods can be successful at reducing the overall burden of prior OUDs.Copyright © 2023 by the American College of Osteopathic Family Physicians. All rights reserved.

Patient experiences of methadone treatment changes during the first wave of COVID-19: a national community-driven survey.

BACKGROUND: During COVID-19, the Substance Abuse and Mental Health Services Administration (SAMHSA) allowed Methadone Maintenance Treatment (MMT) programs to relax in-person MMT requirements to reduce COVID-19 exposure. This study examines patient-reported changes to in-person methadone clinic attendance requirements during COVID-19. METHODS: From June 7, 2020, to July 15, 2020, a convenience sample of methadone patients (N = 392) were recruited in collaboration with National Survivors Union (NSU) in 43 states and Washington D.C. through social media (Facebook, Reddit, Twitter, and Web site pop-ups). The community-driven research (CDR) online survey collected information on how patient take-home methadone dosing and in-person drug testing, counseling, and clinic visit frequency changed prior to COVID-19 (before March 2020) to during COVID-19 (June and July 2020). RESULTS: During the study time period, the percentage of respondents receiving at least 14 days of take-home doses increased from 22 to 53%, while the percentage receiving one or no take-home doses decreased from 22.4% before COVID-19 to 10.2% during COVID-19. In-person counseling attendance decreased from 82.9% to 19.4%. While only 3.3% of respondents accessed counseling through telehealth before COVID-19, this percentage increased to 61.7% during COVID-19. Many respondents (41.3%) reported visiting their clinics in person once a week or more during COVID-19. CONCLUSIONS: During the first wave of COVID-19, methadone patients report decreased in-person clinic attendance and increased take-home doses and use of telehealth for counseling services. However, respondents reported considerable variations, and many were still required to make frequent in-person clinic visits, which put patients at risk of COVID-19 exposure. Relaxations of MMT in-person requirements during COVID-19 should be consistently implemented and made permanent, and patient experiences of these changes should be explored further.

Incremental expenditures attributable to daily dispensation and witnessed ingestion for opioid agonist treatment in British Columbia: 2014-20.

BACKGROUND AND AIM: While daily witnessed opioid agonist treatment (OAT) ingestion is common in British Columbia (BC), Canada, and elsewhere, sparse evidence supports this resource-intensive practice. Many settings across North America relaxed restrictions for take-home dosing during the COVID-19 pandemic and have reported consistent or improved patient outcomes. This study measured excess expenditures attributed to daily witnessed pharmacy dispensing compared with weekly or biweekly dispensation schedules. DESIGN, SETTING AND PARTICIPANTS: This study was a population-level retrospective analysis. We included all methadone, buprenorphine/naloxone and slow-release oral morphine dispensations in BC from 1 January 2014 to 30 December 2020. A total of 24 357 107 OAT dispensations among 51 195 unique individuals with 122 793 person-years of follow-up were included during the study period. MEASUREMENTS: Total expenditures for each person-week of OAT with an estimated expenditure under two scenarios are as follows: (1) a weekly dispensation scenario and (2) a biweekly dispensation scenario. FINDINGS: We estimated excess expenditures attributable to current dispensing practices of between $38 million (2014) and $47.4 million (2018) compared with a hypothetical weekly dispensing schedule, and $43.9 million (2014) to $54.9 million (2018) compared with biweekly dispensing. The majority of these expenditures (58-64%) were attributed to pharmacy dispensing fees ($23 million in 2014 to $30 million in 2018 compared with weekly dispensing; $26.6 million in 2014 to $34.7 million in 2018 compared with biweekly dispensing). CONCLUSION: Daily witnessed opioid agonist treatment ingestion results in more than $30 million in excess expenditures annually in the province of British Columbia, Canada compared with the costs of weekly or biweekly dispensation schedules.

The development and validation of the pandemic medication-assisted treatment questionnaire for the assessment of pandemic crises impact on medication management and administration for patients with opioid use disorders.

Pandemic and the globally applied restriction measures mainly affect vulnerable population groups, such as patients with opioid use disorders. Towards inhibiting SARS-Cov-2 spread, the medication-assisted treatment (MAT) programs follow strategies targeting the reduction of in-person psychosocial interventions and an increase of take-home doses. However, there is no available instrument to examine the impact of such modifications on diverse health aspects of patients under MAT. The aim of this study was to develop and validate the PANdemic Medication-Assisted Treatment Questionnaire (PANMAT/Q) to address the pandemic effect on the management and administration of MAT. In total, 463 patients under ΜΑΤ participated. Our findings indicate that PANMAT/Q has been successfully validated exerting reliability and validity. It can be completed within approximately 5 min, and its implementation in research settings is advocated. PANMAT/Q could serve as a useful tool to identify the needs of patients under MAT being at high risk of relapse and overdose.

Use of Methadone Versus Oxycodone to Facilitate Weaning of Parenteral Opioids in Critically Ill Adult Patients.

BACKGROUND: No previous literature has compared methadone with oxycodone for intravenous (IV) opioid weaning. OBJECTIVE: To determine if a weaning strategy using enteral methadone or oxycodone results in faster time to IV opioid discontinuation. METHODS: This was a single-center, retrospective, cohort medical record review of mechanically ventilated adults in an intensive care unit (ICU) who received a continuous IV infusion of fentanyl or hydromorphone for ≥72 hours and an enteral weaning strategy using either methadone or oxycodone from January 1, 2020, through December 31, 2021. Differences between groups were controlled for using Cox proportional hazards models. The primary outcome was time to continuous IV opioid discontinuation from the initiation of enteral opioids. Secondary outcomes included the primary endpoint stratified for COVID-19, duration of mechanical ventilation, ICU and hospital length of stay, and safety measures. RESULTS: Ninety-three patients were included, with 36 (38.7%) patients receiving methadone and 57 (61.3%) receiving oxycodone. Patients weaned using methadone received IV opioids significantly longer before the start of weaning (P = 0.04). However, those on methadone had a significantly faster time to discontinuation of IV opioids than those on oxycodone, mean (standard deviation) 104.7 (79.4) versus 158.3 hours (171.2), P = 0.04, and, at any time, were 1.89 times as likely to be weaned from IV opioids (hazard ratio, HR 1.89, 95% confidence interval, CI 1.16-3.07, P = 0.01). CONCLUSION AND RELEVANCE: This was the first study showing enteral methadone was associated with a shorter duration of IV opioids without differences in secondary outcomes compared with oxycodone. Prospective research is necessary to confirm this finding.

How to advise women on the safe use of medicines while breastfeeding

Medicines use plays an important role in women's decisions to start or continue breastfeeding. Some may stop breastfeeding or the medicine to avoid combining the two, as they feel very strongly about tainting their milk when breastfeeding[10]. Women deserve to be involved in discussions on compatibility, using evidence-based resources presented in a manner in which they can understand. There is a presumption by some healthcare professionals, mothers, families and wider society that formula has benefits over breast milk with a trace of medication in, or that adverse events are likely and serious if this breast milk is consumed. In addition, there is a reticence from healthcare professionals to use professional judgement and go outside the licence application for medicines. This leaves the mother with a dilemma: to interrupt or stop breastfeeding to take the medication, or to delay medication - with chronic diseases, the latter is rarely an acceptable option. In January 2021, the MHRA launched the Safer Medicines Consortium, owing to the "need for reliable and consistent information about medicines used before or during pregnancy and breastfeeding for women and the healthcare professionals who advise them". The vision of the consortium is that "all women will have access to accurate and accessible information to make informed decisions with their healthcare professional about taking medicines before or during pregnancy or breastfeeding"[44]. As experts in medicines, pharmacists should share evidence-based information with the mother and support her in making a decision that is right for her and her baby, as outlined above. Copyright © 2021 Pharmaceutical Press. All rights reserved.