The Naloxone Component of Buprenorphine/Naloxone: Discouraging Misuse, but at What Cost?

Because opioid overdose deaths in the United States continue to rise, it is critical to increase patient access to buprenorphine, which treats opioid use disorder and reduces mortality. An underrecognized barrier to buprenorphine treatment (both for maintenance and treatment of acute withdrawal) is limited access to buprenorphine monoproduct. In the United States, buprenorphine is primarily prescribed as a combination product also containing naloxone, added to reduce the potential for misuse. Because naloxone has relatively low sublingual bioavailability compared with buprenorphine, adverse effects are generally considered mild and rare. The authors' clinical experience, however, suggests that adverse effects may be less benign than generally accepted and can have negative effects for the patient, the provider-patient relationship, and the health care system as a whole. The insistence on prescribing combination product can foster stigma and mistrust, creating barriers to care and increased risk of overdose and death.

"It wasn't here, and now it is. It's everywhere": fentanyl's rising presence in Oregon's drug supply.

BACKGROUND: Illicit fentanyl has contributed to a drastic increase in overdose drug deaths. While fentanyl has subsumed the drug supply in the Northeastern and Midwestern USA, it has more recently reached the Western USA. For this study, we explored perspectives of people who use drugs (PWUD) on the changing drug supply in Oregon, experiences of and response to fentanyl-involved overdose, and recommendations from PWUD to reduce overdose risk within the context of illicit fentanyl's dramatic increase in the recreational drug supply over the past decade. METHODS: We conducted in-depth interviews by phone with 34 PWUD in Oregon from May to June of 2021. We used thematic analysis to analyze transcripts and construct themes. RESULTS: PWUD knew about fentanyl, expressed concern about fentanyl pills, and were aware of other illicit drugs containing fentanyl. Participants were aware of the increased risk of an overdose but remained reluctant to engage with professional first responders due to fear of arrest. Participants had recommendations for reducing fentanyl overdose risk, including increasing access to information, harm reduction supplies (e.g., naloxone, fentanyl test strips), and medications for opioid use disorder; establishing drug checking services and overdose prevention sites; legalizing and regulating the drug supply; and reducing stigma enacted by healthcare providers. CONCLUSION: PWUD in Oregon are aware of the rise of fentanyl and fentanyl pills and desire access to tools to reduce harm from fentanyl. As states in the Western USA face an inflection point of fentanyl in the drug supply, public health staff, behavioral health providers, and first responders can take action identified by the needs of PWUD.

Correlates of days of medication for opioid use disorder exposure among people living with HIV in Northern Vietnam.

BACKGROUND: In Vietnam, access to medications for opioid use disorder (MOUD) for people living with HIV has rapidly expanded, but MOUD use over time remains low. We sought to assess factors associated with days of MOUD treatment exposure. METHODS: From 2015 to 2019, patients with OUD in six Northern Vietnamese HIV clinics were randomized to receive HIV clinic-based buprenorphine (BUP/NX) or referral for methadone maintenance therapy (MMT) and followed for 12 months. All MOUD doses were directly observed and abstracted from dosing logs. The primary outcome was days of MOUD treatment exposure (buprenorphine or methadone) received over 12 months. Negative binomial regression modelled associations with days of MOUD exposure. RESULTS: Of 281 participants, 264 (94%) were eligible for analysis. Participants were primarily male (97%), unmarried (61%), employed (54%), and previously arrested (83%). Participants had a mean 187 (SD 150) days of MOUD exposure with 134 (51%) having at least 180 days, and 35 (13.2%) having at least 360 days of MOUD exposure. Age (IRR 1.26, 95% CI 1.02-1.55), income (IRR 0.96, 95% CI 0.93-1.001), and methadone (IRR 1.88, 95% CI 1.51-2.42) were associated with MOUD exposure in multivariate models. Multivariate models predicted 127 (95% CL 109-147) days of MOUD exposure for HIV clinic based-buprenorphine vs 243 (95% CL 205-288) for MMT. CONCLUSION: MOUD treatment exposure was suboptimal among patients with HIV and OUD in Northern Vietnam and was influenced by several factors. Interventions to support populations at risk of lower MOUD exposure as well programs administering MOUD should be considered in countries seeking to expand access to MOUD.

Discontinuing Methadone and Buprenorphine: A Review and Clinical Challenges.

This paper offers a review and recommendations for clinicians working with patients interested in discontinuing opioid agonist treatment. As buprenorphine/naloxone has gained widespread acceptance for opioid addiction, many treatment providers and patients have a range of hopes and expectations about its optimal use. A surprising number assume buprenorphine/naloxone is primarily useful as a medication to transition off illicit opioid use, and success is partially defined by discontinuing the medication. Despite accumulating evidence that a majority of patients will need to remain on medication to preserve their gains, clinicians often have to address a patient's fervent desire to taper. Using the concept of "recovery capital," our review addresses (1) the appropriate duration of opioid agonist treatment, (2) risks associated with discontinuing, (3) a checklist that guides the patient through self-assessment of the wisdom of discontinuing opioid agonist treatment, and (4) shared decision making about how to proceed.

Analysis of emergency department visits for all reasons by adults with depression in the United States.

BACKGROUND: We aimed to characterize Emergency Department (ED) utilization and outcomes of patients with depression seeking emergency care for all reasons. METHODS: Using 2014-2016 ED data from the National Hospital Ambulatory Medical Care Survey, we investigated demographics, ED resource utilization, clinical characteristics, and disposition of patients with depression versus those without depression. RESULTS: Approximately 10,626,184 (11.4%) out of 92,899,685 annual ED visits were by patients with depression. ED patients with depression were mostly non-Hispanic White (74.0%) and were less likely to be male than patients without depression (aOR: 0.62; [95%] CI: 0.57-0.68). ED patients with depression were more likely to be admitted to the hospital (aOR: 1.50; CI: 1.38-1.63) than patients without depression. Among ED patients with depression, males were more likely than females to be seeking emergency care for psychiatric reasons (OR: 2.45; 95% CI: 2.10-2.87)) and to present with overdose/poisoning (OR: 1.46; CI: 1.03-2.05). CONCLUSIONS: We described the unique demographic, socioeconomic, and clinical characteristics of ED patients with depression, using the most comprehensive, nationally representative study to date. We revealed notable gender disparities in rates and reasons for admissions. The higher hospital and ICU admission rates of ED patients with depression suggests this population requires a higher level of emergency care, for reasons that remain poorly understood.