Economic Evaluation of Extended-Release Buprenorphine for Persons With Opioid Use Disorder.

Importance: In 2017, the US Food and Drug Administration (FDA) approved a monthly injectable form of buprenorphine, extended-release buprenorphine; published data show that extended-release buprenorphine is effective compared with no treatment, but its current cost is higher and current retention is lower than that of transmucosal buprenorphine. Preliminary research suggests that extended-release buprenorphine may be an important addition to treatment options, but the cost-effectiveness of extended-release buprenorphine compared with transmucosal buprenorphine remains unclear. Objective: To evaluate the cost-effectiveness of extended-release buprenorphine compared with transmucosal buprenorphine. Design, Setting, and Participants: This economic evaluation used a state transition model starting in 2019 to simulate the lifetime of a closed cohort of individuals with OUD presenting for evaluation for opioid agonist treatment with buprenorphine. The data sources used to estimate model parameters included cohort studies, clinical trials, and administrative data. The model relied on pharmaceutical costs from the Federal Supply Schedule and health care utilization costs from published studies. Data were analyzed from September 2021 to January 2023. Interventions: No treatment, treatment with transmucosal buprenorphine, or treatment with extended-release buprenorphine. Main Outcomes and Measures: Mean lifetime costs per person, discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Results: The simulated cohort included 100 000 patients with OUD receiving (61% male; mean [SD] age, 38 [11] years) or not receiving medication treatment (58% male, mean [SD] age, 48 [18] years). Compared with no medication treatment, treatment with transmucosal buprenorphine yielded an ICER of $19 740 per QALY. Compared with treatment with transmucosal buprenorphine, treatment with extended-release buprenorphine yielded lower effectiveness by 0.03 QALYs per person at higher cost, suggesting that treatment with extended-release buprenorphine was dominated and not preferred. In probabilistic sensitivity analyses, treatment with transmucosal buprenorphine was the preferred strategy 60% of the time. Treatment with extended-release buprenorphine was cost-effective compared with treatment with transmucosal buprenorphine at a $100 000 per QALY willingness-to-pay threshold only after substantial changes in key parameters. Conclusions and Relevance: In this economic evaluation of extended-release buprenorphine compared with transmucosal buprenorphine for the treatment of OUD, extended-release buprenorphine was not associated with efficient allocation of limited resources when transmucosal buprenorphine was available. Future initiatives should aim to improve retention rates or decrease costs associated with extended-release buprenorphine.

Evaluation of the perioperative analgesic effects of grapiprant compared with carprofen in dogs undergoing elective ovariohysterectomy.

OBJECTIVE: To evaluate and compare postoperative analgesic effects of grapiprant and carprofen in dogs undergoing ovariohysterectomy. ANIMALS: 42 sexually intact female healthy dogs (< 35 kg and 0.5 to 7 years old) were enrolled. PROCEDURES: In a masked, randomized, noninferiority clinical trial, dogs received either 2 mg/kg of grapiprant or 4.4 mg/kg of carprofen orally 2 hours prior to ovariohysterectomy. Postoperative pain was assessed using the Glasgow Composite Pain Scale-Short Form (GCPS-SF) at extubation and 2, 4, 6, 8, 18, and 24 hours postextubation and compared to baseline. After each pain scoring, mechanical nociceptive testing with von Frey monofilaments (vF) was performed to assess hyperalgesia. Hydromorphone (0.05 mg/kg, IM) was administered to any dog with a GCPS-SF of ≥ 5/24. The noninferiority limit (NI) for the GCPS-SF was Δ = 3. The NI for vF was Δ = -0.2. Following noninferiority, a mixed-effect ANOVA and post hoc comparisons were made with the Tukey correction method (P < .05). RESULTS: 3 dogs required rescue analgesia and were excluded from statistical analysis. Of the remaining 39 dogs, the upper CI for GCPS-SF was below the NI of 3 and the lower CI for vF was greater than the NI of -0.2, indicating noninferiority of grapiprant as compared to carprofen. There was no difference between treatment (P = .89) nor treatment by time (P = .62) for GCPS-SF. There was no difference between groups at any time point or over time when vF were used. CLINICAL RELEVANCE: Our study results support the use of grapiprant as an analgesic alternative to carprofen in dogs undergoing ovariohysterectomy.

Factors associated with opioid-involved overdose among previously incarcerated people in the U.S.: A community engaged narrative review.

BACKGROUND: People with a history of incarceration are at high risk for opioid overdose. A variety of factors contribute to this elevated risk though our understanding of these factors is deficient. Research to identify risk and protective factors for overdose is often conducted using administrative data or researcher-derived surveys and without explicit input from people with lived experience. We aimed to understand the scope of U.S. research on factors associated with opioid overdose among previously incarcerated people. We did this by conducting a narrative review of the literature and convening expert panels of people with lived experience. We then categorized these factors using a social determinants of health framework to help contextualize our findings. METHODS: We first conducted a narrative review of the published literature. A search was performed using PubMed and APA PsycInfo. We then convened two expert panels consisting of people with lived experience and people who work with people who were previously incarcerated. Experts were asked to evaluate the literature derived factors for completeness and add factors that were not identified. Finally, we categorized factors as either intermediary or structural according to the World Health Organization's Social Determinants of Health (SDOH) Framework. RESULTS: We identified 13 papers that met our inclusion criteria for the narrative review. Within these 13 papers, we identified 22 relevant factors for their role in the relationship between overdose and people with a history of incarceration, 16 were risk factors and six were protective factors. Five of these were structural factors (three risk and two protective) and 17 were intermediary factors (13 risk and four protective). The expert panels identified 21 additional factors, 10 of which were structural (six risk and four protective) and 11 of which were intermediary (eight risk and three protective). CONCLUSION: This narrative review along with expert panels demonstrates a gap in the published literature regarding factors associated with overdose among people who were previously incarcerated. Additionally, this review highlights a substantial gap with regard to the types of factors that are typically identified. Incorporating voices of people with lived experience is crucial to our understanding of overdose in this at-risk population.

Sedation Characteristics of Intranasal Alfaxalone in Adult Yucatan Swine.

Compared with intravenous and intramuscular methods, intranasal administration of sedatives is a less invasive and nonpainful technique. In this prospective, randomized, crossover study, we evaluated the sedative characteristics of 2 doses (1 and 2 mg/kg) of alfaxalone administered intranasally to 7 adult Yucatan swine. We compared sedation scores before and after administration of alfaxalone and between groups by using a composite sedation scoring system (range, 0 to 12, with 12 being the highest level of sedation)). Pigs were randomly assigned to receive 2 doses of intranasal alfaxalone (1 mg/kg [A1]); 2 mg/kg [A2]) as 2 separate events in a crossover design with a 60-d washout period. Categories scored were posture, palpebral droop, uninhibited behavior, drowsiness, and acceptance of anesthetic facemask. Sedation scores were collected before sedation was administered and then every 3 min for 30 min afterward. Instilled volumes (mean ± 1 SD) were 5.7 ± 0.5 and 11.3 ± 0.8 mL for A1 and A2, respectively. Both alfaxalone doses produced significant increases in sedation scores compared with baseline. Median sedation scores for A1 (6; range, 4-12) were not different from those for A2 (6; range, 6 to 12). Intranasal administration of alfaxalone as the sole sedative agent increased sedation scores from baseline, achieving peak sedation at 6 to 9 min after instillation of A2. However, sedation scores were similar between the 2 groups, and neither dose produced sufficient sedation to facilitate handling or the performance of any clinical procedures. Given the concentration of alfaxalone solution currently available, volume is the major limiting factor regarding testing higher doses of this drug for its use as a sole sedative agent in swine.

Progression from oral to oedipal themes: a defense against experiences of object loss.

This paper will focus on a patient whose associations appeared to involve triangular, oedipally organized themes, but who also had a severely compromised ego. This apparent discrepancy in development can be understood as a defensive maneuver. The defense protected him from experiencing object loss as he reflected on a deprived childhood, sought assistance in managing current romances, and developed a transference and relationship in the therapeutic situation. Discussion of case material, in light of traditional psychoanalytic perspectives, including those put forth by A. Freud, Winnicott, Zetzel, and Brenner, will address whether an apparent "progression" from a cluster of features associated with one phase to those associated with another can serve as a defense. Although "progression" is perhaps not the best term for this phenomenon, it will serve as a concise description for the sake of this article.