Journal of addiction medicine
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Across North America, there is an unprecedented opioid overdose epidemic. Approximately 15% of individuals with severe opioid use disorder (OUD) do not benefit from opioid agonist therapy (OAT) such as buprenorphine/naloxone or methadone and are considered treatment refractory. Of those who inject, injectable OAT (iOAT), with hydromorphone or diacetylmorphine, offered in community settings has demonstrated improved retention to treatment and decreased nonprescription opioid use. This case series seeks to describe iOAT initiation and titration in a hospital setting for treatment refractory individuals with OUD and examine impacts of iOAT on leaving hospital against medical advice (AMA). ⋯ This case series describes a novel approach to the management of treatment refractory individuals with severe OUD during hospitalization. Prescribing iOAT in acute care settings is feasible and may reduce rates of leaving hospital AMA.
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A variety of patients - including women, older, racial/ethnic minority, rural, homeless, and justice-involved patients - are vulnerable to experiencing poor healthcare access and quality, such as lower quality substance use disorder treatment, than other populations. The current study examined receipt of medications for opioid use disorder by vulnerable populations within Veterans Health Administration (VHA) facilities to determine whether there are patient and facility factors that are associated with disparities in care. ⋯ Quality improvement efforts targeted at vulnerable populations are needed at the VHA to ensure these groups receive the same quality of substance use disorder treatment as other veterans.
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Some opioid use disorder (OUD) patients attempt to self-treat using herbal remedies such as kratom. However, kratom use itself can paradoxically cause physical dependence and OUD. Currently, there are no guidelines for treating patients with OUD stemming from kratom use. Our empirically-based hypothesis was that there would be a correlation between the amount of kratom used and the amount of buprenorphine-naloxone required for opioid agonist therapy. ⋯ Based on our analysis, patients using <20 g of kratom/d could be initiated on opioid agonist therapy with 4/1 mg-8/2 mg buprenorphine-naloxone/d, while patients using kratom doses >40 g/d could be initiated with 12/3 mg-16/4 mg of buprenorphine-naloxone/day.
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Settings throughout the United States and Canada continue to face escalating overdose epidemics. Notably, history of overdose is associated with increased risk of fatal overdose. ⋯ This may be partially explained by well-documented challenges of oral MOUD, including the need for frequent visits to the pharmacy to receive their medications, which may limit the flexibility to acquire or sustain employment, and therefore contribute to high rates of opioid addiction care discontinuation. This commentary discusses the potential fit of different extended-release injectable MOUD to circumvent limitations of oral formulations, and thereby improve linkage and retention in care of high-risk populations, such as opioid-overdose survivors.
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A rough, visual estimate of pupil size is used in grading the severity of opioid withdrawal. Few studies have examined the clinical utility of more precise automated pupillometry measurements. ⋯ Automated pupillometry demonstrated a small but significant change in mean pupil size that occurred within 15 minutes of OAT dosing and was associated with low withdrawal scores. This pilot may inform future work to incorporate pupillometry measurement into OAT dosing assessments.