Transitioning from methadone to buprenorphine maintenance in management of opioid use disorder during pregnancy

Background: Opioid use disorder during pregnancy is a growing health concern. Methadone maintenance is the treatment of choice but emerging data indicate buprenorphine is a viable alternative. Due to costs and limited accessibility of methadone, pregnant women may require transition from methadone to buprenorphine for maintenance treatment. Objectives: To assess safety and effectiveness of transitioning from methadone to buprenorphine when necessary during pregnancy. Methods: A standardized protocol using low buprenorphine doses to minimize emergent withdrawal symptoms under careful obstetric and psychiatric monitoring was implemented in 20 pregnant women. Outpatient maternal and neonatal outcomes were assessed. Results: Women maintained on an average methadone dose of 44 ± 4.77 (20–100) mg/day (mean±standard error mean (SEM); range) were successfully transitioned to 12.60 ± 0.8 (8–16) mg/day (mean±SEM; range) of buprenorphine. Within 4 weeks of transition, 15% had illicit drugs detected in urine drug screens. Ninety percent of women maintained outpatient follow-up until delivery. At delivery, 38.9% of mothers were exclusively adherent to buprenorphine (without use of illicit substances and/or other psychotropic medications); this resulted in significantly lower rates of neonatal abstinence syndrome (NAS) and shorter hospital stays. Discussion: Pregnant women transitioned from methadone to buprenorphine maintenance showed maternal and neonatal outcomes comparable to studies of women on buprenorphine throughout pregnancy. Infants born to buprenorphine-maintained women who abstained from illicit substances and other prescribed psychotropic medications experienced less severe NAS and shorter hospitalizations compared with women with illicit substance use and other psychotropic medications. These findings suggest women can safely be transitioned from methadone to buprenorphine during pregnancy.     

A meta-analysis comparing buprenorphine to methadone for treatment of opiate dependence

Background. The unique pharmacological properties of buprenorphine may make it a useful maintenance therapy for opiate addiction. This meta-analysis considers the effectiveness of buprenorphine relative to methadone. Methods. A systematic literature search identified five randomized clinical trials comparing buprenorphine to methadone. Data from these trials were obtained. Retention in treatment was analyzed with a Cox proportional hazards regression. Urinalyses for opiates were studied with analysis of variance and a common method of handling missing values. A meta-analysis was used to combine these results. Results. Subjects who received 8-12 mg/day buprenorphine had 1.26 times the relative risk of discontinuing treatment (95% confidence interval 1.01-1.57) and 8.3% more positive urinalyses (95% confidence interval 2.7-14%) than subjects receiving 50-80 mg/day methadone. Buprenophrine was more effective than 20-35 mg/day methadone. There was substantial variation in outcomes in the different trials. Conclusions. The variation between trials may be due to differences in dose levels, patient exclusion criteria and provision of psychosocial treatment. The difference in the effectiveness of buprenorphine and methadone may be statistically significant, but the differences are small compared to the wide variance in outcomes achieved in different methadone treatment programs. Further research is needed to determine if buprenorphine treatment is more effective than methadone in particular settings or in particular subgroups of patients.     

Barriers and facilitators to end-of-life care communication for patients with COPD

OBJECTIVE: Patients with COPD frequently do not discuss end-of-life care with physicians; therefore, we sought to identify the barriers and facilitators to this communication as a first step to overcoming barriers and capitalizing on facilitators. DESIGN: Fifteen barriers and 11 facilitators to patient-physician communication about end-of-life care were generated from focus groups of patients with COPD. We subsequently conducted a cross-sectional study of 115 patients with oxygen-dependent COPD and their physicians to identify the common barriers and facilitators and examine the association of these barriers and facilitators with communication about end-of-life care. PARTICIPANTS AND SETTING: Patients with oxygen-dependent COPD were recruited from clinics at a university, county, and Veterans Affairs teaching hospital, and an oxygen delivery company. We also recruited the physician identified by each patient as the doctor primarily responsible for their lung disease. MEASUREMENTS AND RESULTS: Patients were interviewed by trained research interviewers. Physician data collection was completed by mail survey. Participation rates were 40% for patients and 86% for physicians. Only 32% of patients reported having a discussion about end-of-life care with their physician. Two of 15 barriers and 8 of 11 facilitators were endorsed by > 50% of patients. The most commonly endorsed barriers were "I'd rather concentrate on staying alive," and "I'm not sure which doctor will be taking care of me." Two barriers were significantly associated with lack of communication, as follows: "I don't know what kind of care I want," and "I'm not sure which doctor will be taking care of me." The greater the number of barriers endorsed by patients, the less likely they were to have discussed end-of-life care with physicians (p < 0.01), suggesting the validity of these barriers. Conversely, the more facilitators, the more likely patients were to report having had end-of-life discussions with their physicians (p < 0.001). CONCLUSION: Although patients endorsed many barriers and facilitators, few barriers were endorsed by most patients. Barriers and facilitators associated with communication are targets for interventions to improve end-of-life care, but such interventions will likely need to address the specific barriers relevant to individual patient-physician pairs.     

Buprenorphine versus methadone maintenance for the treatment of opioid dependence

Aims. To evaluate the effectiveness of buprenorphine compared with methadone maintenance therapy in opiate addicts over a treatment period of 24 weeks. Design. Subjects were randomized to receive either buprenorphine or methadone in an open, comparative study. Setting. Subjects were recruited and treated at the drug addiction outpatient clinic at the University of Vienna. Participants. Sixty subjects (19 females and 41 males) who met DSM-IV criteria for opioid dependence and were seeking treatment. Intervention. Subjects received either sublingual buprenorphine (2-mg or 8-mg tablets; maximum daily dose 8 mg) or oral methadone (racemic D -/+ L-methadone; maximum daily dose 80 mg). A stable dose was maintained following the 6-day induction phase. Measurement. Assessment of treatment retention and illicit substance use (opiates, cocaine and benzodiazepines) was made by urinalysis. Findings. The retention rate was significantly better in the methadone maintained group (p< 0.05) but subjects completing the study in the buprenorphine group had significantly lower rates of illicit opiate consumption (p = 0.04). Conclusion. The results support the superiority of methadone with respect to retention rate. However, they also confirm previous reports of buprenorphine use as an alternative in maintenance therapy for opiate addiction, suggesting that a specific subgroup may be benefiting from buprenorphine. This is the first comparative trial to use sublingual buprenorphine tablets: previously published comparison studies refer to 30% solutions of buprenorphine in alcohol.     

Buprenorphine-based regimens and methadone for the medical management of opioid dependence: selecting the appropriate drug for treatment

Maintenance therapy with methadone or buprenorphine‐based regimens reduces opioid dependence and associated harms. The perception that methadone is more effective than buprenorphine for maintenance treatment has been based on low buprenorphine doses and excessively slow induction regimens used in early buprenorphine trials. Subsequent studies show that the efficacy of buprenorphine sublingual tablet (Subutex®) or buprenorphine/naloxone sublingual tablet (Suboxone®) is equivalent to that of methadone when sufficient buprenorphine doses, rapid induction, and flexible dosing are used. Although methadone remains an essential maintenance therapy option, buprenorphine‐based regimens increase access to care and provide safer, more appropriate treatment than methadone for some patients. (Am J Addict 2010;00:1–12)     

The impact of buprenorphine and methadone on mortality: a primary care cohort study in the United Kingdom

Aims

To estimate whether opioid substitution treatment (OST) with buprenorphine or methadone is associated with a greater reduction in the risk of all‐cause mortality (ACM) and opioid drug‐related poisoning (DRP) mortality.

Design

Cohort study with linkage between clinical records from Clinical Practice Research Datalink and mortality register.

Setting

UK primary care.

Participants

A total of 11 033 opioid‐dependent patients who received OST from 1998 to 2014, followed‐up for 30 410 person‐years.

Measurements

Exposure to methadone (17 373, 61%) OST episodes or buprenorphine (9173, 39%) OST episodes. ACM was available for all patients; information on cause of death and DRP was available for 5935 patients (54%) followed‐up for 16 363 person‐years. Poisson regression modelled mortality by treatment period with an interaction between OST type and treatment period (first 4 weeks on OST, rest of time off OST, first 4 weeks off OST, rest of time out of OST censored at 12 months) to test whether ACM or DRP differed between methadone and buprenorphine. Inverse probability weights were included to adjust for confounding and balance characteristics of patients prescribed methadone or buprenorphine.

Findings

ACM and DRP rates were 1.93 and 0.53 per 100 person‐years, respectively. DRP was elevated during the first 4 weeks of OST [incidence rate ratio (IRR) = 1.93 95% confidence interval (CI) = 0.97–3.82], the first 4 weeks off OST (IRR = 8.15, 95% CI = 5.45–12.19) and the rest of time out of OST (IRR = 2.13, 95% CI = 1.47–3.09) compared with mortality risk from 4 weeks to end of treatment. Patients on buprenorphine compared with methadone had lower ACM rates in each treatment period. After adjustment, there was evidence of a lower DRP risk for patients on buprenorphine compared with methadone at treatment initiation (IRR = 0.08, 95% CI = 0.01–0.48) and rest of time on treatment (IRR = 0.37, 95% CI = 0.17–0.79). Treatment duration (mean and median) was shorter on buprenorphine than methadone (173 and 40 versus 363 and 111, respectively). Model estimates suggest that there was a low probability that methadone or buprenorphine reduced the number of DRP in the population: 28 and 21%, respectively.

Conclusions

In UK general medical practice, opioid substitution treatment with buprenorphine is associated with a lower risk of all‐cause and drug‐related poisoning mortality than methadone. In the population, buprenorphine is unlikely to give greater overall protection because of the relatively shorter duration of treatment.     

Barriers and facilitators for assessment and treatment of hepatitis C virus infection in the opioid substitution treatment setting: insights from the ETHOS study

Provision of hepatitis C virus (HCV) assessment and treatment via opioid substitution treatment (OST) clinics has been posed as an effective means of engaging populations with high HCV prevalence. This study explores OST client and health professional reports concerning barriers and facilitators affecting the delivery and uptake of HCV care and treatment within OST settings. In‐depth interviews were conducted with 57 clients, 16 staff from four NSW clinics participating in the Australian ETHOS study and three peer workers. Client participants included those who had not had HCV assessment; those who had HCV assessment only; and those who were awaiting or undertaking HCV treatment. A clear difference in decisions about HCV treatment emerged between participant groups. For those who have not been assessed, barriers to engaging with HCV care included the perception that they were physically well, were not experiencing HCV symptoms, had other life priorities and were concerned about the side effects and tolerability of treatment. Those who had engaged with care expressed motivations stemming from seeing friends becoming unwell, wanting to live longer and hearing positive stories of treatment. For those interested in HCV treatment, issues related to both provider and setting were important, such as presence of an engaged clinician, an accessible treatment pathway and availability of support. In this integrated care model, some barriers to HCV care and treatment (particularly those relating to health provider and the system) are minimized. In this setting, HCV treatment remained an unattractive option for a significant number of clients. Providing ways for those without HCV symptoms to be assessed for liver damage may be important to open up alternative conversations about HCV care. Further, the importance of a changing discourse of treatment is apparent from these data and could be enhanced by peer communication that provides information about successful treatment experiences.     

Identification and management of hepatitis C patients in primary care clinics

OBJECTIVE: Previous survey-based research suggested that hepatitis C patients receive suboptimal care in primary care settings. The aim of our study was to define the actual level of care hepatitis C patients receive in primary care clinics. METHODS: Medical records of 229 hepatitis C antibody-positive (group 1), 229 hepatitis C antibody-negative (group 2), and 229 patients not tested for hepatitis C antibody (group 3) were reviewed to assess the indications for hepatitis C testing and the subsequent management and referral of hepatitis C antibody-positive patients diagnosed in primary care clinics. In addition, the compliance of primary care physicians with hepatitis C screening and testing guidelines was assessed. RESULTS: Only 16% of group 1 and 10% of group 2 patients were tested for hepatitis C based on physician-identified risk factors. Only 1% of group 3 patients had documented discussion of hepatitis C risk factors during their initial visit with a primary care physician. The majority of hepatitis C antibody-positive patients was appropriately evaluated in primary care clinics, and most (77%) hepatitis C RNA-positive patients with elevated liver enzymes were referred for subspecialty care. Of the 59 patients who underwent liver biopsy, 40% had bridging fibrosis or cirrhosis. CONCLUSIONS: Hepatitis C testing is rarely initiated in primary care clinics based on physician-identified risk factors. Interventions should be developed to optimize early diagnosis of hepatitis C as significant liver disease may be present despite the absence of symptoms.     

Benefits of and barriers to providing smoking treatment in methadone clinics: findings from a national study

Although smoking increases morbidity and mortality among patients in addictions clinics, few clinics provide routine smoking treatment. To understand staff attitudes toward treatment, we surveyed leaders of outpatient methadone treatment clinics nationwide. Our response rate was 59% (408/697). Most clinic leaders thought they should provide smoking treatment (76%) or refer patients for care (91%); however, fewer than half of these had provided treatment in the month prior to the survey. Leaders said smoking treatment would benefit their clinics, patients and communities, but said barriers-primarily insufficient staff training-prevented routine care. Addressing these barriers could increase smoking treatment in addictions clinics and save lives.     

Physician specialization and the quality of care for human immunodeficiency virus infection

BACKGROUND: There is debate over the types of physicians who should treat patients with complex chronic medical conditions such as human immunodeficiency virus (HIV) infection. We sought to assess the relationship between specialty training and expertise and the quality of care delivered to patients with HIV infection. METHODS: We selected random samples of HIV-infected patients receiving care at 64 Ryan White CARE (Comprehensive AIDS Resources Emergency) Act-funded clinics throughout the country and their primary HIV physicians for an observational cohort study in which quality-of-care measures were assessed by medical record review. RESULTS: We studied 5247 patients linked to 177 physicians who responded to a survey. Fifty-eight percent of the physicians were general medicine physicians ("generalists") and 42% were infectious diseases specialists. Sixty-three percent of the generalists (37% overall) considered themselves expert in HIV care. In hierarchical logistic regression models that controlled for patient characteristics, infectious diseases physicians and expert generalists had similar performance. In contrast, nonexpert generalists delivered lower quality care. More than 80% of the appropriate patients being cared for by infectious diseases physicians and expert generalists were receiving highly active antiretroviral therapy, compared with 73% of appropriate patients of nonexpert generalists (P<.001). Physicians with fewer than 20 patients with active HIV had fewer appropriate patients on highly active antiretroviral therapy (73% vs 82% of physicians with >/=20 such patients, P = .04) and saw patients less frequently. CONCLUSION: These findings extend previous work by examining a range of quality-of-care measures and suggest that generalists with appropriate experience and expertise in HIV care can provide high-quality care to patients with this complex chronic illness.     

Integration of palliative care into primary care for human immunodeficiency virus-infected patients

Palliative care for patients infected with human immunodeficiency virus (HIV) includes components of pain and symptom management, advance care planning, prioritization of life goals, and the support of individuals and families throughout the entire continuum of the disease. There are numerous social stressors such as stigma, infected family members and caregivers, loss of housing and independent living, and the increasing influence of substance use in all communities. Because many barriers prevent those with advanced disease from getting comprehensive pain and symptom management as well as option planning, it is important for all HIV care providers to improve their knowledge, sensitivity, and competence regarding this aspect of care. This article provides an overview of critical issues in palliative care and information on how best to improve HIV primary care.     

Absence of antibody to human immunodeficiency virus in long-term, socially rehabilitated methadone maintenance patients

Human immunodeficiency virus (HIV) infection has become widespread among parenteral drug abusers. We measured antibody to HIV and hepatitis B virus markers in 58 long-term, socially rehabilitated methadone-maintained former heroin addicts. None of the 58 had antibody to HIV, but one or more markers of hepatitis B virus infection were seen in 53 (91%). The duration of methadone maintenance was 16.9 +/- 0.5 years, and the median dose of methadone was 60 mg (range, 5 to 100 mg). Before methadone treatment, the patients had abused heroin parenterally for 10.3 +/- 1.7 years, and they had engaged in additional high-risk practices for HIV infection. We conclude that successful outcomes during methadone maintenance treatment are associated with sparing of parenteral drug abusers from HIV infection.     

Structural barriers to South African volunteer home-based caregivers providing quality care: the need for a policy for caregivers not affiliated to primary healthcare clinics

Community home-based care (CHBC) is a critical component of non-formal care in communities in Africa that have a high prevalence of HIV and tuberculosis (TB). Community carers consisting primarily of volunteers are critical role players in African healthcare systems and particularly in South Africa’s strategy to fight HIV and AIDS. This paper explores the structural barriers volunteer caregivers need to overcome to provide quality CHBC. The researchers used two focus group discussions with key informants (each with four participants), and semi-structured interviews with six key informants to collect data relating to the meaning of quality CHBC. The data were coded using Tesch’s data analysis technique. A major theme that emerged from the results was “Addressing structural challenges to improve the quality of CHBC”. Subthemes underpinning this theme were: 1) lack of standardised training of volunteer caregivers; 2) the need for a scope of practice, parameters and legal boundaries; 3) lack of monitoring and evaluation (M&E) of CHBC; and 4) the importance of mentoring and supervision in CHBC. CHBC policy should address the need for standardised training programmes for caregivers, so that they are equipped with multiple skills. Furthermore CHBC policy must emphasise mentoring as well as M&E to encourage quality care. Finally, the policy should provide a clear scope of practice for caregivers to regulate their competencies and boundaries.     

The management of children born to human immunodeficiency virus seropositive women

Increasing numbers of children born to human immunodeficiency virus (HIV) antibody-positive women are being identified, but guidelines as to their management are lacking. We have therefore established a paediatric counselling and screening clinic for managing such children in Edinburgh. During a period of 3 years, 49 infants and children of 43 HIV seropositive women have been seen. After a median follow-up period of 23 months, four children were found to have clinical evidence of HIV disease which was non-specific and could have been missed had they not been regularly monitored. Thus, close surveillance of infants born to seropositive women is important. Identifying a single clinic where this is done has allowed experience to accumulate on issues beyond the medical management of these infants as well as contributing to the clinical care of infants with symptoms. Based on this experience, we have developed guidelines for managing children born to HIV antibody-positive women.     

Drug-addicted prisoners: seroprevalence of human immunodeficiency virus and hepatitis B and C virus soon after the marketing of buprenorphine

PURPOSE: Considering the importance to public health and the frequency with which drug addicts are imprisoned, we studied the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV), as well as drug addiction of patients admitted to the Elsau prison in Strasbourg (France). METHODS: The prospective study included all entering inmates from 1 September to 31 October 1997 (270 persons) to whom HIV, HBV and HCV blood tests were offered as well as a questionnaire on their drug addiction. RESULTS: Thirty-six percent of the entering inmates were drug addicts, of whom 1% were HIV positive, 11.2% HBV positive and 30% HCV positive, compared to, respectively, 0.6, 9.9 and 6.4% for non-drug addicts. Ninety-five of the 98 patients used several drugs, including buprenorphine for 53 patients. At the beginning of this study, buprenorphine had been available in France for 9 months. CONCLUSION: The results are to be taken seriously regarding the misuse of this product in this selected population (intravenous use, multiple drug use, dealing).