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Polysubstance use may complicate treatment outcomes for individuals who use opioids. This research aimed to examine the prevalence of polysubstance use in an opioid use disorder treatment trial population and polysubstance use’s association with opioid relapse and craving.
This study is a secondary data analysis of individuals with opioid use disorder who received at least one dose of medication (n=474) as part of a 24-week, multi-site, open label, randomized Clinical Trials Network study (CTN-0051, X:BOT) comparing the effectiveness of extended-release naltrexone versus buprenorphine. Models examined pretreatment polysubstance use and polysubstance use during the initial 4 weeks of treatment on outcomes of relapse by week 24 of the treatment trial and opioid craving.
Polysubstance use was generally not associated with treatment outcomes of opioid relapse and craving. Proportion of days of pretreatment sedative use was associated with increased likelihood of opioid relapse (OR: 1.01, 95% CI: 1.00–1.02). Proportion of days of cocaine use during the initial 4 weeks of treatment was associated with increased likelihood of opioid relapse (OR: 1.05, 95% CI: 1.01–1.09) but this effect was no longer significant once the potential of confounding by opioid use was considered. Sedative use during initial 4 weeks of treatment was associated with increased opioid craving (b: 0.77, 95% CI: 0.01–1.52). The study found no other significant relationships.
Conclusions: In the current study population, polysubstance use was only marginally associated with 24-week treatment outcomes.
Related protocols: CTN-0051
Benzodiazepines and opioids are used alone or in conjunction in certain care settings, but each have the potential for misuse. This longitudinal observational study, developed with CTN support through the Ohio Valley Node “base” award, evaluated substance use and mental health outcomes associated with providing opioids with or without benzodiazepine to treat traumatic injury in the emergency department (ED) setting.
Researchers analyzed a limited dataset obtained through the IBM Watson Health Explorys. Matched cohorts were defined for: 1) patients treated with opioids during the ED encounter (ED-Opioid) vs. neither opioid or benzodiazepine treatment (No medication) (n = 5372); 2) patients treated with opioids and benzodiazepines during the ED encounter (ED-Opioid+Benzodiazepines) vs. No Medication (n = 2454); and 3) ED-Opioid+Benzodiazepines vs. ED-Opioid (n = 2454). Patients consisted of adults with an emergency department encounter in the MetroHealth System (Cleveland, Ohio) with a chief complaint of traumatic injury and medical records for five years following the encounter. Control patients for each cohort were matched to the exposure patients on demographics, body mass index, and residential zip code median income. Outcomes were five-year incidence rates for alcohol, substance use, depression, and anxiety-related diagnoses.
Results indicated that, although receiving opioids during the ED visit predicted a relatively lower likelihood of subsequent substance use and mental health diagnoses, the brief co-use of benzodiazepines was strongly associated with poorer outcomes.
Conclusions: Even brief exposure to co-prescribed opioids and benzodiazepines during emergency traumatic injury care may be associated with negative substance use and mental health consequences in the years following the event.
Strategies are needed to identify at-risk patients for adverse events associated with prescription opioids. This study identified prescription opioid misuse in an integrated health system using electronic health record (EHR) data, and examined predictors of misuse and overdose.
The sample included patients from an EHR-based registry of adults who used prescription opioids in 2011 in Kaiser Permanente Northern California, a large integrated health care system. Researchers characterized time-at-risk for opioid misuse and overdose, and used Cox proportional hazard models to model predictors of these events from 2011 to 2014.
Results found that among 396,452 patients, 2.7% were identified with opioid misuse and 1044 had an overdose event. Older patients were less likely to meet misuse criteria or have an overdose. Whites were more likely to be identified with misuse, but not to have an overdose. Alcohol and drug disorders were related to higher risk of misuse and overdose, with the exception that marijuana disorder was not related to opioid misuse. Higher daily opioid dosages and benzodiazepine use increased the risk of both opioid misuse and overdose.
Conclusions: EHR data can be used to identify several risk factors associated with misuse and overdose, including comorbidities and benzodiazepine use, critical information for identifying at-risk patients. Findings can inform targeted patient screening and intervention, prescribing of medications such as buprenorphine for opioid dependence or naloxone for opioid reversal, disease management approaches for this patient population, and guide appropriate opioid prescribing policies which are becoming increasingly conservative and risk being applied without an individualized approach.
Related protocols: CTN-0061-Ot
The use of prescription opioids has increased dramatically in the past 2 decades, with associated increases in opioid misuse/abuse and opioid overdose. These are among the most commonly prescribed medications, with 259 million prescriptions written for opioid pain relievers in the U.S. in 2012.
This study aimed to establish a prescription opioid registry protocol in a large health system, Kaiser Permanente Northern California (KPNC), and to describe algorithms to characterize individuals using prescription opioids, opioid use episodes, and concurrent use of sedative/hypnotics.
Using KPNC electronic health record data, the investigators selected patients using prescription opioids in 2011. Opioid and sedative/hypnotic fills, and physical and psychiatric comorbidity diagnoses were extracted for years 2008 to 2014. Algorithms were developed to identify each patient’s daily opioid and sedative/hypnotic use, and morphine daily-dose equivalent. Opioid episodes were classified as long-term, episodic, or acute. Logistic regression was used to predict characteristics associated with becoming a long-term opioid user.
Results found that in 2011, 18% of KPNC adult members filled at least 1 opioid prescription. Among those patients, 25% used opioids long term and their average duration of use was more than 4 years. Sedative/hypnotics were used by 76% of long-term users. Being older, white, living in a more deprived neighborhood, having a chronic pain diagnosis, and use of sedative/hypnotics were predictors of initiating long-term opioid use.
Conclusions: This study established a population-based opioid registry that is flexible and can be used to address important questions of prescription opioid use. It will be used in future studies to answer a broad range of other critical public health issues relating to prescription opioid use.
Related protocols: CTN-0061-Ot
Residential therapeutic communities (TCs) have demonstrated effectiveness, yet for the most part, they adhere to a drug-free ideology that is incompatible with the use of methadone. This CTN platform study used equivalency testing to explore the consequences of admitting opioid-dependent clients currently on methadone maintenance treatment (MMT) into a TC.
The study compared 24-month outcomes between 125 MMT patients and 106 opioid-dependent drug-free clients with similar psychiatric history, criminal justice pressure and expected length of stay who were all enrolled in a TC. Statistical equivalence was expected between groups on retention in the TC and illicit opioid use. Secondary hypotheses posited statistical equivalence in the use of stimulants, benzodiazepines, and alcohol, as well as in HIV risk behaviors. Results found that the mean number of days in treatment was statistically equivalent for the two groups (166.5 for the MMT group and 180.2 for the comparison group). At each assessment, the proportion of the MMT group testing positive for illicit opioid use was also found for stimulant and alcohol use. The groups were statistically equivalent for benzodiazepine use at all assessments except at 24 months where 7% of the MMT group and none in the comparison group tested positive. Regarding injection- and sex-risk behaviors, the groups were equivalent at all observation points. In conclusion, the authors found that methadone patients fared as well as other opioid users in TC treatment. These findings provide additional evidence that TCs can be successfully modified to accommodate MMT patients.