Relapse to opioid use is common after rapid opioid withdrawal. As a result, short-term taper of opioid agonist/partial agonist medications – such as methadone and buprenorphine/naloxone – are no longer recommended by recent clinical care guidelines for the management of opioid use disorder. Nonetheless, rapid tapers are still used in medically supervised withdrawal settings.
RAPID TAPER CASE SUMMARY:
A person with opioid use disorder was prescribed a rapid buprenorphine/naloxone taper in a medically supervised withdrawal facility; later had a subsequent opioid overdose and death after discharge. The full case description was just published in the Journal of Addiction medicine.
The fatal outcome in this case study underscores the potential severe harms of rapid tapers. Given the increased overdose risk, tapers should be avoided and continuing care strategies – such as maintenance pharmacotherapy – should be started in medically supervised withdrawal settings.
Long-term opioids should be the first line of treatment. This simple measure can help prevent overdoses and deaths. Long term treatment outcomes will improve.
Source: Chang, D., Klimas, J., Wood, E., Fairbairn, N. (2017) A case of fatal overdose following inpatient detoxification: The problematic role of rapid opioid agonist tapers for opioid use disorder. (Online first Sept 19) J Addiction Medicine
In a talk at the 2017 National Institute of Drug Abuse meeting on June 17th, Dr Evan Wood pondered lessons learned and success tips derived from his team’s experiences of building an International centre on substance use. The key ingredients in the recipe for success of research centre on substance use were:
Emphasize research productivity. Integrate educational opportunities and mentorship at every step. Use interdisciplinary approach wherever possible. Integrate research alongside clinical care.
From AIDS to opioids
Historically, the new BC Centre on Substance Use grew out of HIV research centre for excellence. The emergence of powder cocaine in 1990’s led to an HIV outbreak in needle exchange when it was believed to be under control. This helped the team to make a compelling case about their unique situation for funders like the National Institute for Drug Abuse. Next, a centralized database of people treated on anti-retroviral treatment (ART) contains all data on everybody living with HIV in the province. This database enables longitudinal survival analysis of HIV outcomes. Using this data, another prospective cohort study of injecting drug users has demonstrated how the viral load went down between 1996-2004. Furthermore, the first supervised injection facility in North America – Insight – has led to about a dozen of supervised injecting facilities in the area nowadays. In sum, the evolution of the centre from HIV treatment to HIV prevention and now to addiction treatment (because of the population of study) is a result of concentrated efforts by researchers, providers and the community.
The centre’s mission is to provide provincial leadership in substance use and addiction research, education and clinical care guidance and to seamlessly integrate these pillars to help shape a comprehensive, connected system of treatment and care that reaches all British Columbians. (taken from www.bccsu.ca)
International sites with rapidly evolving HIV epidemics in patients with substance use disorder present an opportunity for rapid scale-up of interventions once proven efficacious with a promise of large public health impact (text taken from www.drugabuse.gov). The three speakers in this session moderated by Petra Jacobs, entitled “Research on HIV and Substance Use Disorder: International Perspectives,” including Drs Wood and Korthuis, have presented several research projects supported by NIDA and other institutions. I have attended the session. The discussant, Dr Metzger, closed the session with concluding remarks.
We talked to 787 people receiving methadone for opioid use disorder in Vancouver, Canada. Our new study followed them as they switched from methadone (1mg/mL) to Methadose (10mg/mL). We asked whether their drinking has changed after the switch – between 2013 and 2015. 16% said they drank too much at least once in the last six months. Those who drank too much were not more likely to do so after the shift to Methadose. The Substance Use& Misuse journal has published the study this week. Persons on methadone for opioid use disorder may report going through opioid withdrawal and increasing their illicit opioid use when switched to Methadose. We need to understand impacts of these changes on other forms of drug use. Careful and planned information about upcoming changes may help people cope with the potential risks better.
Against the use of opioids for chronic non-cancer pain to people who have active substance use disorders advises the third recommendation in the new opioid therapy guidelines (May 8th, 2017).
However, this “strong” recommendation is based on low quality of evidence from studies that rarely involve people with active substance use disorders (SUD).
Here, we first highlight the main caveats in the research of pain treatment among people with SUDs, why this has been the case and then we offer potential solutions for overcoming the obstacles in clinical research and policy.
Most clinical trials of pain medications exclude people with SUDs. Denying treatment of pain with opioids to people with active SUDs in the absence of evidence, based on a presumed potential for “more” addiction and documented adverse side effects (overdose), is cautious. However, it is also likely influenced by stereotypes and stigma towards people who use drugs and it further discriminates people with SUDs. Instead of stigma, the society should seek better ways of increasing rapid access to evidence-based opioid agonist therapy for prescription opioid use disorders (see Ahamad & Socias, 2016).
Moreover, this approach can lead to unanticipated consequences, such as seeking illicit drugs (see Voon et al, 2015). It is clear that we need more research to better understand pain treatment among people with SUDs and to give better recommendations to clinicians. But what kind of further research? Firstly, we need clinical trials that specifically include people with SUDs, such as people receiving opioid agonist treatment (Ti et al., 2015). If trialists refuse to include people with pain and concurrent SUDs into pain trials, presumably because of their high-risk for more SUDs, this obstacle can be overcome by including a standardized measure of pain, like the VAS, into every pharmacotherapy trial of SUD treatment.
Which pain patient treated with opioids will develop opioid use disorder?
Secondly, we still don’t know which pain patient treated with opioids will develop opioid use disorder (OUD). Despite the typical occurrence of OUDs among approximately 5.5% of the study populations in pain trials, there is no evidence for a reliable predictor of who will develop OUD. We need to find valid risk indicators.
Finally, the current opioid overdose crisis in many countries is primarily driven by not-as-prescribed-use of fentanyl – an anesthetic used to tranquilize elephants. What if people with opioid use disorders self-medicated their pain with fentanyl (see Voon et al., 2015)? What if their pain, both emotional and physical, was as big as elephants and we had nothing for them? What we offer to them is suspicion, exclusion, denial and mistrust. We should offer compassion and fairness.
- Busse, J. W., et al. (2017). “Guideline for opioid therapy and chronic noncancer pain.” Canadian Medical Association Journal 189(18): E659-E666.
- Socias, M. E. and K. Ahamad (2016). “An urgent call to increase access to evidence-based opioid agonist therapy for prescription opioid use disorders.” Canadian Medical Association Journal 188(17/18): 1208.
- Ti, L., et al. (2015). “Denial of pain medication by health care providers predicts in-hospital illicit drug use among individuals who use illicit drugs.” Pain Research & Management 20(2): 84-88.
- Voon, P., et al. (2015). “Pain among high-risk patients on methadone maintenance treatment.” The journal of pain 16(9): 887-894.