Training medical students in addiction medicine can help in the opioid crisis

Naloxone

Better medical education is one solution to the opioid overdose crisis, but our new study suggests that few students have direct experience of overdose management although many have been exposed to patients using opioids.

Every year, more people die in Ireland due to opioid overdoses than in car accidents. Over 200 overdose deaths occur annually in Ireland. Naloxone is an effective treatment; lay people can use it. We surveyed 243 undergraduate medical students doing their final professional completion module before graduating from University College Dublin. This survey showed that medical students commonly encounter patients with opioid use disorders and want more naloxone training in the medical school.

Overdose prevention and management, including naloxone provision, should be a priority for health education.

A total of 197 (82.1%) completed the survey. Just under half were male, and most were aged under 25 (63.3%) and of Irish nationality (76.7%). The students felt moderately prepared to recognise opioid use disorder, but felt less prepared to manage other aspects of opioid use disorder care. Most had taken a history from a patient with an opioid use disorder (82.8%), and a third had witnessed at least one opioid overdose. Although 10.3% had seen naloxone administered, most had never administered naloxone themselves (98.5%). Half supported wider naloxone availability; this was lower than support rates among GPs (63.6%) and GP trainees (66.1%).

Over half of the medical students supported wider naloxone availability and its lay distribution to address the growing overdose problem in Ireland.

Most students had taken a history from a patient with an opioid use disorder and a third had witnessed at least one opioid overdose.

Few students had direct experience of overdose management although many met patients using opioids.

High level of student exposure to patients using opiates suggests we have an opportunity to increase addiction content in medical curricula.

Educate students

Medical school offers limited addiction medicine education. Medical graduates may not be adequately prepared to diagnose and manage opioid use disorders and emergency drug overdoses.

Tobin, H., Klimas, J., Barry, T., Egan, M., Bury, G. (2017, In Press) Opiate Use Disorders and Overdose: Medical Students Experiences, Satisfaction with Learning and Attitudes toward Community Naloxone Provision. Addictive Behaviors.

Resolving youth opioid addiction needs evidence-based care

youth opioid addiction

Youth opioid addiction, and related harms continue to rise in North America. With an increasing number of opioid overdoses, there remain significant barriers to care for youth with addiction. The time for evidence-based treatment of youth opioid addiction is now.

Based on the extensive literature on treatment of opioid use disorder among adults, medicated-assisted treatment is likely to be an important or even essential component of treatment of opioid use disorder for most youth. This post summarises a recent article in the American Journal of Drug and Alcohol Abuse, where we outline the current dilemmas and questions regarding the use of medication-assisted treatment for youth opioid addiction and propose some potential solutions based on the current evidence.

The prevalence of risky opioid use, opioid use disorder, and related harms continue to rise among youth in North America (age 15–25). These growing harms point to an urgent need to expand and scale-up early access to evidence-based treatments for  youth opioid addiction. Treatment of youth opioid addiction may be different than treatment of adults because neurodevelopment of brain regions, associated with motivation and impulsivity, happens mainly during adolescence and young adulthood.

Strategies that reduce barriers to treatment commonly experienced by youth and that address clinical care dilemmas when treating youth opioid addiction are urgently needed.

Medications for youth opioid addiction

The American Academy of Paediatrics recently supported buprenorphine/naloxone and methadone for youth opioid addiction. Although research has shown their effectiveness in adults, only a few studies did so among youth.

Based on the strong evidence in the adults and available evidence to date among youth, first-line OAT for youth should be buprenorphine/naloxone, with methadone as an alternative treatment option when buprenorphine/naloxone cannot be used.

Minimum age requirement needs re-evaluation

The literature still disagrees regarding the minimal age requirement to prescribe OAT. For instance, buprenorphine/naloxone is currently approved for opioid addiction at age 16 in the United States and at age 18 in Canada. But the U.S. youth has to fail addiction treatment twice before they can be prescribed methadone under the age of 18. Also, treatment with medications has been prescribed to 10 times more adults than youth although it’s the first line of treatment in many guidelines. This underscores the urgent need to improve medication-assisted treatment access for youth. We still need safety data regarding use of OAT among youth. But the pros are likely to outweigh the cons given the lethality and multiple harms associated with opioid addiction.

Longer tapers are more effective than shorter tapers

How long should be the successful tapers and how to do them effectively? These questions are still unanswered by scientific literature. Studies to date have shown that longer tapers are more effective to reduce opioid use and prevent relapse  For this reason, our provincial guidelines in British Columbia, Canada, recommend that tapers for adults, if undertaken, “occur over a minimum 52 weeks duration and with close monitoring during and after the taper given overdose risk is increased.”
Naltrexone injectable versus implantable

Opioid antagonists, such as Naltrexone, have not been evaluated widely among youth. Oral Naltrexone has many problems, such as low compliance, increased risk for relapse and overdose. The researchers should compare methadone or buprenorphine/naloxone with extended-release injectable or implantable naltrexone in youth. This information will help clinicians select the best treatment for youth opioid addiction.

Psychosocial interventions: retention on OAT remains a challenge

Psychosocial interventions are common for treating youth opioid addiction, but are done in a way that is not supported by science. For example, they consist of short-term detox with a referral to individual or group therapy in rehab or outpatient settings. Youth drop out from such treatment frequently. But retention on OAT remains a challenge. For example, one study found that only “56% of youth aged 18–25 years were retained on buprenorphine at 6 months, compared with a 78% of people aged 26 years or more.” OAT seems more efficacious in retaining youth in treatment. Psychosocial intervention is better done in combination with pharmacologic treatment. We need more trials involving youth.

The Prescription Opioid Addiction Treatment Study – POATS

The Prescription Opioid Addiction Treatment Study (POATS) showed that tapering off buprenorphine/naloxone (even after 12 weeks of treatment), was associated with a 90% relapse rate. Ongoing counselling did not make a difference. Based on the adult POATs study, it seems that keeping people on buprenorphine/naloxone is better than tapering them without supports. Psychosocial interventions may help people receiving OAT. Many studies found contingency management helpful. Researchers should do more studies on contigency management.

When in doubt, do not taper

Based on the above, we need more research to better understand optimal treatment approaches for OPIOID ADDICTION in youth. Based on the current evidence, buprenorphine/naloxone appears to be a safe and efficacious option for youth and we propose this should be first-line treatment for OPIOID ADDICTION. More studies comparing OAT and extended-release naltrexone are needed in this population. When treatment is initiated, longer duration (>52 weeks) of OAT is recommended. Decision to taper should be governed by the principle “when in doubt, do not taper” while taking into account the potential risks of relapse and overdose as well as access to chronic relapse prevention care; close monitoring is essential during and after the taper completion. We suggest psychosocial interventions be routinely offered in combination with OAT. Lastly, given the efficacy of OAT, we recommend these medications be provided based on the risk and benefit assessment of each case, regardless of age.

Cited study: Derek C. Chang, Jan Klimas, Evan Wood & Nadia Fairbairn. (In Press) Medication-assisted treatment for youth with opioid use disorder: Current dilemmas and remaining questions. The American Journal of Drug and Alcohol Abuse Vol. 0 , Iss. 0,0

Lisbon conference reviews addiction literature

lisbon

What is the state of the art in addiction research? How do we measure recovery? These, and other questions dominated presentations on systematic reviews of literature at the 2nd European conference on addictive behaviours and dependencies on October 24-26th, 2017, in Lisbon.

This post outlines the many presentations.

Systematic reviews at Lisbon 2017:

October 24th:

– Which individual, social and environmental influences shape different pathways of amphetamine type stimulant use over the life course? A systematic review and thematic synthesis of the qualitative literature. Amy O´Donnell and Michelle Addison, United Kingdom
– Determining the efficacy of an intervention to reduce IPV perpetration by men who misuse substances: a systematic review and meta-analysis. Gail Gilchrist, United Kingdom
– Drug use and infectious diseases: reviewing the evidence; Sarah Larney, Australia

Paper session 16

− Injecting and sexual risk-taking amongst people who inject drugs: a global review. Amy Peacock, Australia
− Needle syringe programmes and opioid substitution therapy for prevention HCV transmission among people who inject drugs: Cochrane systematic review. Matthew Hickman, United Kingdom
− Recent incarceration and risk of hepatitis C and HIV transmission amongst people who inject drugs: a systematic review and meta-analysis. Jack Stone, United Kingdom
− A systematic review and meta-analysis of psychosocial interventions to reduce drug and sexual blood borne virus risk behaviours among people who inject drugs. Gail Gilchrist, United Kingdom
− HIV prevention, treatment and care for people who inject drugs: a systematic review of coverage of interventions. Sarah Larney, Australia

October 25th:

– Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. Marica Ferri, EMCDDA
– What is the base for evidence-based treatment of opioid dependence? A systematic review of outcomes from longitudinal observational studies. Lucas Wiessing, EMCDDA
– Health outcomes for clients of needle and syringe programs in prisons: a systematic review. Heino Stöver, Germany
− Worldwide drug use decriminalization practices: a scoping review. Marta Pinto, Portugal
− Review of the effectiveness of treatment alternatives to incarceration for drug-involved persons. Roger Peters, United States
− Factors related to binge drinking in adolescence: integrative literature review. Tereza Barroso, Portugal

Systematic reviews posters at Lisbon 2017:

October 24th: 13:15 – 14:15 POSTER SESSIONS:

Session 2:

– Alcohol use disorders identification test (audit) and mortality risk in US Veterans and international population: a systematic review and meta-analysis. Sören Kuitunen-Paul, Germany

Session 3:

– Contingency management for drug use in treatment for opiate addiction: a systematic review and meta-analysis. Tom Ainscogh, United Kingdom

24th: 14:30 – 16:00 POSTER SESSIONS:

Session 5:

– A systematic review of internet addiction prevention interventions. Roman Gabrhelík, Czech Republic

October 25th: 11:00 – 12:30 POSTER SESSIONS:

Session 11:

– Prevalence and psychosocial predictors of performance enhancing substances use in physical activity settings: a systematic review. Ana Tavares, Portugal

October 25th: 14:30 – 16:00 POSTER SESSIONS:

Session 15:

– What works in the treatment of women with alcohol-use problems? Systematic review of evidence-based studies. Eva Hoch, Germany

Thank you all presenters for your reviews and conference presentations.

Death after rapid opioid taper

Flame

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.

DISCUSSION:

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
https://www.ncbi.nlm.nih.gov/pubmed/28930773

Clinician-Scientist Training in Addiction Medicine

clinician-scientist
In a new article from the Academic Medicine, we argue that clinician-scientist training is one of the most important bridges to cross the growing divide between recent advances in addiction science and care.
Often, unskilled lay personnel deliver inadequate care, reports state.
Medical education has long been the missing piece in the response to the global addiction problem. Instead of treating addiction as a disease, governments have focused on drug prohibition and control. This approach has failed by many measures, and, as a result, millions of people have suffered. Addiction science has identified a range of more and more evidence-based approaches to treat substance-use disorders.  Especially through early identification and treatment. However, most interventions are not used to their full potential. Better physician education can improve the accurate use of evidence-based treatments.
 
To this end, the British Columbia Centre on Substance Use (BCCSU) and St. Paul’s hospital, have recently opened a large Addiction Medicine Fellowship. The fellowship is 12 months long and trains doctors from general practice, internal medicine and psychiatry. The Addiction Medicine Foundation (AMF) accredited the fellowship and the alumni can write AMF exams. Also, they get research training through intensive mentorship and quality opportunities to write and publish research manuscripts, through academic half-days, journal clubs and conferences. They also get media training, learn to influence public policy, advocate for patients, and lead academic research projects.
 

Why clinician-scientist matters

Most health systems don’t specifically train generalist doctors in addiction medicine; when they do, this is often for a handful of psychiatry programmes that train a definite number of addiction psychiatrists. Our fellowship trains family physicians, internists and other disciplines. This expands the specialist treatment workforce to professionals seeing many people with substance use disorders and well positioned to bridge the implementation gap. Access to effective treatments grows.

Source: Klimas, J., McNeil, R., Small, W., Cullen, W. Clinician-Scientist Training in Addiction Medicine: A Novel Programme in a Canadian Setting.  Academic Medicine 92(10):1367, October 2017.