Intervention on Opioid Disorder

Significance and Background of a Healthcare Problem

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The healthcare problem to be addressed in this paper is on opioid addiction among youths in the United States. It is estimated that more than 115 individuals die daily in the United States for overdosing opioids. This is mainly due to the misuse of, and addiction to opioids such as prescription pain relievers, heroin, and organic opioids such as fentanyl. This has posed a serious national crisis that negatively affects the social and economic welfare. Data from the Center for Disease Control and Prevention estimates that the economic costs for the prescription opioid misuse in the US were approximately $78.5 billion, which includes expenses in health care, reduction in productivity, addiction treatment, and the judicial system involvement (National Institute on Drug Abuse, 2018). The rate of addiction among the youths in America was noted to have risen by six times between 2001 and 2014. However, even with this high numbers, it was indicated that only a few proportions in the affected youths get the medical treatment for preventing overdose or relapse. A study indicated that only 27 percent of youths under treatment of opioid misuse received the recommended anti-addiction medications (Reinberg, 2017).

Significance of Problem 

The opioid crisis among the adolescents and the youths is a fast-growing drug problem in the US. The risk factors for opioid misuse and addiction are relatively common making this an important epidemic that needs to be tackled. The youths at a higher risk of the misuse include those with acute and chronic pain, physical health problems, or a history of mental illness or substance abuse. It is estimated that for every death among the youths due to opioid misuse, there are 119 emergency room visits and 22 admissions. This problem needs to be addressed as it continues to be a leading cause of poisoning deaths in the US. The abuse of opioid causes other health complications, leads to increased expenses on healthcare expenditure to cater for treatment of opioid abuse, resulting in hospitalizations, and associated infections (Green, 2017).

Current Practice Related to Opioid Addiction 

In the current practice of dealing with opioid addiction, the primary practitioners are called upon to distinguish between the medically indicated opioid use that forms part of pain therapy from the inappropriate abuse or addiction. To ascertain the substance use severity, different tools are used such as screening, brief intervention, and referral to treatment tool (SBIRT). Assessment of addiction severity that measures levels of potential risks of diversion is carried out using different scales. The information is used to decide whether to refer the patient to an in-house treatment or addiction specialist. Through the Drug Addiction Treatment Act of 2000, the qualified physicians can treat the opioid-dependent patients with buprenorphine in an office-based environment. This makes the primary care physicians important and active players in the diagnosis and treatment of opioid use disorders. In the pharmacological treatment plan, methadone and buprenorphine are the most commonly used opioid replacement agents used for the treatment and detoxification of opioid-addicted patients. Methadone has however been limited through restrictive regulations and stigmatization on opioid addiction (Bonhomme, Shim, Gooden, Tyus, & Rust, 2012). 

Impact of Opioid Addiction on Patients Cultural Background 

An epidemiology study revealed that in comparison to the whites, the black with co-occurring mood or anxiety and substance use disorder are more likely to get services for mood or anxiety disorder. They are also equally likely to get treatment due to alcohol disorder and more likely to get treatment for the drug use disorders. While under treatment, the minority patients are likely to make return visits. For patients with dual diagnoses of substance abuse and other mental health diagnoses, those with minority background in most cases get treatment in primary care settings as opposed to specialty mental health facility (Bonhomme et al., 2012).

Repeated administration of any opioid in most cases leads to the development of tolerance and physical dependence. Addiction is a slow process and chronic medical illness that does not easily end with opioid discontinuation. Addiction has a high risk of relapse when not accorded proper treatment. Opioid effects are different among different individuals where some patients will exhibit tolerance after just one dose while other will develop tolerance after a number of doses (Volkow & McLellan, 2016).

PICO Question

PICO Table 

P (patient/problem)Opioid Addiction among youths
I (intervention/indicator)Pharmacological treatment methods
C (comparison)Psychosocial interventions 
O (outcome)Reduced opioids dependence 

PICO Question 

Among youths with opioid addiction, how does the use of pharmacological treatment methods compare to psychosocial intervention in reducing the opioids dependence?

Search Strategy

  The search for the literature review was carried out in the medical databases, which included PubMed, Cochrane, and TRIP databases. The keywords used in the search process included ‘opioid addiction’, ‘pharmacological treatment methods’, ‘psychosocial treatment’. In the PubMed database the search resulted to the following MESH Search, ((“therapy”[Subheading] OR “therapy”[All Fields] OR “treatment”[All Fields] OR “therapeutics”[MeSH Terms] OR “therapeutics”[All Fields]) AND (“analgesics, opioid”[Pharmacological Action] OR “analgesics, opioid”[MeSH Terms] OR (“analgesics”[All Fields] AND “opioid”[All Fields]) OR “opioid analgesics”[All Fields] OR “opioid”[All Fields]) AND (“behavior, addictive”[MeSH Terms] OR (“behavior”[All Fields] AND “addictive”[All Fields]) OR “addictive behavior”[All Fields] OR “addiction”[All Fields])) AND (Clinical Trial[ptyp] AND “2013/07/31″[PDat] : “2018/07/29″[PDat])”. 459 articles were located in the PubMed database, 11 articles from the Cochrane Library, and 6 articles from the Trip database. Among the limiters used for this search strategy included systematic reviews and published within the last 5 years. 

Research Evidence source

One of the research evidence sources is the PubMed database. PubMed is a free health science citation & abstracts index from the National Centre for Biotechnology Information at the U.S. National Library of Medicine. PubMed contains articles and other documents from a wide scope including biomedical and clinical research. Among the key features of this evidence source is the MeSH (Medical subject heading that makes it possible to explore and identify vocabulary applied in the database. 

Another research-evidence source is the Cochrane Library. Cochrane Library provides access to the Cochrane Library of Systematic Reviews. Full text of reviews requires a subscription, while index/summaries are a public resource. The articles that can be located here include protocols, methods, trials, evaluations, and assessments. 

A study by Minozzi, Amato, Bellisari and Davoli (2014) was a systematic review of controlled trials. This review involved two trials that had 190 participants. The source of evidence was level 1 evidence since it involved randomized controlled trial. It was however of quality B since it was a systematic review of the controlled trials and the actual research. Among the variables under consideration were detoxification treatment alone, combination of psychosocial intervention. The dependent variables under study were the reduction in the use of substances and improvement in health and social status. Patients treated with buprenorphine had lower drop-out rates with more progressing for long-term naltrexone treatment. Buprenorphine maintenance leads to less dropouts of treatment program in comparison to buprenorphine for detoxification.

Another research evidence source used was by Woolley et al (2016), which was a randomized double blind, placebo-controlled research. This was a high quality source of evidence, as it was a level 1 and quality A. The variables under consideration were Cue-induced craving task, implicit association task, RMET, TASIT. The findings of the research indicated that Oxytocin was well tolerated by patients receiving ORT but no significant effects on IAT scores. There was significant reduction in RMET performance after oxytocin administration.

Non-research evidence source 

Among the non-research source of evidence include the professional standards of care/guidelines and expert opinion. The professional standards of care or clinical practice guidelines are largely adopted as a tool to improve quality of care. Such guidelines are mainly produced in guideline programs and seek to be explicitly evidence-based. 

Expert opinions are mainly contained in the consensus development reports. This involves an assessment of emerging or critical health issues based on expert opinion and used to identify the needs for policy development. Expert opinion is considered as the least reliable type of evidence source. 

The evidence source by Connery (2015) is a best practice source acquired from Harvard Review of Psychiatry. It included the review of Psychosocial treatment for opioid use disorder with medication versus with no medication on retention to treatment, and mortality rates. This is a level III evidence. It indicated that Oral naltrexone was found to lead to poor adherence and higher mortality rates. Extended-release naltrexone not prone to.

Another source of non-research evidence was the clinical guidelines by National Institute on Drug Abuse (2018) that provided more information about the opioid overdose crisis. It provided data from the Center for Disease Control and Prevention, which estimates that the economic costs for the prescription opioid misuse in the U.S., was approximately $78.5 billion. The cost is  inclusive of expenses in healthcare, reduction in productivity, addiction treatment, the judicial system involvement. It provided the priority area in dealing with the crisis, which included improving the access to treatment and recovery services, promoting the use of overdose-reversing drugs, strengthening the understanding of the epidemic, offering support for cutting-edge research, and advancing best practices for pain management. 

Recommended Practice Change

The Food and Drug Administration has approved three pharmacotherapy medications to be used to prevent opioid relapse and stabilization or maintenance treatment of opioid maintenance disorder. These include buprenorphine, naltrexone, and methadone. The three acts as ligands that bind central mu-opioid receptors as the molecular target in the action. They, however, differ in their intrinsic activators at the receptor, Pharmacokinetic and pharmacodynamic features, and the mechanism by which they confer relapse-prevention.  

The first step in the pharmacotherapy is determining whether the patient has opioid dependence with physiological dependence. The three medications have tested on their efficacy and safety in the dealing with OIU with past signs of physiological dependence. It is indicated that adding an agonist maintenance to the relapse-prevention treatment increases the probability that the patient will stop the opioid dependence during active treatment.  

The recommended practice change being recommended here is use of buprenorphine. The properties of buprenorphine include partial agonist intrinsic activity and high affinity in MOR binding. It has slow MOR dissociation, which allows thrice-weekly sublingual dosing with the potential of high-dose weekly formulations. Its mechanism for preventing relapse includes reducing opioid craving, withdrawal, and stress reactivity. It also acts by competitively blocking and reducing the reinforcing effects of other opioids (Connery, 2015). 

Buprenorphine was approved as a pharmacological treatment by the FDA in 2002 for use in treating opioid-dependent men and opioid dependent women who are not pregnant. It was proved to be effective therapy due to its wide safety margin. Its effectiveness is associated to the fact that it is an antagonist which prevent the stimulation of kappa opioid receptor there resulting to positive mood and feelings of well-being. Buprenorphine is recommended in either of its two formulations; buprenorphine hydrochloride tablet (Subutex) or combination tablet (suboxone) of the Subutex and naloxone HCL (Jones, 2004). In their study, Korthuis, McCaty, Weimer, Bougatsos, Blazina, Zakher, Grusing, Devine, & Chou (2017), revealed that the use of buprenorphine led to a 49% treatment retention at 12 months, and a reduction of opioid use within a period of 30 days from 84% to 42% in 12 months. Similar results were highlighted by D’Onofrio, O’Connor, & Pantalon (2015) who indicated that engagement in treatment of illicit opioid use with buprenorphine lead to reduction in the mean number of days of illicit opioid use per week from 5.4 days to 0.9 days which is equivalent to 83.3%. Weinstein, Kim, Cheng, Quinn, Hui, Labelle, Drainoni, Bachman, & Samet, 2017 asserted this when their study revealed that more that 50% of the patients under the Office Based Opioid Treatment with buprenorphine were successfully retained for a period longer than year.

Process of Implementing the Recommendation

Stakeholders

  The three main stakeholders in the implementation of the pharmacotherapy would include the healthcare practitioners, the patient, and DEA. The patient is likely to experience some withdrawal symptoms. It is therefore important to fully engage the patient and assist him/her in dealing with the withdrawal symptoms to prevent falling back into the misuse of opioid. The practitioners, on the other hand, needs to be made aware of risks likely to face the patient thereby anticipate how to handle such behaviors and understand the need for establishing a relationship with the patient. The practitioners also need to understand that they are required to register with the Drug Enforcement Authority before they can make the prescriptions of the controlled substances, a category which the pharmacotherapy drugs fall. There are extra requirements for practitioners who treat opioid-use disorder, as they are required to manage the patients in a federal licensed opioid treatment program. The DEA is an important stakeholder in the adoption of the recommendation of using pharmacotherapy to treat opioid use disorder. This is because these drugs fall under the category of controlled substances and, therefore, DEA needs to manage their use and distribution. DEA enforces rules on prescription and treatment of OUD by the practitioners.

Barriers to Implementation of the Recommendation

A barrier that may largely affect the application of pharmacotherapy in the management of opioid use disorder is the strict government and insurance policies. Here, the most reported factors include the requirement to attend an 8-hour training session before being allowed to prescribe office-based treatment for opioid dependence, obstacles in third party payer reimbursement, complex regulations on Medicaid coverage of pharmacotherapy, and limitation of treatment coverage. These barriers cause delays, which may subject the patients to adverse outcomes (Molfenter, et al, 2018).

Another barrier likely to be experienced is the logistical issues. This includes the inadequate access to prescribing physicians, limited clinical and administrative assistance, cost issues, a complication in coordinating care, and the burden of laboratory testing. This barrier has been associated with the low access of pharmacotherapy among the public sector programs.  

Strategies to Overcome the Barriers

Various solutions have been proposed to address the logistical barrier facing the pharmacotherapy application. In dealing with the barrier and financial cost, it can be noted that the use of methadone maintenance utilization leads to a reduction in the overall health care costs for patients addicted to opioids. The methadone maintenance programs have flexible clinical regulations that make them more accessible. It may also be important to extend the prescribing rights to nurse practitioners and physicians’ assistants. This would enhance the access to office-based opioid treatment. 

In dealing with barriers due to government policies and insurance, top-down institutional support would be important. Health insurance plans need to increase their scope to benefit coverage to cater for medication on substance use. State governments may help by developing policies that may cater for medications for substance use disorder. Insurance cover should be extending to cater for administrative and clinical resources required in pharmacotherapy (Sharma, Kelly, Mitchell, Gryczynski, O’Grady, Schwartz, 2017).

Indicator to Measure the Recommendation

An important indicator to be considered on the evaluation of the recommended plan is on retention in treatment after initiation of the therapy. The retention in the treatment is associated with better outcomes. This indicator considers how well patients progress with the treatment without dropping out of the treatment program. High retention rate indicates that the therapy is effective in the treatment of opioid use disorder. 

References

Bonhomme, J., Shim, R. S., Gooden, R., Tyus, D., & Rust, G. (2012). Opioid Addiction and Abuse in Primary Care Practice: A Comparison of Methadone and Buprenorphine as Treatment Options. Journal of the National Medical Association104(0), 342–350.

Connery, H. S. (2015). Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harvard review of psychiatry23(2), 63-75. https://pdfs.semanticscholar.org/959c/e3caf1fe3bed9da973bc8a1530a9ead497b1.pdf

Dugosh, K., Abraham, A., Seymour, B., McLoyd, K., Chalk, M., & Festinger, D. (2016). A Systematic Review on the Use of Psychosocial Interventions in Conjunction With Medications for the Treatment of Opioid Addiction. Journal of Addiction Medicine10(2), 91–101. 

D’onofrio, G., O’connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens, P. H., … & Fiellin, D. A. (2015). Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. Jama313(16), 1636-1644.

Green, J. (2017). Epidemiology of opioid abuse and addiction. Journal of Emergency Nursing43(2), 106-113.

Jones, H. E. (2004). Practical considerations for the clinical use of buprenorphine. Science & Practice Perspectives2(2), 4.

Korthuis, P. T., McCarty, D., Weimer, M., Bougatsos, C., Blazina, I., Zakher, B., … & Chou, R. (2017). Primary care–based models for the treatment of opioid use disorder: a scoping review. Annals of internal medicine166(4), 268-278.

Molfenter, T., Sherbeck, C., Starr, S., Kim, J. S., Zehner, M., Quanbeck, A., … & McCarty, D. (2018). Payer policy behavior towards opioid pharmacotherapy treatment in Ohio. Journal of addiction medicine12(2), 85.

Minozzi, S., Amato, L., Bellisario, C., & Davoli, M. (2014). Maintenance treatments for opiate-dependent adolescents. The Cochrane database of systematic reviews, (6), CD007210-CD007210.

National Institute on Drug Abuse. (2018). Opioid Overdose Crisis. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis

Reinberg, S. (2017). Opioid Abuse by US Youths Up by Sixfold Since 2001. United Press International. Retrieved from https://www.upi.com/Health_News/2017/06/19/Opioid-abuse-by-US-youths-up-sixfold-since-2001-Study/7621497890855/

Sharma, A., Kelly, S. M., Mitchell, S. G., Gryczynski, J., O’Grady, K. E., & Schwartz, R. P. (2017). Update on barriers to pharmacotherapy for opioid use disorders. Current psychiatry reports19(6), 35.

Volkow, N. D., & McLellan, A. T. (2016). Opioid abuse in chronic pain—misconceptions and mitigation strategies. New England Journal of Medicine374(13), 1253-1263.

Weinstein, Z. M., Kim, H. W., Cheng, D. M., Quinn, E., Hui, D., Labelle, C. T., … & Samet, J. H. (2017). Long-term retention in office based opioid treatment with buprenorphine. Journal of substance abuse treatment74, 65-70.Woolley, J. D., Arcuni, P. A., Stauffer, C. S., Fulford, D., Carson, D. S., Batki, S., & Vinogradov, S. (2016). The effects of intranasal oxytocin in opioid-dependent individuals and healthy control subjects: a pilot study. Psychopharmacology233(13), 2571-2580.

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