Systematic review on intentional non-medical fentanyl use among people who use drugs

ObjectivesFentanyl is a highly potent opioid and has, until recently, been considered an unwanted contaminant in the street drug supply among people who use drugs (PWUD). However, it has become a drug of choice for an increasing number of individuals. This systematic review evaluated intentional non-medical fentanyl use among PWUD, specifically by summarizing demographic variance, reasons for use, and resulting patterns of use.MethodsThe search strategy was developed with a combination of free text keywords and MeSH and non-MeSH keywords, and adapted with database-specific filters to Ovid MEDLINE, Embase, Web of Science, and PsychINFO. Studies included were human studies with intentional use of non-medical fentanyl or analogues in individuals older than 13. Only peer-reviewed original articles available in English were included.ResultsThe search resulted in 4437 studies after de-duplication, of which 132 were selected for full-text review. Out of 41 papers included, it was found that individuals who use fentanyl intentionally were more likely to be young, male, and White. They were also more likely to have experienced overdoses, and report injection drug use. There is evidence that fentanyl seeking behaviours are motivated by greater potency, delay of withdrawal, lower cost, and greater availability.ConclusionsAmong PWUD, individuals who intentionally use fentanyl have severe substance use patterns, precarious living situations, and extensive overdose history. In response to the increasing number of individuals who use fentanyl, alternative treatment approaches need to be developed for more effective management of withdrawal and opioid use disorder.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier CRD42021272111

Substance Dependence Among Bipolar, Unipolar Depression and Psychotic Homeless: A Canadian National Study

Introduction: Homeless individuals are often mischaracterized as members of a homogeneous population that suffers from a wide mental health and addiction issues, with little consideration of potentially important differences within or between samples. The aim of the present study was to investigate the comorbidy of alcohol and/or substance dependence (ASD) and major psychiatric diagnoses (bipolar disorder, unipolar depression, and psychotic disorder) in a large Canadian sample of homeless individuals, and to examine potential sources of variability including location and ethnicity.Materials and Methods: A sample of 1,585 homeless individuals were assessed for alcohol and/or substance dependence and bipolar disorder, unipolar depression and psychotic disorder with the Mini-International Neuropsychiatric Interview (version 6.0). Regional and ethnic differences in major psychiatric diagnoses between homeless with and without ASD were examined using univariate (i.e., chi-square) and multivariate (i.e., logistic regression) statistics.Results: Members of the sample with ASD were found to be younger, Aboriginal, less well-educated, and born in the Americas. They were more significantly more prevalent in Western Canada and less prevalent in Central and Eastern Canada. The odds of having ASD were higher among people affected by bipolar disorder and (to a less extent) unipolar depression.Limitations: Data collected were self-reported and no urinalyses were performed. We considered diagnosis of ASD according to the previous 12 months only.Conclusions: Homeless people with major mental illness are at high risk for concurrent ASD, however the prevalence of ASD varies significantly between cities, and based on ethnicity and specific psychiatric diagnosis (with greater prevalence in individuals affected by bipolar disorder and, to a less extent, unipolar depression). Clinicians, administrators and policy makers should develop and deliver services based on careful assessment of the local population

Opium tincture for opioid substitution treatment

Opioids have served as a dual-purpose substance throughout the human history. While they are listed as an essential medicine by the World Health Organization, on account of their effectiveness at treating pain, their harmful use also leaves a significant burden on societies. Among treatments developed to address the latter, opioid substitution treatment (OST) is a very well-documented and evidence-based treatment, which has shown to improve a multitude of treatment outcomes for patients with opioid dependence. Besides well-established medicines for OST, such as methadone and buprenorphine, opium tincture (OT), a hydro alcoholic preparation of opium, is used for this purpose on a large scale in Iran. The first step of this thesis, which was a systematic review, (2014 - 2016) did not find adequate evidence to make a conclusive recommendation about the safety and efficacy of OT for OST. Following this review, a non- inferiority randomized clinical trial (opium trial) with 204 participants and a 12-week follow-up period, compared the safety and efficacy of OT with methadone in treatment of opioid dependence. A comparison of international samples with participants of opium trial at baseline revealed that patterns of substance use and related risk behaviors differed significantly between Iran and other regions of the world, a factor which needs to be considered when generalizing the findings of the opium trial. Next, the comparison of outcomes between the two arms showed that OT was a clinically effective medication and that OT was more effective than methadone at reducing participants’ opioid use outside of treatment; however, the study could not conclude whether or not OT was non-inferior to methadone at retaining participants in treatment. The number of people with AEs (adverse events) were not significantly different between the two groups. There was no serious adverse event in the OT arm and one in the methadone arm. Substitution treatment with OT has expanded in Iran since its introduction and the results of this trial show potential for its further use. OT can serve as a culturally acceptable and widely available medication for OST, diversifying the treatment options for this condition.Medicine, Faculty ofExperimental Medicine, Division ofMedicine, Department ofGraduat

Chronic Pain among Individuals Experiencing Homelessness and Its Interdependence with Opioid and Other Substance Use and Mental Illness

Chronic pain and substance use disorders are serious conditions that are prevalent among homeless populations. The aim of this study was to examine the association between chronic pain and substance use among individuals experiencing homelessness and mental illness. We analyzed cross-sectional data from two sites of the At Home/Chez Soi study (Vancouver and Toronto) using bivariate statistics and multivariate logistic regression. Substance use and chronic pain parameters were assessed with the Maudsley Addiction Profile and purpose-designed short instruments. The sample comprised 828 participants. Mean age was 42.4 years and 54% reported chronic pain. In bivariate analysis, chronic pain was significantly associated with use of opioids and stimulants, daily substance use, polysubstance use and injecting as route of administration. In multivariate analysis, only daily substance use (OR: 1.46, 95% CI: 1.02–2.09) and injecting (OR: 1.81, 95% CI: 1.08–3.05) remained as significant associated factors, whereas neither use of opioids nor use of stimulants specifically were significantly associated with chronic pain. Among participants with chronic pain, daily substance users (50% vs. 22%, p < 0.001) and injectors (66% vs. 24%, p < 0.001) were more likely to use non-prescribed medication for pain. Participants with daily substance use were less likely to receive professional treatment (52% vs. 64%, p = 0.017) and prescribed pain medication (42% vs. 54%, p = 0.023). Our findings suggest an association of chronic pain with patterns related to severity of substance use rather than to specific substance use in homeless persons with mental illness. Interventions aiming at prevention and treatment of chronic pain in this population should consider severity of substance use and associated risk behavior over use of specific substances.Medicine, Faculty ofNon UBCPsychiatry, Department ofReviewedFacultyResearcherOthe

Case report: Successful induction of buprenorphine/naloxone using a microdosing schedule and assertive outreach

Background: The requirement for moderate withdrawal prior to initiation can be a barrier to buprenorphine/naloxone induction. Case presentation: We aimed to use a microdosing regimen to initiate regular dosing of buprenorphine/naloxone in a high-risk patient with a history of failed initiations due, in part, to withdrawal symptoms. Using an assertive outreach model and a buprenorphine/naloxone microdosing schedule, we initiated treatment of an individual’s opioid use disorder. There was a successful buprenorphine/naloxone microdosing induction as the team reached a therapeutic dose of buprenorphine/naloxone. Including the induction period, the medication was used consistently for 4 weeks. Conclusions: A microdosing schedule can be used to induce a patient onto buprenorphine/naloxone with no apparent withdrawal; gradually reducing illicit substance use. This case report builds on previous literature, highlighting ways to minimize barriers to induction of buprenorphine/naloxone, using a microdosing schedule and assertive outreach. Given the safety profile of buprenorphine and its potential to be a lifesaving intervention, a larger study of microdosing is indicated.Medicine, Faculty ofOther UBCNon UBCOccupational Science and Occupational Therapy, Department ofReviewedFacult

Comparing rapid micro-induction and standard induction of buprenorphine/naloxone for treatment of opioid use disorder: protocol for an open-label, parallel-group, superiority, randomized controlled trial

Background: Buprenorphine/naloxone (Suboxone) is a current first-line treatment for opioid use disorder (OUD). The standard induction method of buprenorphine/naloxone requires patients to be abstinent from opioids and therefore experience withdrawal symptoms prior to induction, which can be a barrier in starting treatment. Rapid micro-induction (micro-dosing) involves the administration of small, frequent does of buprenorphine/naloxone and removes the need for a period of withdrawal prior to the start of treatment. This study aims to compare the effectiveness and safety of rapid micro-induction versus standard induction of buprenorphine/naloxone in patients with OUD. Methods: This is a randomized, open-label, two-arm, superiority, controlled trial comparing the safety and effectiveness of rapid micro-induction versus standard induction of buprenorphine/naloxone for the treatment of OUD. A total of 50 participants with OUD will be randomized at one Canadian hospital. The primary outcome is the completion of buprenorphine/naloxone induction with low levels of withdrawal. Secondary outcomes are treatment retention, illicit drug use, self-reported drug use behaviour, craving, pain, physical health, safety, and client satisfaction. Discussion: This is the first randomized controlled trial to compare the effectiveness and safety of rapid micro-induction versus standard induction of buprenorphine/naloxone. This study will thereby generate evidence for a novel induction method which eliminates substantial barriers to the use of buprenorphine/naloxone in the midst of the ongoing opioid crisis. Trial registration ClinicalTrials.gov, NCT04234191; date of registration: January 21, 2020; https://clinicaltrials.gov/ct2/show/NCT04234191Medicine, Faculty ofOther UBCNon UBCAnesthesiology, Pharmacology and Therapeutics, Department ofEmergency Medicine, Department ofMedicine, Department ofPsychiatry, Department ofReviewedFacult

DataSheet_1_Systematic review on intentional non-medical fentanyl use among people who use drugs.docx

ObjectivesFentanyl is a highly potent opioid and has, until recently, been considered an unwanted contaminant in the street drug supply among people who use drugs (PWUD). However, it has become a drug of choice for an increasing number of individuals. This systematic review evaluated intentional non-medical fentanyl use among PWUD, specifically by summarizing demographic variance, reasons for use, and resulting patterns of use.MethodsThe search strategy was developed with a combination of free text keywords and MeSH and non-MeSH keywords, and adapted with database-specific filters to Ovid MEDLINE, Embase, Web of Science, and PsychINFO. Studies included were human studies with intentional use of non-medical fentanyl or analogues in individuals older than 13. Only peer-reviewed original articles available in English were included.ResultsThe search resulted in 4437 studies after de-duplication, of which 132 were selected for full-text review. Out of 41 papers included, it was found that individuals who use fentanyl intentionally were more likely to be young, male, and White. They were also more likely to have experienced overdoses, and report injection drug use. There is evidence that fentanyl seeking behaviours are motivated by greater potency, delay of withdrawal, lower cost, and greater availability.ConclusionsAmong PWUD, individuals who intentionally use fentanyl have severe substance use patterns, precarious living situations, and extensive overdose history. In response to the increasing number of individuals who use fentanyl, alternative treatment approaches need to be developed for more effective management of withdrawal and opioid use disorder.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier CRD42021272111.</p