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      Leveraging the role of community pharmacists in the prevention, surveillance, and treatment of opioid use disorders

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          Abstract

          The global rise in opioid-related harms has impacted the United States severely. Current efforts to manage the opioid crisis have prompted a re-evaluation of many of the existing roles in the healthcare system, in order to maximize their individual effects on reducing opioid-associated morbidity and preventing overdose deaths. As one of the most accessible healthcare professionals in the US, pharmacists are well-positioned to participate in such activities. Historically, US pharmacists have had a limited role in the surveillance and treatment of substance use disorders. This narrative review explores the literature describing novel programs designed to capitalize on the role of the community pharmacist in helping to reduce opioid-related harms, as well as evaluations of existing practices already in place in the US and elsewhere around the world. Specific approaches examined include strategies to facilitate pharmacist monitoring for problematic opioid use, to increase pharmacy-based harm reduction efforts (including naloxone distribution and needle exchange programs), and to involve community pharmacists in the dispensation of opioid agonist therapy (OAT). Each of these activities present a potential means to further engage pharmacists in the identification and treatment of opioid use disorders (OUDs). Through a careful examination of these approaches, we hope that new strategies can be adopted to leverage the unique role of the community pharmacist to help reduce opioid-related harms in the US.

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          Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence

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            Treatment utilization among persons with opioid use disorder in the United States

            Background The United States is experiencing an opioid overdose epidemic. Treatment use data from diverse racial/ethnic groups with opioid use disorder (OUD) are needed to inform treatment expansion efforts. Methods We examined demographic characteristics and behavioral health of persons aged ≥12 years that met criteria for past-year OUD (n=6,125) in the 2005–2013 National Surveys on Drug Use and Health (N=503,101). We determined the prevalence and correlates of past-year use of alcohol/drug use treatment and opioid-specific treatment to inform efforts for improving OUD treatment. Results Among persons with OUD, 81.93% had prescription (Rx) OUD only, 9.75% had heroin use disorder (HUD) only, and 8.32% had Rx OUD+HUD. Persons with Rx OUD+HUD tended to be white, adults aged 18–49, males, or uninsured. The majority (80.09%) of persons with OUD had another substance use disorder (SUD), and major depressive episode (MDE) was common (28.74%). Of persons with OUD, 26.19% used any alcohol or drug use treatment, and 19.44% used opioid-specific treatment. Adolescents, the uninsured, blacks, native-Hawaiians/Pacific-Islanders/Asian-Americans, persons with Rx OUD only, and persons without MDE or SUD particularly underutilized opioid-specific treatment. Among alcohol/drug use treatment users, self-help group and outpatient rehabilitation treatment were commonly used services. Conclusions Most people with OUD report no use of OUD treatment. Multifaceted interventions, including efforts to access insurance coverage, are required to change attitudes and knowledge towards addiction treatment in order to develop a supportive culture and infrastructure to enable treatment-seeking. Outreach efforts could target adolescents, minority groups, and the uninsured to improve access to treatment.
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              Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial.

              To examine patient and medication characteristics associated with retention and continued illicit opioid use in methadone (MET) versus buprenorphine/naloxone (BUP) treatment for opioid dependence. This secondary analysis included 1267 opioid-dependent individuals participating in nine opioid treatment programs between 2006 and 2009 and randomized to receive open-label BUP or MET for 24 weeks. The analyses included measures of patient characteristics at baseline (demographics; use of alcohol, cigarettes and illicit drugs; self-rated mental and physical health), medication dose and urine drug screens during treatment, and treatment completion and days in treatment during the 24-week trial. The treatment completion rate was 74% for MET versus 46% for BUP (P < 0.01); the rate among MET participants increased to 80% when the maximum MET dose reached or exceeded 60 mg/day. With BUP, the completion rate increased linearly with higher doses, reaching 60% with doses of 30-32 mg/day. Of those remaining in treatment, positive opioid urine results were significantly lower [odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.52-0.76, P < 0.01] among BUP relative to MET participants during the first 9 weeks of treatment. Higher medication dose was related to lower opiate use, more so among BUP patients. A Cox proportional hazards model revealed factors associated with dropout: (i) BUP [versus MET, hazard ratio (HR) = 1.61, CI = 1.20-2.15], (ii) lower medication dose (<16 mg for BUP, <60 mg for MET; HR = 3.09, CI = 2.19-4.37), (iii) the interaction of dose and treatment condition (those with higher BUP dose were 1.04 times more likely to drop out than those with lower MET dose, and (iv) being younger, Hispanic and using heroin or other substances during treatment. Provision of methadone appears to be associated with better retention in treatment for opioid dependence than buprenorphine, as does use of provision of higher doses of both medications. Provision of buprenorphine is associated with lower continued use of illicit opioids. © 2013 Society for the Study of Addiction.
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                Author and article information

                Contributors
                paxton.bach@bccsu.ubc.ca
                hartungd@ohsu.edu
                Journal
                Addict Sci Clin Pract
                Addict Sci Clin Pract
                Addiction Science & Clinical Practice
                BioMed Central (London )
                1940-0632
                1940-0640
                2 September 2019
                2 September 2019
                2019
                : 14
                : 30
                Affiliations
                [1 ]ISNI 0000 0001 2288 9830, GRID grid.17091.3e, British Columbia Centre on Substance Use, , University of British Columbia, ; 400-1045 Howe Street, Vancouver, BC V6Z 2A9 Canada
                [2 ]College of Pharmacy, Oregon State University/Oregon Health and Science University, Robertson Collaborative Life Science Building, 2730 SW Moody Ave, CL5CP, Portland, OR 97201-5042 USA
                Author information
                http://orcid.org/0000-0002-2413-9133
                Article
                158
                10.1186/s13722-019-0158-0
                6717996
                31474225
                3e986474-e77c-448e-b8cf-5d4c628b3c05
                © The Author(s) 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 14 February 2019
                : 6 August 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100000026, National Institute on Drug Abuse;
                Award ID: R25DA033211
                Award ID: R25DA037756
                Award ID: R01 DA044284-01A1
                Award ID: 1R01DA045745
                Award ID: R01DA046468
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/100000030, Centers for Disease Control and Prevention;
                Award ID: R01CE003008
                Award ID: 1U01CE002786
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/100000133, Agency for Healthcare Research and Quality;
                Award ID: R18 HS024227
                Award ID: HHSA2902015000091
                Award Recipient :
                Categories
                Review
                Custom metadata
                © The Author(s) 2019

                Health & Social care
                community pharmacy services,opioid-related disorders,opiate substitution treatment,harm reduction

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