Literature Collection

The clinical trial by Kraft et al. provides evidence of a practical alternative pharmacologic approach to the management of the neonatal abstinence syndrome. However, accumulating data show that the appropriate use of nonpharmacologic therapy, especially rooming-in care by parents, results in substantially fewer infants who require opioid therapy to control withdrawal symptoms after exposure to opioids in utero.1-4 In the treatment of withdrawal in infants, the use of the model for treatment in adults, which involves suppression of symptoms with an opiate followed by a tapering reduction in dose, may also need to be challenged. The use of opioid treatment on an as-needed basis3 may prove to be a safer and healthier approach than the use of opioid treatment on a scheduled basis. We strongly advocate that centers caring for infants with the neonatal abstinence syndrome adopt a model of care in which nonpharmacologic treatment is considered to be the primary treatment, with pharmacotherapy secondary. In particular, the facilitation of rooming in and increased parental presence aids in achieving the triple aim of improved quality, improved patient experience, and reduced health care costs.5

Several studies that have focused on deliberate, nonpharmacologic care have shown a reduced need for medications and substantially shorter lengths of stay than the BBORN trial, some as short as 5.9 days.2-4 With small group sizes in this trial, we cannot assume that disparate nonpharmacologic interventions were adequately addressed with randomization, and without controlling for these nonpharmacologic factors it is difficult to interpret the effect of differing pharmacologic therapies. The results of a trial that randomly assigned infants with the neonatal abstinence syndrome to various levels of nonpharmacologic care and that did not control for medication therapy would be similarly difficult to interpret. Nonpharmacologic care has been shown to be an effective therapy for infants with the neonatal abstinence syndrome, and it needs to be treated as such in the literature.

Background  Conventional buprenorphine inductions require patients to abstain from full agonist opioids until they experience mild-to-moderate opioid withdrawal. We described a successful buprenorphine induction case in a pregnant patient using microdosing, which avoided withdrawal symptoms. Case Presentation  The patient is a 29-year-old G2P1001 at 18 2/7 weeks of gestation, who desired a switch from methadone to buprenorphine to minimize neonatal opioid withdrawal syndrome (NOWS), which complicated her last pregnancy. She was given increasing microdoses of buprenorphine over a 7-day period, while continuing her daily dose of methadone. She discontinued the methadone on day 8. She did well during the week of buprenorphine microdosing, with no complaints of withdrawal or cravings. She was engaged in her prenatal care. Her dose of buprenorphine was increased to 8 mg twice daily in the third trimester for some withdrawal symptoms in the evening consisting of new onset nausea and vomiting. The patient underwent an elective 39-week induction of labor and had a spontaneous vaginal delivery of an appropriately grown male fetus. Only nonpharmacologic interventions were used. Conclusion  Buprenorphine microdosing was well tolerated in this patient and avoided withdrawal symptoms in the mothers, and NOWS. A microdosing study in pregnancy is indicated.

Buprenorphine maintenance therapy (BMT) expands treatment access for opioid dependence and can be integrated into primary health-care settings. Treating opioid dependence, however, should ideally improve other aspects of overall health, including preventive services. Therefore, we examined how BMT affects preventive health-care outcomes, specifically nine nationally recommended primary care quality health-care indicators (QHIs), within federally qualified health centers (FQHCs) from an observational cohort study of 266 opioid-dependent patients initiating BMT between 07/01/07 and 11/30/08 within Connecticut’s largest FQHC network. Nine nationally recommended preventive QHIs were collected longitudinally from electronic health records, including screening for chronic infections, metabolic conditions, and cancer. A composite QHI score (QHI-S), based on the percentage of eligible QHIs achieved, was categorized as QHI-S ≥80 % (recommended) and ≥90 % (optimal). The proportion of subjects achieving a composite QHI-S ≥80 and ≥90 % was 57.1 and 28.6 %, respectively. Screening was highest for hypertension (91.0 %), hepatitis C (80.1 %), hepatitis B (76.3 %), human immunodeficiency virus (71.4 %), and hyperlipidemia (72.9 %) and lower for syphilis (49.3 %) and cervical (58.5 %), breast (44.4 %), and colorectal (48.7 %) cancer. Achieving QHI-S ≥80 % was positively and independently associated with ≥3-month BMT retention (adjusted odds ratio (AOR) = 2.19; 95 % confidence interval (CI) = 1.18–4.04) and BMT prescription by primary care providers (PCPs) rather than addiction psychiatric specialists (AOR = 3.38; 95 % CI = 1.78–6.37), and negatively with being female (AOR = 0.30; 95 % CI = 0.16–0.55). Within primary health-care settings, achieving greater nationally recommended health-care screenings or QHIs was associated with being able to successfully retain patients on buprenorphine longer (3 months or more) and when buprenorphine was prescribed simultaneously by PCPs rather than psychiatric specialists. Decreased preventive screening for opioid-dependent women, however, may require gender-based strategies for achieving health-care parity. When patients can be retained, integrating BMT into urban FQHCs is associated with improved health outcomes including increased multiple preventive health-care screenings.

BACKGROUND: Buprenorphine is a highly effective medication for opioid use disorder that is underused by health care professionals (HCPs). Medications for opioid use disorder (MOUD) misinformation may be an important barrier to buprenorphine access, but most implementation strategies have aimed to reduce negative attitudes towards patients with opioid use disorder (OUD) rather than misinformation specific to buprenorphine use. In this study, we assessed the degree to which HCPs endorsed misinformation related to buprenorphine, and whether this is associated with willingness to provide care to patients with OUD. METHODS: In September-December of 2022, we surveyed HCPs practicing in Ohio (n = 409). Our primary outcomes included a previously validated 5-item measure of HCP willingness to treat patients with OUD, and three other measures of willingness. Our key independent variable was a study-developed 5-item measure of endorsement of misinformation related to buprenorphine, which assessed beliefs in buprenorphine's efficacy in managing withdrawal symptoms and reducing overdose deaths as well as beliefs about the role of buprenorphine in achieving remission. We computed descriptive and bivariable statistics and fit regression models predicting each outcome of interest. RESULTS: On average, HCPs scored 2.34 out of 5.00 (SD = 0.80) on the composite measure of buprenorphine misinformation. 48.41% of participants endorsed at least one piece of misinformation. The most endorsed items were that buprenorphine is ineffective at reducing overdose deaths (M = 2.75, SD =0 .98), and that its use substitutes one drug for another (M = 2.41, SD = 1.25). HCP endorsement of buprenorphine misinformation significantly and negatively predicted willingness to work with patients with OUD (b = - 0.34; 95% CI - 0.46, - 0.21); intentions to increase time spent with this patient population (b = - 0.36; 95% CI - 5.86, - 1.28); receipt of an X-waiver (OR = 0.54, 95% CI 0.38, 0.77); and intention to get an X-waiver (OR: 0.56; 95% CI: 0.33-0.94). CONCLUSIONS: Misinformation is common among HCPs and associated with lower willingness to treat patients with OUD. Implementation strategies to increase MOUD use among HCPs should specifically counter misinformation related to buprenorphine. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT05505227. Registered 17 August 2022, https://clinicaltrials.gov/ct2/show/NCT05505227.