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- Page navigation anchor for Buprenorphine/naloxone ‘micro-dosing’: an alternate induction approach for the treatment of opioid use disorder in the wake of North America’s increasingly potent illicit drug marketBuprenorphine/naloxone ‘micro-dosing’: an alternate induction approach for the treatment of opioid use disorder in the wake of North America’s increasingly potent illicit drug market
After reviewing the article by Bruneau et al,(1) we agree that appropriate therapy should be used to manage opioid use disorders, with buprenorphine-naloxone (BUP/NX) being a first-line option. A significant limitation of the medication, however, is the need for an individual to abstain from opioid use for a period of time prior to BUP/BX initiation. Such a requirement is necessary to allow adequate time for the elimination of systemic full opioid agonists to avoid precipitation of opioid withdrawal with the use of BUP/NX (a partial opioid agonist with high affinity for the mu opioid receptor). In the current fentanyl era however, successfully achieving this ‘opioid washout’ can be a challenge. While fentanyl has a rapid onset and short duration of action, the substance itself is lipophilic resulting in distribution to the peripheral tissues in a manner that is not dose-dependent.(2, 3) Consequently, continuous and prolonged use of fentanyl can result in an increased volume of distribution systemically with slow dissipation overall.(2) Accordingly, the pharmacokinetics of fentanyl combined with its high prevalence in the illicit drug market appear (at least anecdotally) to be increasing the incidence of precipitated withdrawal during the BUP/NX induction process. This occurs despite patients objectively being in moderate to severe opioid withdrawal prior to initiation on the medication.
To address this, some prescribers in British Columbia (and likely beyond) are a...
Show MoreCompeting Interests: None declared. - Page navigation anchor for Extended-release naltrexone overlooked in opioid use disorders guidelineExtended-release naltrexone overlooked in opioid use disorders guideline
The article by Bruneau et al. (1) on the management of opioid use disorders (OUD) is excellent but for the omission of monthly injectable extended-release naltrexone (XR-NTX). The authors review the oral formulation of this opioid antagonist, which they correctly grade as a weak recommendation based on low quality evidence. In contrast, XR-NTX has been shown in two recent randomized controlled trials to be similarly effective to buprenorphine-naloxone (BUP-NX) for retention in treatment and reduction in drug use once initiated post detoxification (2, 3). Importantly, XR-NTX is overall cost effective (4), and can also treat alcohol use disorders (5). Patients taking XR-NTX have no euphoria or physical dependence, an attractive choice for those with safety-sensitive work.
The US Food and Drug Administration (FDA) authorized XR-NTX in 2010. The American Society of Addiction Medicine National Practice Guideline for the treatment of OUD recommends the use of XR-NTX (6). This position is supported by Dr. Nora Volkow, Head of the US National Institute on Drug Abuse (NIDA) (7).
Since April of 2017, Health Canada has allowed the prescribing of XR-NTX under a special dispensation for urgent public need (8). Unfortunately, no public funding has been put in place to support this abstinence-based treatment. Bruneau and colleagues note, “The evidence base for pharmacotherapies not yet widely available in Canada, including long-acting and extended-release opioid antagonist...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Management of opioid use disorders: a national clinical practice guidelineRE: Management of opioid use disorders: a national clinical practice guideline
What about the patients that do not abuse their pain meds That want to get off their pain meds? I’ve been taking prescribed opioids for more than 10 years. I’m now in the process of getting off these meds and withdrawing slowly at home. There needs to be s strategy for us folks that have never abused or overdosed but need to get off their pain meds. It feels virtually impossible to stop via slow withdrawal that can take years to accomplish.
Competing Interests: None declared.