Evaluating Slow-Release Oral Morphine to Narrow the Treatment Gap for Opioid Use Disorders

Socías, M. Eugenia; Wood, Evan

doi:10.7326/m17-2373

Cited by 12 publications

(11 citation statements)

References 7 publications

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“…The present meta-analysis demonstrates the consistent pattern in clinical trials evaluating the impact of SROM. Because most OUD patients do not access agonist therapies,10 and since poor retention in methadone has been linked to heightened mortality and other health outcomes,14 SROM may have a promising role in OUD treatment, especially given methadone’s known side-effect profile, the likely attractiveness of SROM to some patients and the apparent reduction in craving when on SROM in comparison to methadone 8 17 28. Unless future trials report contradictory findings, the public health crisis presented by illicitly manufactured opioids,2 and the known limitations of existing agonist therapies,14 34 these data should inform future investigations of SROM as a therapeutic tool among people undergoing treatment for OUD.…”

Section: Discussionmentioning

confidence: 99%

“…While methadone and buprenorphine/naloxone are proven effective,6 7 they have a known limited ability to attract and retain patients in treatment. For instance, past studies have demonstrated that most individuals who overdose are not on agonist treatment at the time of death, and that, overall, agonist therapies remain sorely underused with only a fraction of eligible patients in the USA accessing these therapies 8–10. While overall low rates of methadone and buprenorphine/naloxone use are partially due to poor access and limited service delivery,10 the balance of medication benefits and side-effects (eg, sweating, weight gain) and other limitations of these therapies (eg, corrected QT (QTc) interval prolongation, sleep disturbance, need for daily visits and supervised urine collection in some settings), also result in low rates of patient retention once individuals initiate therapy 11–13.…”

Section: Introductionmentioning

confidence: 99%

“…In the light of increasing recognition that a range of additional forms of OAT are necessary for some persons with complex OUD, interest in slow release oral morphine (SROM) as an OUD treatment agent has steadily grown 8 15. A 2013 review by the Cochrane Collaboration reviewed the literature for SROM as treatment for OUD.…”

Section: Introductionmentioning

confidence: 99%

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Slow release oral morphine versus methadone for the treatment of opioid use disorder

Klimas

Gorfinkel

Giacomuzzi³

et al. 2019

BMJ Open

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ObjectiveTo assess the efficacy of slow release oral morphine (SROM) as a treatment for opioid use disorder (OUD).DesignSystematic review and meta-analysis of randomised controlled trials (RCTs).Data sourcesThree electronic databases were searched through 1 May 2018: the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. We also searched the following electronic registers for ongoing trials: ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Current Controlled Trials and the EU Clinical Trials Register.Eligibility criteria for selecting studiesWe included RCTs of all durations, assessing the effect of SROM on measures of treatment retention, heroin use and craving in adults who met the diagnostic criteria for OUD.Data extraction and synthesisTwo independent reviewers extracted data and assessed risk of bias. Data were pooled using the random-effects model and expressed as risk ratios (RRs) or mean differences with 95% CIs. Heterogeneity was assessed (χ2 statistic) and quantified (I2 statistic) and a sensitivity analysis was undertaken to assess the impact of particular high-risk trials.ResultsAmong 1315 records screened and four studies reviewed, four unique randomised trials met the inclusion criteria (n=471), and compared SROM with methadone. In the meta-analysis, we observed no significant differences between SROM and methadone in improving treatment retention (RR=0.98; 95%CI: 0.94 to 1.02, p=0.34) and heroin use (RR=0.96; 95% CI: 0.61 to 1.52, p=0.86). Craving data was not amenable to meta-analysis. Available data implied no differences in adverse events, heroin, cocaine or benzodiazepine use.ConclusionsMeta-analysis of existing randomised trials suggests SROM may be generally equal to methadone in retaining patients in treatment and reducing heroin use while potentially resulting in less craving. The methodological quality of the included RCTs was low-to-moderate.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Slow release oral morphine versus methadone for the treatment of opioid use disorder

Klimas

Gorfinkel

Giacomuzzi³

et al. 2019

BMJ Open

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“…Hospitalisation with these infections represents a 'reachable moment' to effectively engage untreated patients into OAT [9][10][11][12][13]. Unfortunately, buprenorphine and methadone are not desired, tolerable or sufficiently beneficial for all patients, and up to 50% stop within 6 months [14,15]. This contributes to enormous unmet need, with more than 1 million Americans estimated to have untreated OUD [14].…”

Section: Introductionmentioning

confidence: 99%

Uptake of slow‐release oral morphine as opioid agonist treatment among hospitalised patients with opioid use disorder

Brothers

Fraser

MacAdam

et al. 2021

Drug and Alcohol Review

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Introduction. Buprenorphine and methadone are highly effective first-line medications for opioid agonist treatment (OAT) but are not acceptable to all patients. We aimed to assess the uptake of slow-release oral morphine (SROM) as second-line OAT among medically ill, hospitalised patients with opioid use disorder who declined buprenorphine and methadone. Methods. This study included consecutive hospitalised patients with untreated moderate-to-severe opioid use disorder referred to an inpatient addiction medicine consultation service, between June 2018 and September 2019, in Nova Scotia, Canada. We assessed the proportion of patients initiating first-line OAT (buprenorphine or methadone) in-hospital, and the proportion initiating SROM after declining first-line OAT. We compared rates of outpatient OAT continuation (i.e., filling outpatient OAT prescription or attending first outpatient OAT clinic visit) by medication type, and compared OAT selection between patients with and without chronic pain, using χ 2 tests. Results. Thirty-four patients were offered OAT initiation in-hospital; six patients (18%) also had chronic pain. Twenty-one patients (62%) initiated first-line OAT with buprenorphine or methadone. Of the 13 patients who declined first-line OAT, seven (54%) initiated second-line OAT with SROM in-hospital. Rates of outpatient OAT continuation after hospital discharge were high (>80%) and did not differ between medications (P = 0.4). Patients with co-existing chronic pain were more likely to choose SROM over buprenorphine or methadone (P = 0.005). Discussion and Conclusions. The ability to offer SROM (in addition to buprenorphine or methadone) increased rates of OAT initiation among hospitalised patients. Increasing access to SROM would help narrow the opioid use disorder treatment gap of unmet need.[Brothers TD, Fraser J, MacAdam E, Morgan B, Webster D. Uptake of slow-release oral morphine as opioid agonist treatment among hospitalised patients with opioid use disorder.

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“…There has been a longstanding need to expand access to opioid agonist treatment (OAT) to address the challenges of the opioid overdose crisis. However, while existing traditional OAT approaches (i.e., methadone and buprenorphine) are successful for many patients, these options have limitations such as limited ability to attract and retain patients in treatment [7]. In particular, these OAT options may have unwanted side effects for some patients [8] and often require daily presentation for witnessed ingestion at a methadone program or pharmacy.…”

Section: Introductionmentioning

confidence: 99%

Fentanyl assisted treatment: a possible role in the opioid overdose epidemic?

Bardwell

Wood

Brar

2019

Subst Abuse Treat Prev Policy

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BackgroundThe current opioid overdose epidemic affecting communities across North America is increasingly driven by illicitly manufactured fentanyl and its related analogues. A variety of public health interventions have been implemented and scaled up, including opioid agonist treatments (OAT). While these treatments are successful for many individuals, they have a variety of limitations. It is critical to trial alternative treatments if conventional opioid agonist treatment options are not successful for a proportion of patients who use illicit fentanyl.Main bodyPrescription fentanyl has been widely used for pain management. The use of transdermal fentanyl, specifically, which provides long acting and stable drug levels post-titration over several days, should be explored as an opioid agonist treatment option. The use of transdermal fentanyl for patients who use illicit fentanyl is currently being piloted in Vancouver, Canada. To address potential diversion, the patch is signed, dated, and a film dressing is applied to mitigate tampering. Evaluation outcomes are still pending, but there have been no adverse outcomes thus far and clinical improvements have been noted for many patients. This exploratory therapeutic approach should be considered across multiple settings and rigorously evaluated.ConclusionsThere are known limitations to existing OAT options and there is a need to urgently evaluate alternative strategies for patients who are using illicit fentanyl not successfully treated with conventional OAT. Many patients may be attracted to, and retained in, fentanyl assisted treatment. This may be another strategy for certain patients to prevent harms caused by illicit fentanyl use, including overdose and death.

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Evaluating Slow-Release Oral Morphine to Narrow the Treatment Gap for Opioid Use Disorders

Cited by 12 publications

References 7 publications

Slow release oral morphine versus methadone for the treatment of opioid use disorder

Slow release oral morphine versus methadone for the treatment of opioid use disorder

Uptake of slow‐release oral morphine as opioid agonist treatment among hospitalised patients with opioid use disorder

Fentanyl assisted treatment: a possible role in the opioid overdose epidemic?

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