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Posted: Fri Feb 19, 2016 5:52 am
by rickbennettmd
ran across a recent pertinent study:

Research Report
A cost-effectiveness analysis of opioid substitution therapy upon prison release in reducing mortality among people with a history of opioid dependence
Natasa Gisev1,*, Marian Shanahan1, Don J. Weatherburn2, Richard P. Mattick1, Sarah Larney1,3, Lucy Burns1 andLouisa Degenhardt1,4
Article first published online: 23 SEP 2015
DOI: 10.1111/add.13073
Addiction
Volume 110, Issue 12, pages 19751984, December 2015


summary: 13,500 subjects
inmates given MAT (here OST -- Opiate Substitution Therapy) had a >50% reduction in death rate in the 6 months following prison discharge!


Findings
A total of 13#8201;468 individuals were matched (6734 in each group). Twenty (0.3%) people released onto OST died, compared with 46 people (0.7%) not released onto OST. The final average costs were lower for the group that received OST post-release ($7206 versus $14#8201;356). The incremental cost-effectiveness ratio showed that OST post-release was dominant, incurring lower costs and saving more lives. The probability that OST post-release is cost-effective per life-year saved is 96.7% at a willingness to pay of $500.

Conclusion
Opioid substitution treatment (compared with no such treatment), given on release from prison to people with a history of opioid dependence, is cost-effective in reducing mortality in the first 6#8201;months of release.

Posted: Fri Feb 19, 2016 5:52 am
by rickbennettmd
re: preemptively treating patients an with opiate addiction history with MAT upon release from prison

I agree that these patients most definitely very often need and would benefit from pharmaceutically based use prevention programs upon discharge.

I have heard post-incarceration relapse histories so many times. Sometimes months after discharge, other instances within the hour of release.

It does seem undesirable and perhaps risky to reintroduce formerly opiate dependendent patients to an opiate high in the induction and early maintenance period of Suboxone or methadone therapy, however. This would occur in patients who had not used or minimally used in prison and thus would have no opiate tolerance.

For one thing, wouldn't "whetting the appetite" of an addict create a major risk of a relapse to poorly controlled, flagrant abuse?

I would very much like to hear opinions and experiences of other practitioners regarding this.


Antagonist therapy also comes to mind for these patients, of course.

But Vivitrol (depo-naltrexone) is so absurdly expensive, well beyond the means of the great majority of patients emerging from prison.

How does daily po naltrexone compare in price? Is it actually affordable?

Daily oral naltrexone therapy has a bad reputation for compliance, I realize. But perhaps an addict who has not used for a substantial period of time could control the temptation to go off this med to use?


Posted: Fri Feb 19, 2016 5:52 am
by drpasser
Yes. Inductions on pts c Opiate Use D/Os just released from jail makes good sense to me.

Keep em from relapsing and improve their functioning.

I try and enlist family support, as much as possible, especially c pts c complicated social histories. They just need enhanced services, at least for a while, to help them land on their feet, not back in jail.

:-)

Posted: Fri Feb 19, 2016 5:52 am
by peterorrin
What about inducting someone just released from jail? A social worker told me she sought buprenorphine for him, but: 1) the CT bup list is incredibly unreliable, 2) no bup provider takes "Husky", our Medicaid, and 3) the rest take only cash. There is NO bup tx avail for this category of patient, so he has signed up with a methadone clinic. It will be an impossibly long commute (forget meaningful work). We need to identify federally-approved clinics that could waiver one of their docs.

Cheers,
Peter

Posted: Fri Feb 19, 2016 5:52 am
by drpasser
Most pts are in WDRL for inductions. Occasionally, they aren't, for various reasons as discussed above.

I will start a pt on bupe, if he or she meets the indication based on the dx of Opiate Use D/O. Having a spouse is helpful for historical data.

Best
Kevin

Posted: Fri Feb 19, 2016 5:52 am
by fishdoc
At 24 hours after hydrocodone there should be a positive UDS. A few patients will have negative drug screens, but most new patients will at least have metabolites of some opioid unless they have been incarcerated. While addicts are great actors and liars, it is required that they be in moderate to severe withdrawal before we prescribe buprenorphine. I strongly encourage patients with negative urines and not in withdrawal to start on Vivitrol. As you know many patients will sell their Subs or trade for their preferred drug.

Posted: Fri Feb 19, 2016 5:52 am
by NoDrugs4u
There is a precedent for treating "Patients Not Physically Dependent on Opioids" in the SAMHSA TIP40 guidelines, page 54. But this sounds like this patient is scamming you for whatever reason.

Hydrocodone should show up on UDS after 24 hours. Therefore, patient is lying to you about opiate use. I would say bye-bye.

Posted: Fri Feb 19, 2016 5:52 am
by Dave
A negative urine screen makes it looks like he was lying about using opiates. Did he have symptoms of withdrawal? His surprise at hearing he had to provide a urine sample also is suspicious. What did he say when told his urine showed no opiate? I don't think he is a candidate for induction unless he fesses up and tells the truth.

Posted: Fri Feb 19, 2016 5:52 am
by robertsonjon
I'd look for the clinical signs of withdrawal, runny nose, fine tremor, etc. That makes me nervous, too. My tests are good enough to pick up hydrocodone or its metabolites hydromorphone and norhydrocodone for about 5 days after.

If his hands aren't shaking, I wouldn't prescribe at this time. I'd tell him he may not be physically dependent on it, and just needs counseling to deal with what he perceives to be an addiciton problem.

Posted: Fri Feb 19, 2016 5:52 am
by MChaplin
did you check your state's prescription monitoring program to see if he has a hx of obtaining meds from ER? or do you have a reliable family member to corroborate his story? did he in fact appear to be in WDRL with a positive COWS including at least some objective signs (runny nose/tearing, trembling, increased heart rate etc) ? based on the information you describe I would tell him that you couldn't start the suboxone that day but if he is willing to stay in treatment, you can continue to evaluate...and then try to get more information. with a clean urine, he could start oral naltrexone...