Rheumatology News

Practice guideline released for treating opioid use disorder

BY MARY ANN MOON

Frontline Medical News

From Journal of Addiction Medicine

he American Society of Addiction Medicine has released

a practice guideline to help clinicians evaluate and treat

opioid use disorder, with the ultimate goal of getting more

physicians to provide effective treatment.

Effective treatment of opioid use disorder “requires skill and

time that are not generally available to primary care doctors in

most practice models,” so much of the treatment provided in

primary care has been “suboptimal.” This has probably wors-

ened what the United States Centres for Disease Control and

Prevention has described as an epidemic of opioid misuse and

related deaths, said Dr Kyle Kampman and Dr Margaret Jarvis,

cochairs of the ASAM’s guideline committee.

“At the same time, access to competent treatment is pro-

foundly restricted because few physicians are willing and able

to provide it,” they noted.

This guideline “is primarily intended for clinicians involved

in evaluating patients and providing authorisation for phar-

macologic treatments at any level,” said Dr Kampman of the

University of Pennsylvania, Philadelphia, and Dr Jarvis, of the

Marworth Alcohol & Chemical Dependency Centre, an entity

of the Geisinger Health System, Waverly, Pennsylvania.

To develop the guideline, the committee – experts and

researchers in internal medicine, family medicine, addiction

medicine, addiction psychiatry, general psychiatry, obstetrics,

pharmacology, and neurobiology, including some with allopathic

or osteopathic training – first reviewed 34 existing clinical

guidelines and 27 recent studies in the literature assessing

medications used with psychosocial interventions. None of

the existing guidelines included all the medications currently

in use, and few addressed critical special populations such as

pregnant women, patients with comorbid psychiatric disorders,

and patients with chronic pain.

The ASAM guideline specifically addresses these and other

special populations (for example, adolescents, patients in the

criminal justice system). It includes detailed sections on treat-

ing opioid withdrawal and opioid overdose, as well as compre-

hensive discussions of methadone, buprenorphine, naltrexone,

and psychosocial therapies.

The guideline offers numerous clinical recommendations

regarding patient assessment and diagnosis.

First, “addiction should be considered a bio-psycho-social-

spiritual illness, for which the use of medication(s) is but only

one component of overall treatment.” In addition to a thorough

history and physical exam (including specific laboratory tests

needed for this patient population), patients should undergo

a mental health assessment with particular attention to pos-

sible psychiatric comorbidities. And since opioid use often

co-occurs with other substance-related disorders, “the totality

of substances that surround the addiction” should be assessed

before treatment is considered.

Notably, the concomitant use of alcohol, sedatives, hypnot-

ics, or anxiolytics with opioids can cause respiratory depression.

Patients who use these agents may automatically require a

higher level of care than that offered in typical primary care

practices.

As well, social and environmental factors should be assessed,

to identify both barriers to and facilitators for addiction treat-

ment in general and pharmacotherapy in particular. “At a

minimum, psychosocial treatment should include the following:

psychosocial needs assessment, supportive counselling, links to

existing family supports, and referrals to community services.”

Physicians should be prepared to collaborate with qualified

behavioural health care providers, the guideline states.

Urinary drug testing is recommended, both during the assess-

ment process and frequently throughout treatment.

Regarding treatment, the guideline recommends considering

the patient’s preferences, past treatment history, and the treat-

ment setting when deciding whether to prescribe methadone,

bupenorphrine, or naltrexone. The treatment venue is as impor-

tant as the specific medication selected. Office-based treatment,

which provides medication prescribed either weekly or monthly,

is limited to buprenorphine only. It might not be suitable for

patients who regularly use alcohol or other substances.

In contrast, treatment programs provide daily supervised dos-

ing of methadone and, increasingly, buprenorphine. Methadone

is recommended for patients who fail on buprenorphine or who

would benefit from daily dosing and supervision.

Naltrexone can be prescribed in any setting by any clinician,

but prescribers must be aware that adherence to oral naltrex-

one is generally poor, which often leads to treatment failure.

Extended-release injectable naltrexone reduces but doesn’t elimi-

nate adherence issues. Clinicians should reserve naltrexone “for

patients who would be able to comply with special techniques to

enhance their adherence, such as observed dosing.”

Dr Kampton disclosed research ties with Braeburn Pharmaceuti-

cals; Dr Jarvis disclosed business ties with US Preventive Medicine.

Fibromyalgia found in 20% with spondyloarthritis;

could affect management decisions

BY JEFF EVANS

Frontline Medical News

From Arthritis Research & Therapy

he presence of fibromyalgia in patients

who are undergoing treatment of spondy-

loarthritis (SpA) is associated with higher

measures of disease activity and shorter dura-

tion of first-time treatment with tumour necro-

sis factor inhibitors, according to results of a

study measuring the impact and prevalence of

fibromyalgia coexisting with SpA.

The results confirm “that the existence of

concomitant FM [fibromyalgia] in SpA might

complicate the evaluation of treatment re-

sponse and [suggest] that coexistence of FM

should be carefully screened when initiating a

TNFi [tumour necrosis factor inhibitor] and/or

evaluating its treatment effect, especially in the

presence of peripheral and/or enthesitic symp-

toms and in the presence of very severe disease

activity and patient-reported scores,” wrote Dr

Natalia Bello and her colleagues at Cochin

Hospital, Paris (

Arthritis Res Ther

2016 Feb

9;18:42. doi: 10.1186/s13075-016-0943-z).

They recruited patients fromCochin Hospi-

tal, a tertiary care facility, and its rheumatology

department’s outpatient clinic. Rather than

use the 1990American College of Rheumatol-

ogy (ACR) classification criteria of FM or the

2010 ACR or modified 2010 ACR diagnostic

criteria, which were developed for research

and classification purposes, the investigators

diagnosed FM based on a score of 5 or 6 on the

six-question, self-reported Fibromyalgia Rapid

Screening Tool (FiRST), which has 90.5%

sensitivity and 85.7% specificity for FM.

Patients’ SpA diagnoses were made by their

rheumatologists. Overall, 30% of the cohort

was female and had a mean age of 43 years.

The overall FM prevalence in the cohort was

21.4% (42 of 196 patients) and did not differ

significantly according to whether the patients

met either the clinical or imaging ASAS (As-

sessment of Spondyloarthritis International

Society) criteria (21.3% vs 18.8%, respectively)

or whether they did or did not fulfil the ASAS

criteria (21.1% vs 30.0%, respectively).

Previous studies have shown the preva-

lence of FM at 12.6–15.0% in SpA patients.

Classifying axial SpA based on the clinical

arm criteria alone has been controversial,

the investigators said, mainly because it does

not require an objective sign of inflammation

(abnormal C-reactive protein or presence of

inflammatory lesions seen on MRI of the

sacroiliac joint) or structural damage in the

sacroiliac joint seen on pelvic radiographs. But

at least in this study there was no difference in

FM prevalence in regard to whether patients

met either the imaging and clinical arms of

the ASAS classification criteria for axial SpA

or both.

The study, according to the best knowledge

of the investigators, is the first “to evaluate the

prevalence of FM in a population of patients

with SpA with regard to the fulfilment of the

ASAS classification criteria.”

FM patients had as expected a significantly

higher rate of either history of depression, or

use of psychotropic drugs or strong opioids,

compared with patients without FM (67% vs

35%; P < 0.01). Rates of exposure to treat-

ment with different drug types (nonsteroidal

anti-inflammatory drugs or conventional an-

tirheumatic disease-modifying drugs) did not

differ between those with and without FM,

but FM patients switched significantly more

often from their first TNFi (15.2% vs 4.0%)

and used it for a significantly shorter mean

duration (1.7 vs 3.5 years). The percentage

of patients still taking their first TNFi after

2 years also was significantly lower among FM

patients (28.1% vs 41.7%).

Within the entire cohort, FM patients

more often had enthesitis (59.5% vs 39.0%,

P = 0.01), a higher total Bath Ankylosing

Spondylitis Disease Activity Index (4.7 vs 2.6;

P < 0.01), higher global visual analog scale (5.9

vs 3.0; P < 0.01), and higher Bath Ankylos-

ing Spondylitis Functional Index (4.8 vs 2.0;

P < 0.01).

The authors suggested that FM patients’

higher rates of peripheral symptoms and

enthesitis may warrant the use of the FiRST

questionnaire in clinical practice before start-

ing a TNFi in SpA patients to detect poten-

tially coexisting FM.

The authors had no conflicts of interest to de-

clare.

At a minimum, psychosocial treatment should include

the following: psychosocial needs assessment,

supportive counselling, links to existing family

supports, and referrals to community services.

heumatology

ews

• Vol. 4 • No. 1 • 2016

PAIN