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Stewardson AJ, Davis JS, Dunlop AJ, Tong SYC, Matthews GV. How I manage severe bacterial infections in people who inject drugs. Clin Microbiol Infect 2024; 30:877-882. [PMID: 38316359 DOI: 10.1016/j.cmi.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/21/2024] [Accepted: 01/30/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Injecting drug use is a risk factor for severe bacterial infection, but there is limited high-quality evidence to guide clinicians providing care to people who inject drugs. Management can be complicated by mistrust, stigma, and competing patient priorities. OBJECTIVES To review the management of severe infections in people who inject drugs, using an illustrative clinical scenario of complicated Staphylococcus aureus bloodstream infection. SOURCES The discussion is based on recent literature searches of relevant topics. Very few randomized clinical trials have focussed specifically on the management of severe bacterial infections among people who inject drugs. Most recommendations are, therefore, based on observational studies, extrapolation from other patient groups, and the experience and opinions of the authors. CONTENT We discuss evidence and options regarding the following management issues for severe bacterial infections among people who inject drugs: initial management of sepsis; indications for surgical management; assessment and management of substance dependence; approaches to antibiotic administration following clinical stability; opportunistic health promotion; and secondary prevention of bacterial infections. Throughout, we highlight the importance of harm reduction and strategies to optimize patient engagement in care through a patient-centred approach. IMPLICATIONS We advocate for a multi-disciplinary trauma-informed approach to the management of severe bacterial infection among people who inject drugs. We emphasize the need for pragmatic trials to inform management guidelines, including those that are co-designed with the community. In particular, research is needed to establish the comparative effectiveness, safety, and cost-effectiveness of inpatient intravenous antibiotics vs. early oral antibiotic switch, outpatient parenteral therapy, and long-acting lipoglycopeptide antibiotics in this scenario.
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Affiliation(s)
- Andrew J Stewardson
- Department of Infectious Diseases, The Alfred and Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Joshua S Davis
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia; Infection Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia; Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Adrian J Dunlop
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia; NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, NSW, Australia; Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; Hunter Medical Research Institute, The University of Newcastle, Newcastle, NSW, Australia
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Gail V Matthews
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia; St Vincent's Hospital, Sydney, NSW, Australia
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Álvaro-Alonso EA, Gómez-Álvarez MDC, Segovia-Tapiador B, Del-Pino-Illaconza MI, Valencia J, Ryan P, Aguilar-Ros A, Escobar-Rodríguez I. Persistence in the Methadone Maintenance Program and Its Relationship with the Medication Regimen Complexity Index in Opioid-Dependent Patients. Pharmaceuticals (Basel) 2024; 17:567. [PMID: 38794137 PMCID: PMC11123973 DOI: 10.3390/ph17050567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
It has been shown that the Medication Regimen Complexity Index (MRCI) is a useful and reliable tool for calculating the complexity of the pharmacotherapeutic regimen (CPR). Furthermore, a high MRCI is associated with lower adherence. However, the MRCI of opioid-dependent patients (ODP) has not been studied. The aim of this study is to calculate the Methadone Maintenance Program (MMP) persistence and the MRCI score in a ODP cohort. Second, to analyze its relationship and association with other variables. To accomplish this research, an observational study including adults with a confirmed diagnosis of opiate-dependency according to the DSM-5 in a MMP center was carried out. To define MMP-persistence, a group was created by the researchers who defined five weighted items according to their agreed importance. Our first contribution was to create a new definition of MMP-persistence. This study also identified age, comorbidities, and received methadone maintenance doses as successful predictors for MMP-persistence. We have also shown that the MRCI does not seem to be a useful tool to determine MMP-persistence, probably because there are multiple factors that influence it in addition to the CPR. It is necessary to continue searching for more precise selection and stratification tools for ODP to improve their persistence.
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Affiliation(s)
- Elena Alba Álvaro-Alonso
- Pharmacy Department, Infanta Leonor University Hospital, Av. Gran Vía del Este, 80, 28031 Madrid, Spain;
| | - María del Carmen Gómez-Álvarez
- General Subdirectorate of Pharmaceutical Inspection and Management, Authorization Area for Pharmaceutical Centers, Services and Establishments, Ministry of Health, C/Aduana, 29, 28013 Madrid, Spain;
| | - Beatriz Segovia-Tapiador
- Vallecas Comprehensive Care Center for Drug Addicts, Calle de las Cinco Villas, 5, 28051 Madrid, Spain; (B.S.-T.); (M.I.D.-P.-I.)
| | - María Isabel Del-Pino-Illaconza
- Vallecas Comprehensive Care Center for Drug Addicts, Calle de las Cinco Villas, 5, 28051 Madrid, Spain; (B.S.-T.); (M.I.D.-P.-I.)
| | - Jorge Valencia
- Internal Medicine Department, Infanta Leonor University Hospital, Av. Gran Vía del Este, 80, 28031 Madrid, Spain; (J.V.); (P.R.)
| | - Pablo Ryan
- Internal Medicine Department, Infanta Leonor University Hospital, Av. Gran Vía del Este, 80, 28031 Madrid, Spain; (J.V.); (P.R.)
| | - Antonio Aguilar-Ros
- Instituto Universitario de Estudios de las Adicciones IEA-CEU, Universidad San Pablo-CEU, CEU Universities, Urbanización Montepríncipe, 28660 Boadilla del Monte, Spain;
| | - Ismael Escobar-Rodríguez
- Pharmacy Department, Infanta Leonor University Hospital, Av. Gran Vía del Este, 80, 28031 Madrid, Spain;
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Magel T, Arreola LAG, Guh D, MacDonald S, Harrison S, Schechter M, Oviedo-Joekes E. Building Capacity for Injectable Diacetylmorphine and Hydromorphone for the Treatment of Opioid Use Disorder: Identifying Typical Doses. J Psychoactive Drugs 2024:1-14. [PMID: 38590251 DOI: 10.1080/02791072.2024.2338734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/22/2024] [Indexed: 04/10/2024]
Abstract
Identifying typical doses of existing opioid use disorder medications, such as injectable opioid agonist treatment (iOAT), can support client and program needs, and potentially increase iOAT expansion. Longitudinal data from participants in a cohort study (n = 131), along with clinic dispensation records from August 2014 to April 2020, were used to examine physician prescribed as well as used doses of injectable diacetylmorphine and hydromorphone. Dosage groups, by medication and prescribed dose per session, were created for both hydromorphone and diacetylmorphine. A total of 534, 522 injections were registered during the study period among 129 participants. Mean received diacetylmorphine doses ranged from 106 to 989 mg per day, with most clients using 125-262 mg per session (mean 192.99 mg) and attending 2.40 sessions per day. Mean received hydromorphone doses ranged from 51.09 to 696.06 mg per day, with the majority using 88-154 mg per session (mean 121.32 mg; 2.43 sessions). Average daily doses remained stable overtime and, while mid-range doses were most typical, participants used the whole spectrum of allowable dose prescriptions. Evidence supporting typical doses of iOAT can be integrated into program planning to better allow providers and prescribers to anticipate program needs and engage in individualized care.
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Affiliation(s)
- Tianna Magel
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Daphne Guh
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, Vancouver, BC, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, Vancouver, BC, Canada
| | - Scott Harrison
- Providence Health Care, Urban Health and Substance Use, Vancouver, BC, Canada
| | - Martin Schechter
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, Vancouver, BC, Canada
| | - Eugenia Oviedo-Joekes
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, Vancouver, BC, Canada
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Liu PS, Kuo TY, Chen IC, Lee SW, Chang TG, Chen HL, Chen JP. Optimizing methadone dose adjustment in patients with opioid use disorder. Front Psychiatry 2024; 14:1258029. [PMID: 38260800 PMCID: PMC10800821 DOI: 10.3389/fpsyt.2023.1258029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction Opioid use disorder is a cause for concern globally. This study aimed to optimize methadone dose adjustments using mixed modeling and machine learning. Methods This retrospective study was conducted at Taichung Veterans General Hospital between January 1, 2019, and December 31, 2020. Overall, 40,530 daily dosing records and 1,508 urine opiate test results were collected from 96 patients with opioid use disorder. A two-stage approach was used to create a model of the optimized methadone dose. In Stage 1, mixed modeling was performed to analyze the association between methadone dose, age, sex, treatment duration, HIV positivity, referral source, urine opiate level, last methadone dose taken, treatment adherence, and likelihood of treatment discontinuation. In Stage 2, machine learning was performed to build a model for optimized methadone dose. Results Likelihood of discontinuation was associated with reduced methadone doses (β = 0.002, 95% CI = 0.000-0.081). Correlation analysis between the methadone dose determined by physicians and the optimized methadone dose showed a mean correlation coefficient of 0.995 ± 0.003, indicating that the difference between the methadone dose determined by physicians and that determined by the model was within the allowable range (p < 0.001). Conclusion We developed a model for methadone dose adjustment in patients with opioid use disorders. By integrating urine opiate levels, treatment adherence, and likelihood of treatment discontinuation, the model could suggest automatic adjustment of the methadone dose, particularly when face-to-face encounters are impractical.
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Affiliation(s)
- Po-Shen Liu
- Department of Psychiatry, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Teng-Yao Kuo
- Fundamental General Education Center, National Chinyi University of Technology, Taiping, Taiwan
| | - I-Chun Chen
- Department of Psychiatry, Taichung Veterans General Hospital, Taichung, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Shu-Wua Lee
- Department of Psychiatry, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ting-Gang Chang
- Department of Psychiatry, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hou-Liang Chen
- Tsaotun Psychiatric Center, Ministry of Health and Welfare, Nantou, Taiwan
| | - Jun-Peng Chen
- Biostatistics Task Force of Taichung Veterans General Hospital, Taichung, Taiwan
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5
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Casey S, Regan S, Gale E, Adams ZM, Lambert E, Omede FO, Wakeman SE. Rapid Methadone Induction in a General Hospital Setting: A Retrospective, Observational Analysis. Subst Abus 2023; 44:177-183. [PMID: 37728091 DOI: 10.1177/08897077231185655] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND Outpatient methadone guidelines recommend starting at a low dose and titrating slowly. As fentanyl prevalence and opioid-related mortality increases, there is a need for individuals to rapidly achieve a therapeutic methadone dose. Hospitalization offers a monitored setting for methadone initiation, however dosing practices and safety are not well described. METHODS Retrospective, observational analysis of hospitalized patients with opioid use disorder seen by an inpatient addiction consult team in an academic medical center who were newly initiated on methadone between 2016 and 2022. We calculated initial daily dose, maximum daily dose, timing interval of dose escalation, whether patients were connected to an opioid treatment program (OTP) prior to discharge, whether adverse effects or safety events occurred during the hospitalization, and whether such events were definitely or probably related versus possibly related or unrelated to methadone. RESULTS One hundred twelve patients were included. The mean initial daily methadone dose administered was 32 mg (range: 10-90 mg). The mean maximum dose reached was 76.8 mg (range 30-165 mg). The mean number of days from initial to peak dose was 5.6 days (range 1-19 days). Overall, 30% of patients experienced a safety event, most commonly sedation. Only 4 safety events were deemed probably or definitely related to methadone. In regression analyses, there was no significant difference between starting doses among patients with or without sedation but there was a relationship between last dose and the likelihood of any possibly related event, with those ending at a dose of 100 mg or higher having a higher likelihood event, compared to those ending at lower doses (47.8% vs 12.4%, P < .001). Seventy-six percent were connected to OTP before discharge. CONCLUSION Among hospitalized patients initiating methadone, rapid dose titration was infrequently associated with related safety events and most were connected to community-based methadone treatment before discharge.
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Affiliation(s)
- Sarah Casey
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Susan Regan
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Evan Gale
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Zoe M Adams
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Eugene Lambert
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Faith O Omede
- Department of Internal Medicine, Mass General Community Physicians, Salem, MA, USA
| | - Sarah E Wakeman
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Tang X, Fan C, Wang C, Wang W, Chen Z, Xu C, Ling L. The risk assessment of relapse among newly enrolled participants in methadone maintenance treatment: A group-LASSO based Bayesian network study. Front Public Health 2023; 10:1032217. [PMID: 36733286 PMCID: PMC9886899 DOI: 10.3389/fpubh.2022.1032217] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/23/2022] [Indexed: 01/18/2023] Open
Abstract
Background Relapse is a great barrier to improving the effectiveness of methadone maintenance treatment (MMT). Participants with different treatment durations could vary in their compliance with MMT, which may lead to different levels of relapse risk. This study aims to identify the risk factors for relapse and assess the relapse risk of MMT participants of different treatment durations. Method This retrospective study used data collected from seven MMT clinics in Guangdong Province, China, from January 2010 to April 2017. Newly enrolled participants who received 6 (n = 903) and 12 (n = 710) months of consecutive treatment with complete data were included. We selected significant risk factors for relapse through the group lasso regression and then incorporated them into Bayesian networks to reveal relationships between factors and predict the relapse risk. Results The results showed that participants who received 6-month treatment had a lower relapse rate (32.0%) than those of 12-month treatment (39.0%, P < 0.05). Factors including personal living status and daily methadone dose were only influential to those who received the 6-month treatment. However, age, age at the initial drug use, HIV infection status, sexual behaviors, and continuous treatment days were common factors of both durations. The highest relapse risk for those after the 6-month treatment was inferred as 66.7% while that of the 12-month treatment was 83.3%. Farmers and those who have high accessibility to MMT services may require additional attention. Conclusion It is necessary to implement targeted interventions and education based on the treatment durations of participants to decrease the relapse rate. Meanwhile, those about HIV/sexually transmitted infection prevention and anti-narcotics should be held in the whole process.
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Affiliation(s)
- Xijia Tang
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Chaonan Fan
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Chijie Wang
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Wenjuan Wang
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zouxiang Chen
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Chaofan Xu
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Li Ling
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong, China,Clinical Research Design Division, Clinical Research Center, Sun-Yat sen Memorial Hospital, Sun Yat-sen University, Guangdong, China,*Correspondence: Li Ling ✉
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7
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Cui Z, Bach P, Ti L, Hayashi K, Morgan J, Milloy MJ, Kerr T. Opioid agonist therapy engagement and crystal methamphetamine use: The impact of unregulated opioid use in Vancouver, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 110:103879. [PMID: 36265327 PMCID: PMC9886012 DOI: 10.1016/j.drugpo.2022.103879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/21/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Crystal methamphetamine use has substantially increased among people who use opioids in recent years, yet the impact of opioid agonist therapy (OAT) on crystal methamphetamine use remains poorly characterized. Therefore, we sought to examine the relationship between OAT engagement and crystal methamphetamine use and to assess if this relationship differs according to the ongoing use of unregulated opioids. METHODS Data was collected from two harmonized ongoing prospective cohorts of people who use drugs in Vancouver, Canada, between December 2005 and March 2020. We employed multivariable generalized estimating equations to study the relationship between OAT engagement and crystal meth use stratified by ongoing unregulated opioid use. RESULTS Of 1742 participants who reported frequent opioid use at baseline, the median age was 42 years, and 61.3% were male. Multivariable analyses showed that compared to those who had not received OAT for at least one year: in the absence of ongoing unregulated opioid use, individuals who recently discontinued (adjusted Odds Ratio [aOR] = 0.47, 95% CI = 0.27-0.79), newly initiated (aOR = 0.52, 95% CI = 0.31-0.89), or were retained on OAT (aOR = 0.48, 95% CI = 0.31-0.72) reported a lower frequency of crystal methamphetamine use; in the presence of ongoing unregulated opioid use, individuals who newly initiated OAT reported a greater crystal methamphetamine use frequency (aOR = 1.24, 95% CI = 1.02-1.51). CONCLUSIONS We demonstrated a differential relationship between OAT engagement and crystal methamphetamine use that was conditional on the ongoing use of unregulated opioids. Our findings highlight the complexity of OAT implementation and suggest that polysubstance use patterns should be an important consideration for care providers when devising comprehensive treatment strategies and prognosticating treatment effects.
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Affiliation(s)
- Zishan Cui
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, British Columbia, V6T 1Z3 Canada
| | - Paxton Bach
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, British Columbia, V6T 1Z3 Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, British Columbia, V6T 1Z3 Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Jeffrey Morgan
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, British Columbia, V6T 1Z3 Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, British Columbia, V6T 1Z3 Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, British Columbia, V6T 1Z3 Canada.
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Moses TE, Rhodes GL, Tavakoli E, Christensen CW, Amirsadri A, Greenwald MK. Predictors of Retention and Drug Use Among Patients With Opioid Use Disorder Transferred to a Specialty "Second Chance" Methadone Program. Subst Abuse 2022; 16:11782218221138335. [PMID: 36407024 PMCID: PMC9669697 DOI: 10.1177/11782218221138335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/22/2022] [Indexed: 11/17/2022]
Abstract
Background Many patients in methadone treatment have difficulty achieving or maintaining drug abstinence, and many clinics have policies that lead to discharging these patients. We designed a pilot "Second Chance" (SC) program for patients scheduled to be discharged from other local methadone clinics to be transferred to our clinic. Aim Determine whether SC patients' retention and opioid use is related to physical or mental health conditions, non-opioid substance use, or treatment features. Methods From December 2012 to December 2014, this program enrolled 70 patients who were discharged from other clinics in the area; we were their last remaining option for methadone treatment. Unlike the clinic's standard policies, the treatment focus for SC patients was retention rather than abstinence. This program focused on connection to care (eg, psychiatric services) and enabled patients to continue receiving services despite ongoing substance use. Each patient was assessed at treatment entry and followed until June 2016 to evaluate outcomes. Results SC patients receiving disability benefits (n = 37) vs. non-disabled (n = 33) had significantly (P < .05) higher rates of current DSM-IV Axis I psychiatric diagnosis (97% vs 70%), prescriptions for opioids (84% vs 55%) and benzodiazepines (65% vs 27%), and higher methadone doses at admission (58 vs 46 mg) but did not differ significantly in rates of 6-month or 1-year retention (77% and 56%, respectively) or all-drug use (39% positive urine drug screens). Methadone doses >65 mg predicted significantly longer retention and less opioid use, but these effects were not moderated by baseline characteristics. Conclusions Patients in methadone treatment struggling to achieve abstinence may benefit from retention-oriented harm-reduction programs. Higher methadone doses can improve retention and opioid abstinence despite psychiatric comorbidities. Further work is needed to improve program implementation and outcomes in this complex population.
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Affiliation(s)
- Tabitha E Moses
- Department of Psychiatry and Behavioral
Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Gary L Rhodes
- Department of Psychiatry and Behavioral
Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Emytis Tavakoli
- Ontario Shores Centre for Mental Health
Sciences, Toronto, CA, Canada
| | - Carl W Christensen
- Department of Psychiatry and Behavioral
Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Alireza Amirsadri
- Department of Psychiatry and Behavioral
Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Mark K Greenwald
- Department of Psychiatry and Behavioral
Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA,Mark K Greenwald, Department of Psychiatry
and Behavioral Neurosciences, Wayne State University School of Medicine, 3901
Chrysler Service Drive, Suite 2A, Detroit, MI 48201, USA.
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9
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Bazazi AR, Culbert GJ, Wegman MP, Heimer R, Kamarulzaman A, Altice FL. Impact of prerelease methadone on mortality among people with HIV and opioid use disorder after prison release: results from a randomized and participant choice open-label trial in Malaysia. BMC Infect Dis 2022; 22:837. [PMID: 36368939 PMCID: PMC9652918 DOI: 10.1186/s12879-022-07804-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Mortality is elevated after prison release and may be higher in people with HIV and opioid use disorder (OUD). Maintenance with opioid agonist therapy (OAT) like methadone or buprenorphine reduces mortality in people with OUD and may confer benefits to people with OUD and HIV leaving prison. Survival benefits of OAT, however, have not been evaluated prospectively in people with OUD and HIV leaving prison. METHODS This study prospectively evaluated mortality after prison release and whether methadone initiated before release increased survival after release in a sample of men with HIV and OUD (n = 291). We linked national death records to data from a controlled trial of prerelease methadone initiation conducted from 2010 to 2014 with men with HIV and OUD imprisoned in Malaysia. Vital statistics were collected through 2015. Allocation to prerelease methadone was by randomization (n = 64) and participant choice (n = 246). Cox proportional hazards models were used to estimate treatment effects of prerelease methadone on postrelease survival. RESULTS Overall, 62 deaths occurred over 872.5 person-years (PY) of postrelease follow-up, a crude mortality rate of 71.1 deaths per 1000 PY (95% confidence interval [CI] 54.5-89.4). Most deaths were of infectious etiology, mostly related to HIV. In a modified intention-to-treat analysis, the impact of prerelease methadone on postrelease mortality was consistent with a null effect in unadjusted (hazard ratio [HR] 1.3, 95% CI 0.6-3.1) and covariate-adjusted (HR 1.2, 95% CI 0.5-2.8) models. Predictors of mortality were educational level (HR 1.4, 95% CI 1.0-1.8), pre-incarceration alcohol use (HR 2.0, 95% CI 1.1-3.9), and lower CD4+ T-lymphocyte count (HR 0.8 per 100-cell/mL increase, 95% CI 0.7-1.0). CONCLUSIONS Postrelease mortality in this sample of men with HIV and OUD was extraordinarily high, and most deaths were likely of infectious etiology. No effect of prerelease methadone on postrelease mortality was observed, which may be due to study limitations or an epidemiological context in which inadequately treated HIV, and not inadequately treated OUD, is the main cause of death after prison release. TRIAL REGISTRATION NCT02396979. Retrospectively registered 24/03/2015.
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Affiliation(s)
- Alexander R. Bazazi
- grid.47100.320000000419368710Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-228 USA
- grid.47100.320000000419368710Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT USA
- grid.266102.10000 0001 2297 6811Department of Psychiatry, University of California, San Francisco, San Francisco, CA USA
| | - Gabriel J. Culbert
- grid.185648.60000 0001 2175 0319Population Health Nursing Science, University of Illinois at Chicago, Chicago, IL USA
| | - Martin P. Wegman
- grid.47100.320000000419368710Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-228 USA
| | - Robert Heimer
- grid.47100.320000000419368710Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT USA
| | - Adeeba Kamarulzaman
- grid.47100.320000000419368710Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-228 USA
- grid.10347.310000 0001 2308 5949Faculty of Medicine, Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
| | - Frederick L. Altice
- grid.47100.320000000419368710Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-228 USA
- grid.47100.320000000419368710Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT USA
- grid.10347.310000 0001 2308 5949Faculty of Medicine, Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
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Nielsen S, Tse WC, Larance B. Opioid agonist treatment for people who are dependent on pharmaceutical opioids. Cochrane Database Syst Rev 2022; 9:CD011117. [PMID: 36063082 PMCID: PMC9443668 DOI: 10.1002/14651858.cd011117.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND There are ongoing concerns regarding pharmaceutical opioid-related harms, including overdose and dependence, with an associated increase in treatment demand. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin. OBJECTIVES: To assess the effects of maintenance opioid agonist pharmacotherapy for the treatment of pharmaceutical opioid dependence. SEARCH METHODS We updated our searches of the following databases to January 2022: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, four other databases, and two trial registers. We checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA We included RCTs with adults and adolescents examining maintenance opioid agonist treatments that made the following two comparisons. 1. Full opioid agonists (methadone, morphine, oxycodone, levo-alpha-acetylmethadol (LAAM), or codeine) versus different full opioid agonists or partial opioid agonists (buprenorphine) for maintenance treatment. 2. Full or partial opioid agonist maintenance versus non-opioid agonist treatments (detoxification, opioid antagonist, or psychological treatment without opioid agonist treatment). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. MAIN RESULTS We identified eight RCTs that met inclusion criteria (709 participants). We found four studies that compared methadone and buprenorphine maintenance treatment, and four studies that compared buprenorphine maintenance to either buprenorphine taper (in addition to psychological treatment) or a non-opioid maintenance treatment comparison. We found low-certainty evidence from three studies of a difference between methadone and buprenorphine in favour of methadone on self-reported opioid use at end of treatment (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.28 to 0.86; 165 participants), and low-certainty evidence from four studies finding a difference in favour of methadone for retention in treatment (RR 1.21, 95% CI 1.02 to 1.43; 379 participants). We found low-certainty evidence from three studies showing no difference between methadone and buprenorphine on substance use measured with urine drug screens at end of treatment (RR 0.81, 95% CI 0.57 to 1.17; 206 participants), and moderate-certainty evidence from one study of no difference in days of self-reported opioid use (mean difference 1.41 days, 95% CI 3.37 lower to 0.55 days higher; 129 participants). There was low-certainty evidence from three studies of no difference between methadone and buprenorphine on adverse events (RR 1.13, 95% CI 0.66 to 1.93; 206 participants). We found low-certainty evidence from four studies favouring maintenance buprenorphine treatment over non-opioid treatments in terms of fewer opioid positive urine drug tests at end of treatment (RR 0.66, 95% CI 0.52 to 0.84; 270 participants), and very low-certainty evidence from four studies finding no difference on self-reported opioid use in the past 30 days at end of treatment (RR 0.63, 95% CI 0.39 to 1.01; 276 participants). There was low-certainty evidence from three studies of no difference in the number of days of unsanctioned opioid use (standardised mean difference (SMD) -0.19, 95% CI -0.47 to 0.09; 205 participants). There was moderate-certainty evidence from four studies favouring buprenorphine maintenance over non-opioid treatments on retention in treatment (RR 3.02, 95% CI 1.73 to 5.27; 333 participants). There was moderate-certainty evidence from three studies of no difference in adverse effects between buprenorphine maintenance and non-opioid treatments (RR 0.50, 95% CI 0.07 to 3.48; 252 participants). The main weaknesses in the quality of the data was the use of open-label study designs, and difference in follow-up rates between treatment arms. AUTHORS' CONCLUSIONS There is very low- to moderate-certainty evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. Methadone or buprenorphine did not differ on some outcomes, although on the outcomes of retention and self-reported substance use some results favoured methadone. Maintenance treatment with buprenorphine appears more effective than non-opioid treatments. Due to the overall very low- to moderate-certainty evidence and small sample sizes, there is the possibility that the further research may change these findings.
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Affiliation(s)
- Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Frankston, Australia
| | - Wai Chung Tse
- Monash Addiction Research Centre, Monash University, Frankston, Australia
- School of Medicine, Monash University, Melbourne, Australia
| | - Briony Larance
- School of Psychology, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, Australia
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11
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Pilarinos A, Fast D, Nosova E, Kwa Y, Joe R, Buxton JA, DeBeck K. Initiation of opioid agonist treatment and subsequent substance use and other patterns among adolescents and young adults in Vancouver, Canada. Drug Alcohol Depend 2022; 235:109441. [PMID: 35427979 PMCID: PMC9872979 DOI: 10.1016/j.drugalcdep.2022.109441] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 03/30/2022] [Accepted: 04/03/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Opioid agonist treatments (OAT) are effective interventions for reducing illicit opioid use; however, less is known about OAT among adolescents and young adults (AYA). This study sought to examine OAT retention and discontinuation among AYA. METHODS Data were derived from the At-Risk Youth Study, a prospective cohort of street-involved AYA in Vancouver, Canada, between September 2005 and December 2018. Multivariable Cox regression analysis was employed to identify sociodemographic, substance use, and other factors associated with time to first OAT. Substance use, homelessness, service utilization, and criminal justice patterns among AYA who did and did not initiate OAT were examined using before and after analysis. RESULTS Of 676 AYA who reported weekly illicit opioid use, 454 (67.2%) reported not being on OAT at some point over the study period and 217 (32.1%) initiated OAT over follow-up. In non-linear growth curve analysis, only participants retained in OAT demonstrated significant reductions in daily illicit opioid use when compared to 'no OAT' controls (p < 0.05). Nevertheless, reductions in homelessness (p = 0.070) and increases in difficulty accessing services (p = 0.078) were observed between participants retained in OAT vs. 'no OAT' controls, while reductions in homelessness (p = 0.085) and weekly non-medical prescription opioid use (NMPOU) (p = 0.061) were observed between 'OAT discontinuers' vs. 'no OAT' controls. CONCLUSIONS Despite finding that OAT retention was associated with significant reductions in daily illicit opioid use, no significant improvements in other key indicators were observed. This underscores the importance of providing supports alongside OAT to improve treatment outcomes among AYA.
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Affiliation(s)
- Andreas Pilarinos
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada,Interdisciplinary Studies Graduate Program, University of British Columbia, 270-2357 Main Mall, Vancouver, BC V6T 1Z4, Canada
| | - Danya Fast
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada,Department of Medicine, University of British Columbia, 317-2914 Health Sciences Mall, Vancouver, BC V6T1Z3, Canada
| | - Ekaterina Nosova
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada,Department of Medicine, University of British Columbia, 317-2914 Health Sciences Mall, Vancouver, BC V6T1Z3, Canada
| | - Yandi Kwa
- Vancouver Coastal Health, 520 West 6th Avenue, Vancouver, BC V5Z 1A1, Canada
| | - Ronald Joe
- Vancouver Coastal Health, 520 West 6th Avenue, Vancouver, BC V5Z 1A1, Canada
| | - Jane A. Buxton
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; School of Public Policy, Simon Fraser University, 515 West Hastings Street, Suite 3271, Vancouver, BC V6B 5K3, Canada.
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12
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Strang J. Take-Home Naloxone and the Prevention of Deaths from Heroin Overdose: Pursuing Strong Science, Fuller Understanding, Greater Impact. Eur Addict Res 2022; 28:161-175. [PMID: 34963112 DOI: 10.1159/000519939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 09/07/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND CONTEXT Realization of the life-saving potential of "take-home naloxone" has been a personal journey, but it has also been a collective journey. It has been a story of individual exploration and growth, and also a story of changes at a societal level. "Take-home naloxone" has matured since its first conceptualization a quarter of a century ago. It required recognition of the enormous burden of deaths from drug overdose (particularly heroin and other opioids), and also realization of critical clusterings (such as post-release from prison). It also required realization that, since many overdose deaths are witnessed, we can potentially prevent many deaths by mobilizing drug users themselves, their families, and the wider caring community to act as intervention workforce to give life-saving interim emergency care. Summary of Scope: This article explores 5 areas (many illustrations UK-based where the author works): firstly, the need for strong science; secondly, our improved understanding of opioid overdose and deaths; thirdly, the search for greater impact from our policies and interventions; fourthly, developing better forms of naloxone; and fifthly, examining the challenges still to be addressed. KEY MESSAGES "Take-home naloxone" is an exemplar of harm reduction with potential global impact - drug policy and practice for the public good. However, "having the potential" is not good enough - there needs to be actual implementation. This will be easier once the component parts of "take-home naloxone" are improved (better naloxone products, better training aids, revised legislation, and explicit funding support). Many improvements are already possible, but we hesitate about implementation. It is our responsibility to drive progress faster. With "take-home naloxone," we can be proud of what we have achieved, but we must also be humble about how much more we still need to do.
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Affiliation(s)
- John Strang
- National Addiction Centre, Kings College London, London, United Kingdom
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13
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Analisi di Budget Impact della formulazione depot di buprenorfina a rilascio prolungato per la gestione di pazienti affetti da disturbo da uso di oppiacei. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2021; 8:96-104. [PMID: 36627866 PMCID: PMC9616199 DOI: 10.33393/grhta.2021.2237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/06/2021] [Indexed: 01/13/2023] Open
Abstract
Background: Opioid use disorder (OUD) is a disorder associated with significant rate of morbidity and mortality. Frequent clinic attendance for supervised consumption of sublingual buprenorphine is common. Prolonged-release buprenorphine (PRB) allows a management based on weekly or monthly subcutaneous injections, thus limiting the burdens of clinic attendance and the risks associated with sublingual formulations. Objective: To determine the price level of PRB that allows to obtain a neutral impact from the point of view of the economic resources absorbed, in comparison with the alternatives currently available in the Italian context for the management of patients suffering from OUD. Methods: The analysis assumes a daily PRB cost of € 8.526 (neutral cost). The analysis aims to determine the economic impact associated with the introduction of PRB in the Italian context for the management of OUD patients. Results are expressed in terms of differential resources absorbed in the alternative scenarios. A one-way sensitivity analysis was also carried out to test the robustness of the results. Results: The introduction of PRB implies an increase in the drug acquisition costs over the 5-year time horizon of € 23,016,194.61: such costs are fully compensated by the other cost driver considered in the analysis (drug tests provided, health professionals’ time destined to the provision of the treatment, indirect costs, for savings equal to € 7,255,602.59, € 10,714,320.08 and € 5,046,271.94 respectively) demonstrating its effectiveness in particular by an organizational point of view. Lower price levels for PRB would imply significant savings for the SSN. Conclusions: PRB resulted to be associated to a lower level of resources’ absorption in the Italian sector as compared with the available alternatives thus allowing to re-allocate health founds to other fields of the care sector ensuring greater safety for patients and a decreased misuse and diversion rate.
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Pharmacy Technicians, Stigma, and Compassion Fatigue: Front-Line Perspectives of Pharmacy and the US Opioid Epidemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126231. [PMID: 34207590 PMCID: PMC8296092 DOI: 10.3390/ijerph18126231] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 01/30/2023]
Abstract
The opioid epidemic in the United States has led to a quadrupling of opioid overdoses since the 1990s. Stigmas exist among healthcare professionals, and it is essential to educate the next generation of pharmacy technicians regarding opioid use disorder. The main objective of this study was to characterize the phenomenon of stigma through the pharmacy technician lens when taking care of patients who are using opioid medications. Grounded in Van Manen’s phenomenological approach and the Link and Phelan stigmatization model, a qualitative study was conducted from February to June 2020 to understand pharmacy technicians’ perceptions and attitudes towards patients using opioid medications. Focus groups (n = 46) with pharmacy technicians were conducted in-person and online over five months in 2020. Thematic analysis identified three themes that characterize the stigma and the relationship between pharmacy technicians and patients taking opioid medications: (1) pharmacy technician perspectives on stigma and patients with addictive opioid-use behavior; (2) current approaches of pharmacy technicians towards patients with addictive opioid-use behavior; (3) future approaches of pharmacy technicians towards patients with addictive opioid-use behavior. The findings highlight an “ever-present” negative connotation associated with the stigma that is formed from patient interaction. It is necessary to develop proper resources and educational materials to manage the stigma that exists in pharmacies throughout the nation. These resources will facilitate how to address and prevent the stigma among pharmacy technicians in the U.S.
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Abstract
Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.
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Affiliation(s)
- Megan Buresh
- Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert Stern
- Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Darius Rastegar
- Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Geddes L, Iversen J, Wand H, Maher L. Incidence and factors associated with discontinuation of opioid agonist therapy among people who inject drugs in Australia. Addiction 2021; 116:525-535. [PMID: 32557931 DOI: 10.1111/add.15168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/30/2020] [Accepted: 06/17/2020] [Indexed: 12/30/2022]
Abstract
AIMS To estimate incidence and predictors of opioid agonist therapy (OAT) discontinuation in a national cohort of people who inject drugs (PWID). DESIGN AND SETTING Annually repeated cross-sectional serosurveillance among PWID attending ~50 needle-syringe programmes across Australia. PARTICIPANTS Between 1995 and 2018, 2651 PWID who reported current OAT and had subsequent survey participation completed 6739 surveys. Respondents were followed over 11 984 person-years of observation (PYO). Respondents were predominantly male (60%), and the median age was 34 years. Heroin was the most commonly reported drug last injected (46%), and methadone was the most commonly prescribed OAT (77%). MEASUREMENTS The primary outcome was discontinuation of OAT (methadone, buprenorphine or buprenorphine-naloxone). Among respondents who reported current OAT, those who did not report current OAT in all subsequent records were defined as discontinued, and those with current OAT at all subsequent records were defined as retained. Predictors of discontinuation included self-reported demographic (sex, location, Indigenous status) and drug use characteristics (drug last injected, frequency of injection). FINDINGS Just fewer than one-third of respondents (29%) reported an OAT discontinuation event. The crude discontinuation rate was 6.3 [95% confidence intervals (CI) = 5.9-6.8] per 100 PYO. Discontinuation was significantly higher among respondents who reported last injecting pharmaceutical opioids [adjusted hazard ratio (aHR) = 1.75, 95% CI = 1.41-2.17, P < 0.001], being prescribed buprenorphine (aHR = 1.44, 95% CI = 1.18-1.76, P = 0.001) or buprenorphine-naloxone (aHR = 1.68, 95% CI = 1.20-2.34, P = 0.002), daily or more frequent injection (aHR = 1.51, 95% CI = 1.23-1.85, P < 0.001), recent public injecting (aHR = 1.37, 95% CI = 1.17-1.60, P < 0.001), incarceration in the previous 12 months (aHR = 1.31, 95% CI = 1.05-1.64, P = 0.017), recent receptive syringe or injection equipment sharing (aHR = 1.28, 95% CI = 1.10-1.48, P = 0.001) and male sex (aHR = 1.27, 95% CI = 1.09-1.47, P = 0.002). CONCLUSION People who inject drugs attending needle-syringe programmes in Australia appear to be significantly more likely to discontinue opioid agonist treatment if they were prescribed buprenorphine or buprenorphine-naloxone compared with methadone, are male or report injection risk behaviours and recent incarceration.
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Affiliation(s)
- Louise Geddes
- The Kirby Institute for Infection and Immunity, UNSW Sydney, Sydney, NSW, Australia
| | - Jenny Iversen
- The Kirby Institute for Infection and Immunity, UNSW Sydney, Sydney, NSW, Australia
| | - Handan Wand
- The Kirby Institute for Infection and Immunity, UNSW Sydney, Sydney, NSW, Australia
| | - Lisa Maher
- The Kirby Institute for Infection and Immunity, UNSW Sydney, Sydney, NSW, Australia.,The Burnet Institute, Melbourne, VIC, Australia
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Nance RM, Trejo MEP, Whitney BM, Delaney JAC, Altice FL, Beckwith CG, Chander G, Chandler R, Christopoulous K, Cunningham C, Cunningham WE, Del Rio C, Donovan D, Eron JJ, Fredericksen RJ, Kahana S, Kitahata MM, Kronmal R, Kuo I, Kurth A, Mathews WC, Mayer KH, Moore RD, Mugavero MJ, Ouellet LJ, Quan VM, Saag MS, Simoni JM, Springer S, Strand L, Taxman F, Young JD, Crane HM. Impact of Abstinence and of Reducing Illicit Drug Use Without Abstinence on Human Immunodeficiency Virus Viral Load. Clin Infect Dis 2021; 70:867-874. [PMID: 30994900 DOI: 10.1093/cid/ciz299] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 04/11/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Substance use is common among people living with human immunodeficiency virus (PLWH) and a barrier to achieving viral suppression. Among PLWH who report illicit drug use, we evaluated associations between HIV viral load (VL) and reduced use of illicit opioids, methamphetamine/crystal, cocaine/crack, and marijuana, regardless of whether or not abstinence was achieved. METHODS This was a longitudinal cohort study of PLWH from 7 HIV clinics or 4 clinical studies. We used joint longitudinal and survival models to examine the impact of decreasing drug use and of abstinence for each drug on viral suppression. We repeated analyses using linear mixed models to examine associations between change in frequency of drug use and VL. RESULTS The number of PLWH who were using each drug at baseline ranged from n = 568 (illicit opioids) to n = 4272 (marijuana). Abstinence was associated with higher odds of viral suppression (odds ratio [OR], 1.4-2.2) and lower relative VL (ranging from 21% to 42% by drug) for all 4 drug categories. Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with VL suppression (OR, 2.2, 1.6, respectively). Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with lower relative VL (47%, 38%, respectively). CONCLUSIONS Abstinence was associated with viral suppression. In addition, reducing use of illicit opioids or methamphetamine/crystal, even without abstinence, was also associated with viral suppression. Our findings highlight the impact of reducing substance use, even when abstinence is not achieved, and the potential benefits of medications, behavioral interventions, and harm-reduction interventions.
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Affiliation(s)
- Robin M Nance
- Department of Biostatistics, University of Washington, Collaborative Health Studies Coordinating Center, Seattle
| | - Maria Esther Perez Trejo
- Department of Biostatistics, University of Washington, Collaborative Health Studies Coordinating Center, Seattle
| | - Bridget M Whitney
- Department of Biostatistics, University of Washington, Collaborative Health Studies Coordinating Center, Seattle
| | - Joseph A C Delaney
- Department of Biostatistics, University of Washington, Collaborative Health Studies Coordinating Center, Seattle
| | - Fredrick L Altice
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Curt G Beckwith
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Geetanjali Chander
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | | | - Chinazo Cunningham
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | | | - Carlos Del Rio
- Department of Global Health, Emory University, Atlanta, Georgia
| | - Dennis Donovan
- Department of Psychiatry, University of Washington, Seattle
| | - Joseph J Eron
- Department of Medicine, University of North Carolina, Chapel Hill
| | | | | | | | - Richard Kronmal
- Department of Biostatistics, University of Washington, Collaborative Health Studies Coordinating Center, Seattle
| | - Irene Kuo
- Department of Epidemiology, George Washington University, Washington, DC
| | - Ann Kurth
- School of Nursing, Yale University School of Medicine, New Haven, Connecticut
| | - W Chris Mathews
- Department of Medicine, University of California-San Diego, UCSD Medical Center
| | | | - Richard D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | | | - Vu M Quan
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael S Saag
- Department of Medicine, University of Alabama-Birmingham
| | - Jane M Simoni
- Department of Psychology, University of Washington, Seattle
| | - Sandra Springer
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Lauren Strand
- Department of Biostatistics, University of Washington, Collaborative Health Studies Coordinating Center, Seattle
| | - Faye Taxman
- Department of Criminology, George Mason University, Fairfax, Virginia
| | | | - Heidi M Crane
- Department of Medicine, University of Washington, Seattle
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18
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Volkow ND, Blanco C. The changing opioid crisis: development, challenges and opportunities. Mol Psychiatry 2021; 26:218-233. [PMID: 32020048 PMCID: PMC7398847 DOI: 10.1038/s41380-020-0661-4] [Citation(s) in RCA: 168] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/02/2020] [Accepted: 01/23/2020] [Indexed: 12/16/2022]
Abstract
The current opioid epidemic is one of the most severe public health crisis in US history. Responding to it has been difficult due to its rapidly changing nature and the severity of its associated outcomes. This review examines the origin and evolution of the crisis, the pharmacological properties of opioids, the neurobiology of opioid use and opioid use disorder (OUD), medications for opioid use disorder (MOUD), and existing and promising approaches to prevention. The results of the review indicate that the opioid epidemic is a complex, evolving phenomenon that involves neurobiological vulnerabilities and social determinants of health. Successfully addressing the epidemic will require advances in basic science, development of more acceptable and effective treatments, and implementation of public health approaches, including prevention. The advances achieved in addressing the current crisis should also serve to advance the science and treatment of other substance use disorders.
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Affiliation(s)
| | - Carlos Blanco
- National Institute on Drug Abuse, Bethesda, MD, 20892, USA.
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Jin H, Marshall BDL, Degenhardt L, Strang J, Hickman M, Fiellin DA, Ali R, Bruneau J, Larney S. Global opioid agonist treatment: a review of clinical practices by country. Addiction 2020; 115:2243-2254. [PMID: 32289189 PMCID: PMC7554123 DOI: 10.1111/add.15087] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/28/2019] [Accepted: 04/03/2020] [Indexed: 01/30/2023]
Abstract
AIMS We assessed how opioid agonist treatment (OAT) for opioid use disorder (OUD), specifically methadone and buprenorphine, including buprenorphine-naloxone, is delivered in routine clinical practice, with a focus on factors that affect access to and delivery of these services. The aims of this review were to summarize eligibility criteria for entry to OAT, doses in routine clinical practice, access to and eligibility for unsupervised dosing and urine drug screening practices in OAT programs globally. METHODS We completed searches of PubMed, Embase, and grey literature databases for cross-sectional or observational cohort studies of OAT using either methadone or buprenorphine. Dose data extracted from eligible studies were compared with guidelines provided by WHO. RESULTS We found 140 reports from 41 countries that contained data for at least one of the relevant indicators. A diagnosis of opioid dependence or opioid use disorder was the most common eligibility requirement for OAT (13 or 17 countries). Reported mean or median doses for methadone ranged from 16-131 mg whereas range for buprenorphine was 2.5-19 mg. Access to unsupervised dosing under some conditions was reported in 18 of 27 countries. Frequency of regular urine drug screenings (UDS) ranged from several times a week to eight times per year (methadone) or as clinically indicated. CONCLUSIONS Opioid agonist treatment practices, including doses prescribed, vary greatly both within and across countries. Of particular concern is the persistence of lower dose prescribing practices, in which patients may be prescribed doses below those proven to yield significant clinical benefits.
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Affiliation(s)
- Harry Jin
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, United States
| | | | - Louisa Degenhardt
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - John Strang
- South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, United Kingdom
| | - Matt Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - David A. Fiellin
- Yale Schools of Medicine and Public Health, New Haven, Connecticut, United States
| | - Robert Ali
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Julie Bruneau
- Department of Family and Emergency Medicine, Université de Montréal, Québec, Canada
| | - Sarah Larney
- Centre Hospitalier de l’Université de Montréal Research Center, Quebec, Canada
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McNeil R, Puri N, Boyd J, Mayer S, Hayashi K, Small W. Understanding concurrent stimulant use among people on methadone: A qualitative study. Drug Alcohol Rev 2020; 39:209-215. [PMID: 32202009 DOI: 10.1111/dar.13049] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/27/2020] [Accepted: 02/09/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION AND AIMS Opioid-related overdoses are an epidemic in North America, prompting a greater use of medications for opioid use disorder, such as methadone. Although many people work toward overall drug abstinence while on methadone, a sub-population of people with and without histories of polysubstance use engage in stimulant use while on methadone treatment. This study explores motivations for concurrent stimulant and methadone use in a street-involved drug-using population. DESIGN AND METHODS Semi-structured qualitative interviews were conducted with 39 people on methadone in Vancouver, Canada. Participants were recruited from among the participants in two community-based prospective cohort studies consisting of HIV-positive and HIV-negative people who use drugs. Interview transcripts were analysed using an inductive and iterative approach. RESULTS Our analysis identified three primary themes. First, participants articulated how stimulants were used to counter the sedating effects of methadone and enable them to engage in daily and survival activities (e.g. income generation). Second, participants described increased stimulant use to compensate for reduced stimulant intoxication while taking methadone. Finally, participants described the desire to achieve intoxication on stimulants once stable on methadone, as their substance use treatment goals did not involve drug abstinence. DISCUSSION AND CONCLUSION Among a street-involved drug-using population in which people do not have abstinence-based treatment goals, there are several functional reasons to use stimulants concurrently while on methadone. A deeper and more nuanced understanding of substance use motivators may contribute to further research and inform policy and guideline changes that support low threshold and harm reduction-focused methadone treatment programs and other interventions to reduce drug-related harms.
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Affiliation(s)
- Ryan McNeil
- Program in Addiction Medicine, Yale School of Medicine, New Haven, USA.,General Internal Medicine, Yale School of Medicine, New Haven, USA.,British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada
| | - Nitsaha Puri
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Samara Mayer
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Will Small
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
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21
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Minozzi S, Amato L, Jahanfar S, Bellisario C, Ferri M, Davoli M. Maintenance agonist treatments for opiate-dependent pregnant women. Cochrane Database Syst Rev 2020; 11:CD006318. [PMID: 33165953 PMCID: PMC8094273 DOI: 10.1002/14651858.cd006318.pub4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The prevalence of opiate use among pregnant women can range from 1% to 2% to as high as 21%. Just in the United States alone, among pregnant women with hospital delivery, a fourfold increase in opioid use is reported from 1999 to 2014 (Haight 2018). Heroin crosses the placenta, and pregnant, opiate-dependent women experience a six-fold increase in maternal obstetric complications such as low birth weight, toxaemia, third trimester bleeding, malpresentation, puerperal morbidity, fetal distress and meconium aspiration. Neonatal complications include narcotic withdrawal, postnatal growth deficiency, microcephaly, neuro-behavioural problems, increased neonatal mortality and a 74-fold increase in sudden infant death syndrome. This is an updated version of the original Cochrane Review first published in 2008 and last updated in 2013. OBJECTIVES To assess the effectiveness of any maintenance treatment alone or in combination with a psychosocial intervention compared to no intervention, other pharmacological intervention or psychosocial interventions alone for child health status, neonatal mortality, retaining pregnant women in treatment, and reducing the use of substances. SEARCH METHODS We updated our searches of the following databases to February 2020: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science. We also searched two trials registers and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA Randomised controlled trials which assessed the efficacy of any pharmacological maintenance treatment for opiate-dependent pregnant women. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We found four trials with 271 pregnant women. Three compared methadone with buprenorphine and one methadone with oral slow-release morphine. Three out of four studies had adequate allocation concealment and were double-blind. The major flaw in the included studies was attrition bias: three out of four had a high dropout rate (30% to 40%), and this was unbalanced between groups. Methadone versus buprenorphine: There was probably no evidence of a difference in the dropout rate from treatment (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.37 to 1.20, three studies, 223 participants, moderate-quality evidence). There may be no evidence of a difference in the use of primary substances between methadone and buprenorphine (RR 1.81, 95% CI 0.70 to 4.68, two studies, 151 participants, low-quality evidence). Birth weight may be higher in the buprenorphine group in the two trials that reported data MD;-530.00 g, 95%CI -662.78 to -397.22 (one study, 19 particpants) and MD: -215.00 g, 95%CI -238.93 to -191.07 (one study, 131 participants) although the results could not be pooled due to very high heterogeneity (very low-quality of evidence). The third study reported that there was no evidence of a difference. We found there may be no evidence of a difference in the APGAR score (MD: 0.00, 95% CI -0.03 to 0.03, two studies,163 participants, low-quality evidence). Many measures were used in the studies to assess neonatal abstinence syndrome. The number of newborns treated for neonatal abstinence syndrome, which is the most critical outcome, may not differ between groups (RR 1.19, 95% CI 0.87 to1.63, three studies, 166 participants, low-quality evidence). Only one study which compared methadone with buprenorphine reported side effects. We found there may be no evidence of a difference in the number of mothers with serious adverse events (AEs) (RR 1.69, 95% CI 0.75 to 3.83, 175 participants, low-quality evidence) and we found there may be no difference in the numbers of newborns with serious AEs (RR 4.77, 95% CI 0.59, 38.49,131 participants, low-quality evidence). Methadone versus slow-release morphine: There were no dropouts in either treatment group. Oral slow-release morphine may be superior to methadone for abstinence from heroin use during pregnancy (RR 2.40, 95% CI 1.00 to 5.77, one study, 48 participants, low-quality evidence). In the comparison between methadone and slow-release morphine, no side effects were reported for the mother. In contrast, one child in the methadone group had central apnoea, and one child in the morphine group had obstructive apnoea (low-quality evidence). AUTHORS' CONCLUSIONS Methadone and buprenorphine may be similar in efficacy and safety for the treatment of opioid-dependent pregnant women and their babies. There is not enough evidence to make conclusions for the comparison between methadone and slow-release morphine. Overall, the body of evidence is too small to make firm conclusions about the equivalence of the treatments compared. There is still a need for randomised controlled trials of adequate sample size comparing different maintenance treatments.
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Affiliation(s)
- Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Laura Amato
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Shayesteh Jahanfar
- Department of Public Health, School of Population and Public Health, University of British Columbia, Vancouver, Canada
- School of Health Sciences, Central Michigan University, Mount Pleasant, Michigan, USA
- MPH Program, School of Public Health, Central Michigan University, Michigan, USA
| | - Cristina Bellisario
- CPO Piemonte, Dipartimento Interaziendale di Prevenzione Secondaria dei Tumori S.C. Epidemiologia dei Tumori, AO Città della Salute e della Scienza di Torino Via San Francesco da Paola 31, Torino, Italy
| | - Marica Ferri
- Best practices, knowledge exchange and economic issues, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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Noroozi A, Motevalian SA, Zarrindast MR, Alaghband-Rad J, Akhondzadeh S. Adding extended-release methylphenidate to psychological intervention for treatment of methamphetamine dependence: A double-blind randomized controlled trial. Med J Islam Repub Iran 2020; 34:137. [PMID: 33437733 PMCID: PMC7787037 DOI: 10.34171/mjiri.34.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Indexed: 11/29/2022] Open
Abstract
Background: Iran has been faced with an emerging epidemic of methamphetamine (MA) use during recent years. No effective pharmacotherapy has been identified for MA treatment; and psychological interventions are the only available effective treatment. The aim of this study is to investigate the efficacy and safety of extended-release methylphenidate (ER-MTP) for the treatment of methamphetamine dependence.
Methods: Sixty-two people with methamphetamine dependence, according to DSM-IV-TR, were randomly assigned to either fixed-dose extended-release methylphenidate (ER-MTP) (60 mg per day) or placebo for 12 weeks. All participants received twice-weekly cognitive behavioral treatment for stimulant dependence. Recent drug use and craving level were measured using weekly rapid urine test and craving visual analogue scale, respectively. The severity of addiction was measured using the Addiction Severity Index at baseline and study completion. Assessment of MA withdrawal was conducted using Amphetamine Withdrawal Questionnaire and Amphetamine Selective Severity Assessment at baseline, day 3, week 1, week 4 and week 12. Depression and high-risk behaviors assessed with the Beck Depression Inventory and the high-risk behavior questionnaire at baseline, weeks 4 and 12 of the study. SPSS software version 22 was used for data analysis and p<0.05 was considered significant.
Results: Percent of weekly MA negative urine tests was not significantly different between groups during the course of the study (p=0.766). Two groups showed similar retention rates. Changes in MA craving, withdrawal, addiction severity, depression and high-risk behaviors were not significantly different between groups. No serious adverse event was observed.
Conclusion: Our finding did not show the superiority of fixed-schedule ER-MTP over placebo when added to an intensive biweekly outpatient psychosocial treatment. Further studies using individually tailored flexible-dose regimes might provide new insights regarding the safety and efficacy of psychostimulant maintenance treatment for MA dependence.
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Affiliation(s)
- Alireza Noroozi
- Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, Iran.,Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Abbas Motevalian
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad-Reza Zarrindast
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran.,Cognitive and Neuroscience Research Center (CNRC), Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran.,Medical Genomics Research Center, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran.,School of Cognitive Sciences, Institute for Research in Fundamental Sciences (IPM), Tehran, Iran.,Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Alaghband-Rad
- Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahin Akhondzadeh
- Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, Iran.,Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
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23
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Piske M, Zhou H, Min JE, Hongdilokkul N, Pearce LA, Homayra F, Socias ME, McGowan G, Nosyk B. The cascade of care for opioid use disorder: a retrospective study in British Columbia, Canada. Addiction 2020; 115:1482-1493. [PMID: 31899565 DOI: 10.1111/add.14947] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/16/2019] [Accepted: 12/20/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS The 'cascade of care' framework, measuring attrition at various stages of care engagement, has been proposed to guide the public health response to the opioid overdose public health emergency in British Columbia, Canada. We estimated the cascade of care for opioid use disorder and identified factors associated with care engagement for people with opioid use disorder (PWOUD) provincially. DESIGN Retrospective study using a provincial-level linkage of four health administrative databases. SETTING AND PARTICIPANTS All PWOUD in BC from 1 January 1996 to 30 November 2017. MEASUREMENTS The eight-stage cascade of care included diagnosed PWOUD, ever on opioid agonist treatment (OAT), recently on OAT, currently on OAT and retained on OAT: ≥ 1, ≥ 3, ≥ 12 and ≥ 24 months). Health-care use, homelessness and other demographics were obtained from physician billing records, hospitalizations, and drug dispensation records. Receipt of income assistance was indicated by enrollment in Pharmacare Plan C. FINDINGS A total of 55 470 diagnosed PWOUD were alive at end of follow-up. As of 2017, a majority of the population (n = 39 456; 71%) received OAT during follow-up; however, only 33% (n = 18 519) were currently engaged in treatment and 16% (n = 8960) had been retained for at least 1 year. Compared with those never on OAT, those currently engaged in OAT were more likely to be aged under 45 years [adjusted odds ratio (aOR) = 1.75, 95% confidence interval (CI) = 1.64, 1.89], male (aOR = 1.72, 95% CI = 1.64, 1.82), with concurrent substance use disorders (aOR = 2.56, 95% CI = 2.44, 2.70), hepatitis C virus (HCV) (aOR = 1.22, 95% CI = 1.14, 1.33) and either homeless or receiving income-assistance (aOR = 4.35, 95% CI = 4.17, 4.55). Regular contact with the health-care system-either in out-patient or acute care settings-was common among PWOUD not engaged in OAT, regardless of time since diagnosis or treatment discontinuation. CONCLUSIONS People with opioid use disorder in British Columbia, Canada show high levels of out-patient care prior to diagnosis. Younger age, male sex, urban residence, lower income level and homelessness appear to be independently associated with increased opioid agonist treatment engagement.
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Affiliation(s)
- Micah Piske
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Haoxuan Zhou
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Jeong E Min
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | | | | | | | - M Eugenia Socias
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,BC Centre on Substance Use, Vancouver, BC, Canada
| | - Gina McGowan
- British Columbia Ministry of Mental Health and Addictions, Victoria, BC, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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Prescription psychostimulants for the treatment of stimulant use disorder: a systematic review and meta-analysis. Psychopharmacology (Berl) 2020; 237:2233-2255. [PMID: 32601988 DOI: 10.1007/s00213-020-05563-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 05/18/2020] [Indexed: 01/09/2023]
Abstract
RATIONALE Agonist-based pharmacologic intervention is an accepted approach in treatment of opioid and tobacco use disorders. OBJECTIVES We conducted a systematic review and meta-analysis to evaluate usefulness of an agonist approach as treatment of (psycho)stimulant use disorder (PSUD). METHODS We reviewed PubMed/Medline, LILACS, and ClinicalTrials.gov databases searching for randomized, double-blind, placebo-controlled, parallel-design studies evaluating outcomes of individuals treated for cocaine- or amphetamine-type substance use disorder. We combined results of all trials that included the following prescription psychostimulants (PPs): modafinil, methylphenidate, or amphetamines (mixed amphetamine salts, lisdexamphetamine, and dextroamphetamine). The combined sample consisted of 2889 patients. Outcomes of interest included the following: drug abstinence (defined as 2-3 weeks of sustained abstinence and the average maximum days of consecutive abstinence), percentage of drug-negative urine tests across trial, and retention in treatment. We conducted random-effects meta-analyses and assessed quality of evidence using the GRADE system. RESULTS Thirty-eight trials were included. Treatment with PPs increases rates of sustained abstinence [risk ratio (RR) = 1.45, 95% confidence interval (CI) = (1.10, 1.92)] and duration of abstinence [mean difference (MD) = 3.34, 95% CI = (1.06, 5.62)] in patients with PSUD, particularly those with cocaine use disorder (very low-quality evidence). Prescription amphetamines were particularly efficacious in promoting sustained abstinence in patients with cocaine use disorder [RR = 2.44, 95% CI = (1.66, 3.58)], and higher doses of PPs were particularly efficacious for treatment of cocaine use disorder [RR = 1.95, 95% CI = (1.38, 2.77)] (moderate-quality evidence). Treatment with prescription amphetamines also yielded more cocaine-negative urines [MD = 8.37%, 95% CI = (3.75, 12.98)]. There was no effect of PPs on the retention in treatment. CONCLUSION Prescription psychostimulants, particularly prescription amphetamines given in robust doses, have a clinically significant beneficial effect to promote abstinence in the treatment of individuals with PSUD, specifically the population with cocaine use disorder.
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25
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Volkow ND, Blanco C. Medications for opioid use disorders: clinical and pharmacological considerations. J Clin Invest 2020; 130:10-13. [PMID: 31763992 DOI: 10.1172/jci134708] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Abstract
Objectives: Unhealthy alcohol use is associated with negative health outcomes in clients attending methadone maintenance therapy (MMT) programs. However, debates exist regarding the methadone dose of drinkers, and little is known about the health outcomes of drinkers with other types of alcohol use. This study examined the drinking pattern and its association with methadone dose, and depressive and anxiety symptoms in Chinese clients undergoing MMT. Methods: A secondary data analysis was conducted with data from a large-scale cross-sectional survey of 549 clients of 3 MMT clinics in Wuhan, China. Depression, anxiety, and alcohol dependence were measured with Zung Self-rating Depression Scale, Zung Self-rating Anxiety Scale, and Alcohol Dependence Scale, respectively. Drinking pattern was assessed using 3 indicators: weekly amount of alcohol consumed, weekly frequency of alcohol consumed, and severity of alcohol dependence. Results: The prevalence of current drinking, hazardous drinking, regular drinking, and alcohol abuse/dependence was 29.0%, 10.4%, 14.2%, and 8.7%, respectively. In adjustment analyses, relative to nondrinkers, drinkers had significantly lower weight-based methadone dose (β = −0.136, P = 0.008); hazardous drinkers, irregular drinkers, and drinkers without alcohol abuse/dependence had less severe depression (β = −3.67, P = 0.004; β = −2.37, P = 0.034; β = −3.20, P = 0.001) and anxiety (β = −4.90, P < 0.001; β = −3.24, P = 0.006; β = −4.52, P < 0.001), but drinkers with alcohol abuse/dependence had more severe depression (β = 5.55, P < 0.001) and anxiety (β = 4.31, P = 0.005). Conclusion: In Chinese MMT clinics, drinkers may use alcohol to compensate for inadequate MMT and self-medicate negative emotions. Compared with nondrinkers, the severities of depression and anxiety were lower among drinkers without alcohol abuse/dependence, but higher among those with alcohol abuse/dependence.
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Artenie AA, Minoyan N, Jacka B, Høj S, Jutras-Aswad D, Roy É, Gauvin L, Zang G, Bruneau J. Opioid agonist treatment dosage and patient-perceived dosage adequacy, and risk of hepatitis C infection among people who inject drugs. CMAJ 2020; 191:E462-E468. [PMID: 31036608 DOI: 10.1503/cmaj.181506] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Opioid agonist treatment is considered important in preventing acquisition of hepatitis C virus (HCV) among people who inject drugs; however, the role of dosage in opioid agonist treatment is unclear. We investigated the joint association of prescribed dosage of opioid agonist treatment and patient-perceived dosage adequacy with risk of HCV infection among people who inject drugs. METHODS We followed prospectively people who inject drugs at risk of acquiring HCV infection (who were RNA negative and HCV-antibody negative or positive) in Montréal, Canada (2004-2017). At 6-month, then 3-month intervals, participants were tested for HCV antibodies or RNA, and completed an interviewer-administered behavioural questionnaire, reporting the following: current exposure to opioid agonist treatment (yes/no), prescribed dosage either high (methadone ≥ 60 mg/d or buprenorphine ≥ 16 mg/d) or low, and perceived dosage adequacy (adequate/inadequate). We then assigned participants to 1 of 5 exposure categories: no opioid agonist treatment, high dosage of opioid agonist treatment perceived to be adequate, high dosage perceived to be inadequate, low dosage perceived to be adequate or low dosage perceived to be inadequate. To estimate associations between categories of opioid agonist treatment dosage and incident HCV infection, we conducted Cox regression analyses, adjusting for multiple confounding factors. RESULTS Of 513 participants (median age 35.0 yr, 77.6% male), 168 acquired HCV over 1422.6 person-years of follow-up (incidence 11.8/100 person-years, 95% confidence interval [CI] 10.1-13.7). We observed a gradient in the relative risks of HCV infection across categories of opioid agonist treatment dosage. Compared with people who inject drugs not receiving opioid agonist treatment, adjusted hazard ratios were 0.43 (95% CI 0.23-0.84) for those receiving high dosages perceived to be adequate, 0.61 (95% CI 0.25-1.50) for those receiving high dosages perceived to be inadequate, 1.22 (95% CI 0.74-2.00) for those receiving low dosages perceived to be adequate and 1.94 (95% CI 1.11-3.39) for those receiving low dosages perceived to be inadequate. INTERPRETATION Risk of HCV infection varies considerably according to dosage of opioid agonist treatment and patient-perceived adequacy, with associations indicating both protective and harmful effects relative to no exposure to opioid agonist treatment.
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Affiliation(s)
- Andreea A Artenie
- Department of Social and Preventive Medicine (Artenie, Minoyan, Gauvin), School of Public Health, Université de Montréal; Research Centre (Artenie, Minoyan, Jacka, Høj, Jutras-Aswad, Gauvin, Zang, Bruneau), Centre Hospitalier de l'Université de Montréal; Department of Psychiatry (Jutras-Aswad), Université de Montréal, Montréal, Que.; Addiction Studies and Research Program (Roy), Université de Sherbrooke, Longueuil, Que.; Institut national de santé publique du Québec (Roy); Department of Family and Emergency Medicine (Bruneau), Université de Montréal, Montréal, Que
| | - Nanor Minoyan
- Department of Social and Preventive Medicine (Artenie, Minoyan, Gauvin), School of Public Health, Université de Montréal; Research Centre (Artenie, Minoyan, Jacka, Høj, Jutras-Aswad, Gauvin, Zang, Bruneau), Centre Hospitalier de l'Université de Montréal; Department of Psychiatry (Jutras-Aswad), Université de Montréal, Montréal, Que.; Addiction Studies and Research Program (Roy), Université de Sherbrooke, Longueuil, Que.; Institut national de santé publique du Québec (Roy); Department of Family and Emergency Medicine (Bruneau), Université de Montréal, Montréal, Que
| | - Brendan Jacka
- Department of Social and Preventive Medicine (Artenie, Minoyan, Gauvin), School of Public Health, Université de Montréal; Research Centre (Artenie, Minoyan, Jacka, Høj, Jutras-Aswad, Gauvin, Zang, Bruneau), Centre Hospitalier de l'Université de Montréal; Department of Psychiatry (Jutras-Aswad), Université de Montréal, Montréal, Que.; Addiction Studies and Research Program (Roy), Université de Sherbrooke, Longueuil, Que.; Institut national de santé publique du Québec (Roy); Department of Family and Emergency Medicine (Bruneau), Université de Montréal, Montréal, Que
| | - Stine Høj
- Department of Social and Preventive Medicine (Artenie, Minoyan, Gauvin), School of Public Health, Université de Montréal; Research Centre (Artenie, Minoyan, Jacka, Høj, Jutras-Aswad, Gauvin, Zang, Bruneau), Centre Hospitalier de l'Université de Montréal; Department of Psychiatry (Jutras-Aswad), Université de Montréal, Montréal, Que.; Addiction Studies and Research Program (Roy), Université de Sherbrooke, Longueuil, Que.; Institut national de santé publique du Québec (Roy); Department of Family and Emergency Medicine (Bruneau), Université de Montréal, Montréal, Que
| | - Didier Jutras-Aswad
- Department of Social and Preventive Medicine (Artenie, Minoyan, Gauvin), School of Public Health, Université de Montréal; Research Centre (Artenie, Minoyan, Jacka, Høj, Jutras-Aswad, Gauvin, Zang, Bruneau), Centre Hospitalier de l'Université de Montréal; Department of Psychiatry (Jutras-Aswad), Université de Montréal, Montréal, Que.; Addiction Studies and Research Program (Roy), Université de Sherbrooke, Longueuil, Que.; Institut national de santé publique du Québec (Roy); Department of Family and Emergency Medicine (Bruneau), Université de Montréal, Montréal, Que
| | - Élise Roy
- Department of Social and Preventive Medicine (Artenie, Minoyan, Gauvin), School of Public Health, Université de Montréal; Research Centre (Artenie, Minoyan, Jacka, Høj, Jutras-Aswad, Gauvin, Zang, Bruneau), Centre Hospitalier de l'Université de Montréal; Department of Psychiatry (Jutras-Aswad), Université de Montréal, Montréal, Que.; Addiction Studies and Research Program (Roy), Université de Sherbrooke, Longueuil, Que.; Institut national de santé publique du Québec (Roy); Department of Family and Emergency Medicine (Bruneau), Université de Montréal, Montréal, Que
| | - Lise Gauvin
- Department of Social and Preventive Medicine (Artenie, Minoyan, Gauvin), School of Public Health, Université de Montréal; Research Centre (Artenie, Minoyan, Jacka, Høj, Jutras-Aswad, Gauvin, Zang, Bruneau), Centre Hospitalier de l'Université de Montréal; Department of Psychiatry (Jutras-Aswad), Université de Montréal, Montréal, Que.; Addiction Studies and Research Program (Roy), Université de Sherbrooke, Longueuil, Que.; Institut national de santé publique du Québec (Roy); Department of Family and Emergency Medicine (Bruneau), Université de Montréal, Montréal, Que
| | - Geng Zang
- Department of Social and Preventive Medicine (Artenie, Minoyan, Gauvin), School of Public Health, Université de Montréal; Research Centre (Artenie, Minoyan, Jacka, Høj, Jutras-Aswad, Gauvin, Zang, Bruneau), Centre Hospitalier de l'Université de Montréal; Department of Psychiatry (Jutras-Aswad), Université de Montréal, Montréal, Que.; Addiction Studies and Research Program (Roy), Université de Sherbrooke, Longueuil, Que.; Institut national de santé publique du Québec (Roy); Department of Family and Emergency Medicine (Bruneau), Université de Montréal, Montréal, Que
| | - Julie Bruneau
- Department of Social and Preventive Medicine (Artenie, Minoyan, Gauvin), School of Public Health, Université de Montréal; Research Centre (Artenie, Minoyan, Jacka, Høj, Jutras-Aswad, Gauvin, Zang, Bruneau), Centre Hospitalier de l'Université de Montréal; Department of Psychiatry (Jutras-Aswad), Université de Montréal, Montréal, Que.; Addiction Studies and Research Program (Roy), Université de Sherbrooke, Longueuil, Que.; Institut national de santé publique du Québec (Roy); Department of Family and Emergency Medicine (Bruneau), Université de Montréal, Montréal, Que.
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Perry AE, Martyn‐St James M, Burns L, Hewitt C, Glanville JM, Aboaja A, Thakkar P, Santosh Kumar KM, Pearson C, Wright K. Interventions for female drug-using offenders. Cochrane Database Syst Rev 2019; 12:CD010910. [PMID: 31834635 PMCID: PMC6910124 DOI: 10.1002/14651858.cd010910.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND This review represents one in a family of three reviews focusing on the effectiveness of interventions in reducing drug use and criminal activity for offenders. OBJECTIVES To assess the effectiveness of interventions for female drug-using offenders in reducing criminal activity, or drug use, or both. SEARCH METHODS We searched 12 electronic bibliographic databases up to February 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 13 trials with 2560 participants. Interventions were delivered in prison (7/13 studies, 53%) and community (6/13 studies, 47%) settings. The rating of bias was affected by the lack of clear reporting by authors, and we rated many items as 'unclear'. In two studies (190 participants) collaborative case management in comparison to treatment as usual did not reduce drug use (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.20 to 2.12; 1 study, 77 participants; low-certainty evidence), reincarceration at nine months (RR 0.71, 95% CI 0.32 to 1.57; 1 study, 77 participants; low-certainty evidence), and number of subsequent arrests at 12 months (RR 1.11, 95% CI 0.83 to 1.49; 1 study, 113 participants; low-certainty evidence). One study (36 participants) comparing buprenorphine to placebo showed no significant reduction in self-reported drug use at end of treatment (RR 0.57, 95% CI 0.27 to 1.20) and three months (RR 0.58, 95% CI 0.25 to 1.35); very low-certainty evidence. No adverse events were reported. One study (38 participants) comparing interpersonal psychotherapy to a psychoeducational intervention did not find reduction in drug use at three months (RR 0.67, 95% CI 0.30 to 1.50; low-certainty evidence). One study (31 participants) comparing acceptance and commitment therapy (ACT) to a waiting list showed no significant reduction in self-reported drug use using the Addiction Severity Index (mean difference (MD) -0.04, 95% CI -0.37 to 0.29) and abstinence from drug use at six months (RR 2.89, 95% CI 0.73 to 11.43); low-certainty evidence. One study (314 participants) comparing cognitive behavioural skills to a therapeutic community programme and aftercare showed no significant reduction in self-reported drug use (RR 0.86, 95% CI 0.58 to 1.27), re-arrest for any type of crime (RR 0.73, 95% CI 0.52 to 1.03); criminal activity (RR 0.80, 95% CI 0.63 to 1.03), or drug-related crime (RR 0.95, 95% CI 0.68 to 1.32). A significant reduction for arrested (not for parole) violations at six months follow-up was significantly in favour of cognitive behavioural skills (RR 0.43, 95% CI 0.25 to 0.77; very low-certainty evidence). A second study with 115 participants comparing cognitive behavioural skills to an alternative substance abuse treatment showed no significant reduction in reincarceration at 12 months (RR 0.70, 95% CI 0.43 to 1.12; low certainty-evidence. One study (44 participants) comparing cognitive behavioural skills and standard therapy versus treatment as usual showed no significant reduction in Addiction Severity Index (ASI) drug score at three months (MD 0.02, 95% CI -0.05 to 0.09) and six months (MD -0.02, 95% CI -0.09 to 0.05), and incarceration at three months (RR 0.46, 95% CI 0.04 to 4.68) and six months (RR 0.51, 95% CI 0.20 to 1.27); very low-certainty evidence. One study (171 participants) comparing a single computerised intervention versus case management showed no significant reduction in the number of days not using drugs at three months (MD -0.89, 95% CI -4.83 to 3.05; low certainty-evidence). One study (116 participants) comparing dialectic behavioural therapy and case management (DBT-CM) versus a health promotion intervention showed no significant reduction at six months follow-up in positive drug testing (RR 0.67, 95% CI 0.43 to 1.03), number of people not using marijuana (RR 1.23, 95% CI 0.95 to 1.59), crack (RR 1.00, 95% CI 0.87 to 1.14), cocaine (RR 1.02, 95% CI 0.93 to 1.12), heroin (RR 1.05, 95% CI 0.98 to 1.13), methamphetamine (RR 1.02, 95% CI 0.87 to 1.20), and self-reported drug use for any drug (RR 1.20, 95% CI 0.92 to 1.56); very low-certainty evidence. One study (211 participants) comparing a therapeutic community programme versus work release showed no significant reduction in marijuana use at six months (RR 1.03, 95% CI 0.19 to 5.65), nor 18 months (RR 1.00, 95% CI 0.07 to 14.45), heroin use at six months (RR 1.59, 95% CI 0.49 to 5.14), nor 18 months (RR 1.92, 95% CI 0.24 to 15.37), crack use at six months (RR 2.07, 95% CI 0.41 to 10.41), nor 18 months (RR 1.64, 95% CI 0.19 to 14.06), cocaine use at six months (RR 1.09, 95% CI 0.79 to 1.50), nor 18 months (RR 0.93, 95% CI 0.64 to 1.35). It also showed no significant reduction in incarceration for drug offences at 18 months (RR 1.45, 95% CI 0.87 to 2.42); with overall very low- to low-certainty evidence. One study (511 participants) comparing intensive discharge planning and case management versus prison only showed no significant reduction in use of marijuana (RR 0.79, 95% CI 0.53 to 1.16), hard drugs (RR 1.12, 95% CI 0.88 to 1.43), crack cocaine (RR 1.08, 95% CI 0.75 to 1.54), nor positive hair testing for marijuana (RR 0.75, 95% CI 0.55 to 1.03); it found a significant reduction in arrests (RR 0.19, 95% CI 0.04 to 0.87), but no significant reduction in drug charges (RR 1.07, 95% CI 0.75 to 1.53) nor incarceration (RR 1.09, 95% CI 0.86 to 1.39); moderate-certainty evidence. One narrative study summary (211 participants) comparing buprenorphine pre- and post-release from prison showed no significant reduction in drug use at 12 months post-release; low certainty-evidence. No adverse effects were reported. AUTHORS' CONCLUSIONS The studies showed a high degree of heterogeneity for types of comparisons, outcome measures and small samples. Descriptions of treatment modalities are required. On one outcome of arrest (no parole violations), we identified a significant reduction when cognitive behavioural therapy (CBT) was compared to a therapeutic community programme. But for all other outcomes, none of the interventions were effective. Larger trials are required to increase the precision of confidence about the certainty of evidence.
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Affiliation(s)
- Amanda E Perry
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
| | - Marrissa Martyn‐St James
- University of SheffieldSchool of Health and Related Research (ScHARR)Regent Court, 30 Regent StreetSheffieldSouth YorkshireUKS1 4DA
| | - Lucy Burns
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
| | - Catherine Hewitt
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
| | - Julie M Glanville
- York Health Economics ConsortiumMarket SquareUniversity of York, HeslingtonYorkUKYO10 5NH
| | - Anne Aboaja
- Tees, Esk and Wear Valleys NHS Foundation TrustMiddlesbroughUKTS4 3AF
| | | | | | - Caroline Pearson
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
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Mamat R, Nasrulddin NAA, Yusoff NAM. Continued Use of Illicit Substance among Methadone Treatment Patients in Primary Health Care Clinics in East Coast Region of Malaysia. ALCOHOLISM TREATMENT QUARTERLY 2019. [DOI: 10.1080/07347324.2019.1672600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Ruzmayuddin Mamat
- Kuantan Health District Office, Ministry of Health Malaysia, Pejabat Kesihatan Daerah, Kuantan
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30
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Presnall NJ, Wolf DAPS, Brown DS, Beeler-Stinn S, Grucza RA. A comparison of buprenorphine and psychosocial treatment outcomes in psychosocial and medical settings. J Subst Abuse Treat 2019; 104:135-143. [PMID: 31370977 PMCID: PMC7075557 DOI: 10.1016/j.jsat.2019.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Facing an epidemic of opioid-related mortality, many government health departments, insurers, and treatment providers have attempted to expand patient access to buprenorphine in psychosocial substance use disorder (SUD) programs and medical settings. METHODS With Missouri Medicaid data from 2008 to 2015, we used Cox proportional hazard models to estimate the relative hazards for treatment attrition and SUD-related emergency department (ED) visits or hospitalizations associated with buprenorphine in psychosocial SUD programs and medical settings. We also tested the association of buprenorphine with hours of psychosocial treatment during the first 30 days of psychosocial SUD treatment. The analytic sample included claims from 7606 individuals with an OUD diagnosis. RESULTS Compared to psychosocial treatment without buprenorphine (PSY), the addition of buprenorphine (PSY-B) was associated with a significantly reduced hazard for treatment attrition (adjusted hazard ratio: 0.67, 95% CI: 0.62-0.71). Among buprenorphine episodes, office-based (B-OBOT), outpatient hospital (B-OPH), and no documented setting (B-PHA) were associated with reduced hazards for treatment attrition when compared to the psychosocial SUD setting (B-PSY) (adjusted hazard ratios: 0.27, 95% CI: 0.24-0.31; 0.46, 95% CI: 0.39-0.54; 0.70, 95% CI: 0.61-0.81). Compared to B-PSY, B-OBOT and B-PHA were associated with significantly reduced hazards for a SUD-related ED visits or hospitalization (adjusted hazard ratios: 0.59, 95% CI: 0.41-0.85; 0.53, 95% CI: 0.36-0.78). There was no significant difference between B-PSY and B-OPH or B-PSY and PSY in hazard for an SUD-related ED visit or hospitalization. CONCLUSIONS Our findings support the conclusion that adding buprenorphine to Medicaid-covered psychosocial SUD treatment reduces patient attrition and SUD-related ED visits or hospitalizations but that buprenorphine treatment in office-based medical settings is even more effective in reducing these negative outcomes. Policy-makers should consider ways to expand buprenorphine access in all settings, but particularly in office-based medical settings. Buprenorphine treatment in an unbilled setting was associated with an increased hazard for patient attrition when compared to treatment in billed medical settings, indicating the importance of Medicaid-covered provider visits for patient retention.
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Affiliation(s)
- Ned J Presnall
- Brown School of Social Work, Washington University, One Brookings Drive, St. Louis, MO 63130, United States of America; Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, Box 8134, St. Louis, MO 63110, United States of America.
| | - D A Patterson Silver Wolf
- Brown School of Social Work, Washington University, One Brookings Drive, St. Louis, MO 63130, United States of America.
| | - Derek S Brown
- Brown School of Social Work, Washington University, One Brookings Drive, St. Louis, MO 63130, United States of America.
| | - Sara Beeler-Stinn
- Brown School of Social Work, Washington University, One Brookings Drive, St. Louis, MO 63130, United States of America.
| | - Richard A Grucza
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, Box 8134, St. Louis, MO 63110, United States of America.
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31
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Cabrera FF, Gamarra ER, Garcia TE, Littlejohn AD, Chinga PA, Pinentel-Morillo LD, Tirado JR, Chung DY, Pande LJ, McCall KL, Nichols SD, Piper BJ. Opioid distribution trends (2006-2017) in the US Territories. PeerJ 2019; 7:e6272. [PMID: 30671308 PMCID: PMC6338096 DOI: 10.7717/peerj.6272] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/10/2018] [Indexed: 12/25/2022] Open
Abstract
Background The US mainland is experiencing an epidemic of opioid overdoses. Unfortunately, the US Territories (Guam, Puerto Rico, and the Virgin Islands) have often been overlooked in opioid pharmacoepidemiology research. This study examined common prescription opioids over the last decade. Methods The United States Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS) was used to report on ten medical opioids: buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, and oxymorphone, by weight from 2006 to 2017. Florida and Hawaii were selected as comparison areas. Results Puerto Rico had the greatest Territorial oral morphine mg equivalent (MME) per capita (421.5) which was significantly higher (p < .005) than the Virgin Islands (139.2) and Guam (118.9) but significantly lower than that of Hawaii (794.6) or Florida (1,509.8). Methadone was the largest opioid by MMEs in 2017 in most municipalities, accounting for 41.1% of the total in the Virgin Islands, 37.9% in Florida, 36.6% in Hawaii but 80.8% in Puerto Rico. Puerto Rico and Florida showed pronounced differences in the distribution patterns by pharmacies, hospitals, and narcotic treatment programs for opioids. Conclusions Continued monitoring of the US Territories is needed to provide a balance between appropriate access to these important agents for cancer related and acute pain while also minimizing diversion and avoiding the opioid epidemic which has adversely impacted the US mainland.
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Affiliation(s)
- Fedor F Cabrera
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, United States of America
| | - Erik R Gamarra
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, United States of America
| | - Tiffany E Garcia
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, United States of America
| | - Ashanti D Littlejohn
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, United States of America
| | - Poul A Chinga
- Department of Biology, University of Scranton, Scranton, PA, United States of America
| | - Luis D Pinentel-Morillo
- Department of Biology, Pennsylvania State University, State College, PA, United States of America
| | - Jorge R Tirado
- Department of Biology, Elizabethtown College, Elizabethtown College, PA, United States of America
| | - Daniel Y Chung
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, United States of America
| | - Leana J Pande
- Department of Biology, Wilkes University, Wilkes-Barre, PA, United States of America
| | - Kenneth L McCall
- Department of Pharmacy Practice, University of New England, Portland, ME, United States of America
| | - Stephanie D Nichols
- Department of Pharmacy Practice, Husson University School of Pharmacy, Bangor, ME, United States of America
| | - Brian J Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, United States of America.,Center for Pharmacy Innovation and Outcomes, Geisinger Precision Health Center, Forty Fort, PA, United States of America
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32
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D'Aunno T, Park SE, Pollack HA. Evidence-based treatment for opioid use disorders: A national study of methadone dose levels, 2011-2017. J Subst Abuse Treat 2019; 96:18-22. [PMID: 30466543 PMCID: PMC6258192 DOI: 10.1016/j.jsat.2018.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 10/28/2022]
Abstract
The nation's methadone maintenance treatment (MMT) programs play a central role in addressing the current opioid epidemic. Considerable evidence documents the treatment effectiveness of MMT and, in turn, the importance of adequate dosing to MMT's effectiveness. Yet, as recently as 2011, 41% of patients received doses below the level of 80 mg/day. Using survey data from a nationally representative sample of MMT programs in 2011 and 2017, we examine (1) the extent to which the nation's MMT programs are meeting evidence-based standards for methadone dose level and (2) characteristics of MMT programs that are associated with variation in performance. Our results show that 43% of MMT patients receive <80 mg/day in 2017, and 23% of methadone maintenance patients receive daily doses below 60 mg. Results from multivariate regression analysis of the 2017 survey data show that private for-profit and public organizations significantly under-dosed patients compared to private nonprofit providers. Under-dosing also was more common in programs that serve high proportions of African-American patients. These results are concerning because MMT remains the medication of choice for vulnerable patients with the most severe opioid use disorders, and for-profit providers treat a growing proportion of MMT patients.
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33
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Feng N, Lin C, Hsieh J, Rou K, Li L. Family Related Factors and Concurrent Heroin Use in Methadone Maintenance Treatment in China. Subst Use Misuse 2018; 53:1674-1680. [PMID: 29377736 PMCID: PMC6287767 DOI: 10.1080/10826084.2018.1424913] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The use of heroin during Methadone Maintenance Treatment (MMT) is a challenging problem that contributes to poor treatment outcomes. Families may play an important role in addressing concurrent heroin use during MMT, especially in collectivist societies such as China. OBJECTIVES In this study, we explored the relationship between family-related factors and concurrent heroin use during MMT in China. METHODS This study was conducted at 68 MMT clinics in five provinces of China. There were 2,446 MMT clients in the analysis. Demographic information, MMT dosage, family members' heroin use status, family support of MMT, family problem, and self-reported heroin use were collected in a cross-sectional survey. The most recent urinalysis of opiate use was obtained from clinical records. RESULTS Of the 2,446 participants, 533 (21.79%) self-reported heroin use in the previous seven days or had a positive urine morphine test result in the clinic record. Participants whose family member[s] used heroin were 1.59 times (95% CI: 1.17, 2.15) more likely to use concurrently during treatment. Those with family members who totally support them on the MMT were less likely to use (AOR: 0.75, 95% CI: 0.60, 0.94). Having more family problems was positively associated with concurrent heroin use (AOR: 2.01, 95% CI: 1.03, 3.93). CONCLUSIONS The results highlight the importance of the family's role in concurrent heroin use during MMT programs. The study's findings may have implications for family-based interventions that address concurrent heroin use.
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Affiliation(s)
- Nan Feng
- a Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California at Los Angeles , Los Angeles , California , USA
| | - Chunqing Lin
- a Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California at Los Angeles , Los Angeles , California , USA
| | - Julie Hsieh
- a Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California at Los Angeles , Los Angeles , California , USA
| | - Keming Rou
- b National Center for AIDS/STD Control and Prevention , Chinese Centers for Disease Control and Prevention , Beijing , China
| | - Li Li
- a Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California at Los Angeles , Los Angeles , California , USA
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34
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Russolillo A, Moniruzzaman A, McCandless LC, Patterson M, Somers JM. Associations between methadone maintenance treatment and crime: a 17-year longitudinal cohort study of Canadian provincial offenders. Addiction 2018; 113:656-667. [PMID: 28987068 DOI: 10.1111/add.14059] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 06/29/2017] [Accepted: 09/29/2017] [Indexed: 12/19/2022]
Abstract
AIMS To estimate and test the difference in rates of violent and non-violent crime during medicated and non-medicated methadone treatment episodes. DESIGN, SETTING AND PARTICIPANTS The study involved linkage of population level administrative data (health and justice) for all individuals (n = 14 530) in British Columbia, Canada with a history of conviction and who filled a methadone prescription between 1 January 1998 and 31 March 2015. Methadone maintenance treatment was the primary independent variable and was treated as a time-varying exposure. Each participant's follow-up (mean: 8 years) was divided into medicated (methadone was dispensed) and non-medicated (methadone was not dispensed) periods with mean durations of 3.3 and 4.6 years, respectively. MEASUREMENTS Socio-demographics of participants were examined along with the main outcomes of violent and non-violent offences. FINDINGS During the first 2 years of treatment (≤ 2.0 years), periods in which methadone was dispensed were associated with a 33% lower rate of violent crime [0.67 adjusted hazard ratio (AHR), 95% confidence intervals (CI) = 0.59, 0.76] and a 35% lower rate of non-violent crime (0.65 AHR, 95% CI = 0.62, 0.69) compared with non-medicated periods. This equates to a risk difference of 3.6 (95% CI = 2.6, 4.4) and 37.2 (95% CI = 33.0, 40.4) fewer violent and non-violent offences per 100 person-years, respectively. Significant but smaller protective effects of dispensed methadone were observed across longer treatment intervals (2.0 to ≤ 5.0 years, 5.0 to ≤ 10.0 years). CONCLUSIONS Among a cohort of Canadian offenders, rates of violent and non-violent offending were lower during periods when individuals were dispensed methadone compared with periods in which they were not dispensed methadone.
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Affiliation(s)
- Angela Russolillo
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Akm Moniruzzaman
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | | | - Michelle Patterson
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Julian M Somers
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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35
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Alcaraz S, Viladrich C, Trujols J, Siñol N, Pérez de Los Cobos J. Heroin-dependent patient satisfaction with methadone as a medication influences satisfaction with basic interventions delivered by staff to implement methadone maintenance treatment. Patient Prefer Adherence 2018; 12:1203-1211. [PMID: 30022813 PMCID: PMC6044354 DOI: 10.2147/ppa.s164181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The aim of the present study was to test a structural equation model of patient satisfaction with different key facets of methadone maintenance treatment (MMT). In this model, the three dimensions of patient satisfaction with methadone as a medication (ie, personal functioning and well-being, anti-addictive effect on heroin, and anti-addictive effect on non-opioid substances) were expected to predict satisfaction with the basic interventions delivered by the staff of treatment centers to implement MMT. PATIENTS AND METHODS A sample of 210 heroin-dependent patients, resistant to MMT treatment (mean age =41.66 years, SD =6.50; 75.7% male), participated voluntarily in this study. Preliminary analysis based on exploratory structural equation modeling supported the expected three-factor measurement model of the scale to assess satisfaction with medications for addiction treatment - methadone for heroin addiction. Moreover, the 15 items measuring staff's basic interventions were shown to be compatible with the expected single-factor measurement model. Then, both measurement models were included in a structural model. RESULTS Results of this model show that patient satisfaction with the compatibility of methadone with personal functioning and well-being, as well as with the anti-addictive effects of methadone on non-opioid substances, predicts satisfaction with basic interventions conducted at methadone treatment centers (β=0.191 and β=0.152, respectively). CONCLUSION Our results provide further understanding regarding patient satisfaction with MMT, which could help professionals to better understand patient perspective and experience during MMT.
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Affiliation(s)
- Saul Alcaraz
- Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain,
| | - Carme Viladrich
- Department of Psychobiology and Methodology of Health Sciences, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Joan Trujols
- Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain,
- Biomedical Research Networking Center on Mental Health (CIBERSAM), Madrid, Spain
| | - Núria Siñol
- Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain,
| | - José Pérez de Los Cobos
- Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain,
- Biomedical Research Networking Center on Mental Health (CIBERSAM), Madrid, Spain
- Department of Psychiatry and Legal Medicine, School of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
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36
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Mannaioni G, Lanzi C, Lotti M, Galli V, Totti A, Pacileo I, Sili M, Pracucci C, Dilaghi A, Bertieri L, Quaranta M, Orsini F, Occupati B, Michahelles A, Ciuti R, Bianchini E, Fabbro G, Biggeri A, Masini E, Moroni F. Methadone Dose Adjustments, Plasma R-Methadone Levels and Therapeutic Outcome of Heroin Users: A Randomized Clinical Trial. Eur Addict Res 2018; 24:9-18. [PMID: 29393208 DOI: 10.1159/000485029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 11/07/2017] [Indexed: 11/19/2022]
Abstract
AIMS We aimed to improve the retention in treatment and therapeutic outcome of methadone maintenance treatment (MMT) patients by adjusting the oral methadone dose in order to reach a "target" plasma R-methadone level (80-250 ng/mL). METHODS A multicenter randomized controlled trial was organized. RESULTS The intention-to-treat statistical analysis showed that repeated dose adjustments performed in order to obtain therapeutic plasma R-methadone levels did not improve retention in treatment of heroin-dependent patients. However, patients having plasma methadone levels in the "target range" at the beginning of the study had a better retention in treatment than controls. Furthermore, patients succeeding in keeping plasma R-methadone target levels (per protocol analysis) remained in treatment and improved their social scores better than controls. -Conclusion: Although the primary endpoint of this study was not demonstrated, a post hoc and a per protocol analysis suggested that patients in MMT with plasma R-methadone concentrations in the target range have a better therapeutic outcome than controls.
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Affiliation(s)
- Guido Mannaioni
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Cecilia Lanzi
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Michela Lotti
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Valentina Galli
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Arianna Totti
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Ilaria Pacileo
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Maria Sili
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Chiara Pracucci
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Arianna Dilaghi
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Lara Bertieri
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Mariarita Quaranta
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Francesco Orsini
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | | | | | | | | | | | | | - Emanuela Masini
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Flavio Moroni
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
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Wang L, Min JE, Krebs E, Evans E, Huang D, Liu L, Hser YI, Nosyk B. Polydrug use and its association with drug treatment outcomes among primary heroin, methamphetamine, and cocaine users. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 49:32-40. [PMID: 28888099 PMCID: PMC5681890 DOI: 10.1016/j.drugpo.2017.07.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/17/2017] [Accepted: 07/10/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Polydrug use may challenge effective treatment for substance use disorders. We evaluate whether secondary substance use modifies the association between treatment and primary drug use among primary heroin, cocaine and methamphetamine (MA) users. METHODS Data were obtained from prospective cohort studies on people who use illicit drugs (PWUD) in California, USA. Using repeated monthly data on self-reported secondary substance use (heroin, cocaine, MA, alcohol or marijuana; ≥1day in a month), primary drug use (≥1day in a month), and treatment participation, collected via timeline follow-back, we fitted generalized linear mixed multiple regression models controlling for potential confounders to examine the interactions between treatment and secondary substance use on the odds of primary heroin, cocaine and MA use, respectively. RESULTS Included in our study were 587 primary heroin, 444 primary MA, and 501 primary cocaine users, with a median of 32.4, 13.3 and 18.9 years of follow-up, respectively. In the absence of secondary substance use, treatment was strongly associated with decreased odds of primary drug use (adjusted odds ratios (aORs): 0.25, 95% CI: 0.24, 0.27, 0.07 (0.06, 0.08), and 0.07 (0.07, 0.09)) for primary heroin, MA, and cocaine users, respectively. Secondary substance use of any kind moderated these associations (0.82 (0.78, 0.87), 0.25 (0.21, 0.30) and 0.53 (0.45, 0.61), respectively), and these findings were consistent for each type of secondary substance considered. Moreover, we observed different associations in terms of direction and magnitude between secondary substance use and primary drug use during off-treatment periods across substance types. CONCLUSION This study demonstrates secondary substance use moderates the temporal associations between treatment and primary drug use among primary heroin, MA and cocaine users. Disparate patterns of polydrug use require careful measurement and analysis to inform targeted treatment for polydrug users.
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Affiliation(s)
- Linwei Wang
- BC Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
| | - Jeong Eun Min
- BC Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
| | - Elizabeth Evans
- UCLA Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., Ste. 200, Los Angeles, CA 90025, USA; Centre for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Health Service Research & Development, Greater Los Angeles Healthcare System, 1301 Wilshire Blvd (111G), Los Angeles, CA 90073, USA.
| | - David Huang
- UCLA Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., Ste. 200, Los Angeles, CA 90025, USA.
| | - Lei Liu
- Feinberg School of Medicine, Northwestern University, 303 E Chicago Ave, Chicago, IL 60611, USA.
| | - Yih-Ing Hser
- UCLA Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., Ste. 200, Los Angeles, CA 90025, USA.
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, 8888 University Drive, Burnaby, BC V5A 1S6, Canada.
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Müller J, Schmidt D, Kollan C, Lehmann M, Bremer V, Zimmermann R. High variability of TB, HIV, hepatitis C treatment and opioid substitution therapy among prisoners in Germany. BMC Public Health 2017; 17:843. [PMID: 29065873 PMCID: PMC5655863 DOI: 10.1186/s12889-017-4840-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 10/06/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In Germany, medical care of prisoners is completely separated from extramural health care. The extent and quality of medical care among prisoners in Germany are therefore largely unknown. We performed a secondary data analysis of pharmacy sales data for tuberculosis (TB), HIV, hepatitis C (HCV) and opioid substitution treatment (OST) delivered to prisons in 11 federal states (FS) in Germany between 01/2012 and 03/2013. The aims of this study were to assess (i) the treatment availability for the selected diseases and OST in German prisons, (ii) the proportion of prisoners treated per FS and overall for TB, HIV, HCV and OST during the study period. METHODS Substances unique to or typically used for the treatment of each disease were defined as marker substances with defined daily doses (DDD). For each marker substance we assessed the cumulative number of DDD, the average daily number of DDD (DDDd) and average treatment prevalence per day in percent (adTP). Accordingly, the DDDd represents one person treated per day and the adTP means the proportion of prisoners treated per day. We compared the adTP of the diseases with previously measured prevalences. RESULTS We obtained data from pharmacies supplying prisons in 11 of 16 German FS. Of the included prisons, 41% were supplied with medicines for TB, 71% for HIV and 58% for HCV and OST. Twice as many delivered marker substances for TB were indicated for the continuation phase and chemoprevention than the intensive phase. The HIV adTP ranged from 0.06% to 0.94%, HCV adTP ranged from 0.03% to 0.59% and OST adTP ranged from 0% to 7.90%. The overall adTP for the respective treatment was 0.39% for HIV, 0.12% for HCV and 2.18% for OST. CONCLUSIONS According to our findings treatment rates for TB were consistent with the expected TB prevalence, at least in Berlin. HIV treatment seems to be offered to an adequate proportion of estimated infected prisoners. In contrast, the HCV treatment prevalence was low. High variation among FS in provision of all treatments, particularly of OST, point to inconsistent treatment practices, although nationwide extramural treatment guidelines for Germany exist.
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Affiliation(s)
- Jana Müller
- Department of Infectious Disease Epidemiology, HIV/AIDS, STI and Blood-borne Infections, Robert Koch Institute, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Schmidt
- Department of Infectious Disease Epidemiology, HIV/AIDS, STI and Blood-borne Infections, Robert Koch Institute, Berlin, Germany. .,Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Christian Kollan
- Department of Infectious Disease Epidemiology, HIV/AIDS, STI and Blood-borne Infections, Robert Koch Institute, Berlin, Germany
| | - Marc Lehmann
- Head of Medical Services in the Berlin state prison system, Berlin, Germany
| | - Viviane Bremer
- Department of Infectious Disease Epidemiology, HIV/AIDS, STI and Blood-borne Infections, Robert Koch Institute, Berlin, Germany
| | - Ruth Zimmermann
- Department of Infectious Disease Epidemiology, HIV/AIDS, STI and Blood-borne Infections, Robert Koch Institute, Berlin, Germany
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Platt L, Minozzi S, Reed J, Vickerman P, Hagan H, French C, Jordan A, Degenhardt L, Hope V, Hutchinson S, Maher L, Palmateer N, Taylor A, Bruneau J, Hickman M. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev 2017; 9:CD012021. [PMID: 28922449 PMCID: PMC5621373 DOI: 10.1002/14651858.cd012021.pub2] [Citation(s) in RCA: 128] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugsNeedle syringe programmes (NSP) and opioid substitution therapy (OST) are the primary interventions to reduce hepatitis C (HCV) transmission in people who inject drugs. There is good evidence for the effectiveness of NSP and OST in reducing injecting risk behaviour and increasing evidence for the effectiveness of OST and NSP in reducing HIV acquisition risk, but the evidence on the effectiveness of NSP and OST for preventing HCV acquisition is weak. OBJECTIVES To assess the effects of needle syringe programmes and opioid substitution therapy, alone or in combination, for preventing acquisition of HCV in people who inject drugs. SEARCH METHODS We searched the Cochrane Drug and Alcohol Register, CENTRAL, the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment Database (HTA), the NHS Economic Evaluation Database (NHSEED), MEDLINE, Embase, PsycINFO, Global Health, CINAHL, and the Web of Science up to 16 November 2015. We updated this search in March 2017, but we have not incorporated these results into the review yet. Where observational studies did not report any outcome measure, we asked authors to provide unpublished data. We searched publications of key international agencies and conference abstracts. We reviewed reference lists of all included articles and topic-related systematic reviews for eligible papers. SELECTION CRITERIA We included prospective and retrospective cohort studies, cross-sectional surveys, case-control studies and randomised controlled trials that measured exposure to NSP and/or OST against no intervention or a reduced exposure and reported HCV incidence as an outcome in people who inject drugs. We defined interventions as current OST (within previous 6 months), lifetime use of OST and high NSP coverage (regular attendance at an NSP or all injections covered by a new needle/syringe) or low NSP coverage (irregular attendance at an NSP or less than 100% of injections covered by a new needle/syringe) compared with no intervention or reduced exposure. DATA COLLECTION AND ANALYSIS We followed the standard Cochrane methodological procedures incorporating new methods for classifying risk of bias for observational studies. We described study methods against the following 'Risk of bias' domains: confounding, selection bias, measurement of interventions, departures from intervention, missing data, measurement of outcomes, selection of reported results; and we assigned a judgment (low, moderate, serious, critical, unclear) for each criterion. MAIN RESULTS We identified 28 studies (21 published, 7 unpublished): 13 from North America, 5 from the UK, 4 from continental Europe, 5 from Australia and 1 from China, comprising 1817 incident HCV infections and 8806.95 person-years of follow-up. HCV incidence ranged from 0.09 cases to 42 cases per 100 person-years across the studies. We judged only two studies to be at moderate overall risk of bias, while 17 were at serious risk and 7 were at critical risk; for two unpublished datasets there was insufficient information to assess bias. As none of the intervention effects were generated from RCT evidence, we typically categorised quality as low. We found evidence that current OST reduces the risk of HCV acquisition by 50% (risk ratio (RR) 0.50, 95% confidence interval (CI) 0.40 to 0.63, I2 = 0%, 12 studies across all regions, N = 6361), but the quality of the evidence was low. The intervention effect remained significant in sensitivity analyses that excluded unpublished datasets and papers judged to be at critical risk of bias. We found evidence of differential impact by proportion of female participants in the sample, but not geographical region of study, the main drug used, or history of homelessness or imprisonment among study samples.Overall, we found very low-quality evidence that high NSP coverage did not reduce risk of HCV acquisition (RR 0.79, 95% CI 0.39 to 1.61) with high heterogeneity (I2 = 77%) based on five studies from North America and Europe involving 3530 participants. After stratification by region, high NSP coverage in Europe was associated with a 76% reduction in HCV acquisition risk (RR 0.24, 95% CI 0.09 to 0.62) with less heterogeneity (I2 =0%). We found low-quality evidence of the impact of combined high coverage of NSP and OST, from three studies involving 3241 participants, resulting in a 74% reduction in the risk of HCV acquisition (RR 0.26 95% CI 0.07 to 0.89). AUTHORS' CONCLUSIONS OST is associated with a reduction in the risk of HCV acquisition, which is strengthened in studies that assess the combination of OST and NSP. There was greater heterogeneity between studies and weaker evidence for the impact of NSP on HCV acquisition. High NSP coverage was associated with a reduction in the risk of HCV acquisition in studies in Europe.
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Affiliation(s)
- Lucy Platt
- London School of Hygiene and Tropical MedicineDepartment of Social and Environmental Health Research15 ‐ 17 Tavistock PlaceLondonUKWC1H 9SH
| | - Silvia Minozzi
- Lazio Regional Health ServiceDepartment of EpidemiologyVia Cristoforo Colombo, 112RomeItaly00154
| | | | - Peter Vickerman
- University of BristolSchool of Social and Community MedicineBristolUK
| | - Holly Hagan
- New York University College of NursingNew YorkNYUSA
| | - Clare French
- University of BristolSchool of Social and Community MedicineBristolUK
| | - Ashly Jordan
- New York University College of NursingNew YorkNYUSA
| | - Louisa Degenhardt
- UNSWNational Drug and Alcohol Research CentreBuilding R322‐32 King StreetRandwickNSWAustralia2031
| | - Vivian Hope
- Liverpool John Moores UniversityPublic Health InstituteLiverpoolUKL3 2ET
| | | | - Lisa Maher
- Kirby Institute, University of New South WalesSydneyAustralia
| | | | | | - Julie Bruneau
- University of MontrealDepartment of Family and Emergency MedicineMontrealCanada
| | - Matthew Hickman
- University of BristolSchool of Social and Community MedicineBristolUK
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Hayashi K, Ti L, Ayutthaya PPN, Suwannawong P, Kaplan K, Small W, Kerr T. Barriers to retention in methadone maintenance therapy among people who inject drugs in Bangkok, Thailand: a mixed-methods study. Harm Reduct J 2017; 14:63. [PMID: 28882155 PMCID: PMC5590145 DOI: 10.1186/s12954-017-0189-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Methadone maintenance therapy (MMT) is a mainstay for treating opioid use disorder and preventing and managing HIV among people who inject drugs (PWID). While previous research suggested low dosing of methadone and high rates of discontinuation of MMT among PWID in Thailand, little is known about patients' lived experiences with MMT in this setting. Therefore, we conducted a mixed-methods study to examine barriers to retention in MMT among PWID in Bangkok, Thailand, with particular attention to methadone dosing. METHODS Bivariate statistics were used to analyze quantitative survey data collected from methadone-treated PWID between July and October 2011. Qualitative data collected through semi-structured interviews with 16 methadone-treated PWID between July 2011 and June 2012 were analyzed thematically, with a focus on individual-level, social-structural, and environmental barriers to accessing MMT. RESULTS Among 158 survey participants, a median dosage of methadone was 30 mg/day (interquartile range 20-50). Of these, 15.8% reported having acquired street methadone due to low prescribed dosages of methadone and 19.0% reported recent syringe sharing. Qualitative interview data indicated some methadone provider-related barriers, including discouraging patients from using methadone due to it being a Western medicine, difficulty negotiating higher doses of methadone, and abrupt dose reductions without patient consultation (involving the provision of non-medicated "syrup" in some cases). Social-structural and environmental barriers to optimal MMT access included intense police surveillance of methadone clinics; and frequent incarceration of PWID and a lack of access to methadone in prisons. CONCLUSIONS Among our sample of methadone-treated PWID, methadone dosages were suboptimal according to the international guidelines. Poor adherence to international guidelines for opioid agonist therapies, aggressive law enforcement, and a lack of methadone in prisons need to be addressed to optimize MMT and reduce harms associated with untreated opioid use disorder in Thailand.
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Affiliation(s)
- Kanna Hayashi
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
- Research Scientist, BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital Chair in Substance Use Research and Assistant Professor, Faculty of Health Science, Simon Fraser University, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Lianping Ti
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC V6T 1Z3 Canada
| | - Prempreeda Pramoj Na Ayutthaya
- International Reference Group on Transgender Women and HIV/AIDS, Global Forum on MSM & HIV, 436 14th Street, Suite 100, Oakland, CA 94612 USA
| | - Paisan Suwannawong
- Thai AIDS Treatment Action Group, 18/89 Vipawadee Rd., soi 40 Chatuchak, Bangkok, 10900 Thailand
| | - Karyn Kaplan
- Asia Catalyst, 1270 Broadway, Suite 1109, New York, NY 10001 USA
| | - Will Small
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC V6T 1Z3 Canada
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Wilder CM, Hosta D, Winhusen T. Association of methadone dose with substance use and treatment retention in pregnant and postpartum women with opioid use disorder. J Subst Abuse Treat 2017; 80:33-36. [DOI: 10.1016/j.jsat.2017.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/16/2017] [Accepted: 06/22/2017] [Indexed: 10/19/2022]
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Platt L, Sweeney S, Ward Z, Guinness L, Hickman M, Hope V, Hutchinson S, Maher L, Iversen J, Craine N, Taylor A, Munro A, Parry J, Smith J, Vickerman P. Assessing the impact and cost-effectiveness of needle and syringe provision and opioid substitution therapy on hepatitis C transmission among people who inject drugs in the UK: an analysis of pooled data sets and economic modelling. PUBLIC HEALTH RESEARCH 2017. [DOI: 10.3310/phr05050] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background
There is limited evidence of the impact of needle and syringe programmes (NSPs) and opioid substitution therapy (OST) on hepatitis C virus (HCV) incidence among people who inject drugs (PWID), nor have there been any economic evaluations.
Objective(s)
To measure (1) the impact of NSP and OST, (2) changes in the extent of provision of both interventions, and (3) costs and cost-effectiveness of NSPs on HCV infection transmission.
Design
We conducted (1) a systematic review; (2) an analysis of existing data sets, including collating costs of NSPs; and (3) a dynamic deterministic model to estimate the impact of differing OST/NSP intervention coverage levels for reducing HCV infection prevalence, incidence and disease burden, and incremental cost-effectiveness ratios to measure the cost-effectiveness of current NSP provision versus no provision.
Setting
Cost-effectiveness analysis and impact modelling in three UK sites. The pooled analysis drew on data from the UK and Australia. The review was international.
Participants
PWID.
Interventions
NSP coverage (proportion of injections covered by clean needles) and OST.
Outcome
New cases of HCV infection.
Results
The review suggested that OST reduced the risk of HCV infection acquisition by 50% [rate ratio (RR) 0.50, 95% confidence interval (CI) 0.40 to 0.63]. Weaker evidence was found in areas of high (≥ 100%) NSP coverage (RR 0.77, 95% CI 0.38 to 1.54) internationally. There was moderate evidence for combined high coverage of NSPs and OST (RR 0.29, 95% CI 0.13 to 0.65). The pooled analysis showed that combined high coverage of NSPs and OST reduced the risk of HCV infection acquisition by 29–71% compared with those on minimal harm reduction (no OST, ≤ 100% NSP coverage). NSPs are likely to be cost-effective and are cost-saving in some settings. The impact modelling suggest that removing OST (current coverage 81%) and NSPs (coverage 54%) in one site would increase HCV infection incidence by 329% [95% credible interval (CrI) 110% to 953%] in 2031 and at least double (132% increase; 95% CrI 51% to 306%) the number of new infections over 15 years. Increasing NSP coverage to 80% has the largest impact in the site with the lowest current NSP coverage (35%), resulting in a 27% (95% CrI 7% to 43%) decrease in new infections and 41% (95% CrI 11% to 72%) decrease in incidence by 2031 compared with 2016. Addressing homelessness and reducing the harm associated with the injection of crack cocaine could avert approximately 60% of HCV infections over the next 15 years.
Limitations
Findings are limited by the misclassification of NSP coverage and the simplified intervention definition that fails to capture the integrated services that address other social and health needs as part of this.
Conclusions
There is moderate evidence of the effectiveness of OST and NSPs, especially in combination, on HCV infection acquisition risk. Policies to ensure that NSPs can be accessed alongside OST are needed. NSPs are cost-saving in some sites and cost-effective in others. NSPs and OST are likely to prevent considerable rates of HCV infection in the UK. Increasing NSP coverage will have most impact in settings with low coverage. Scaling up other interventions such as HCV infection treatment are needed to decrease epidemics to low levels in higher prevalence settings.
Future work
To understand the mechanisms through which NSPs and OST achieve their effect and the optimum contexts to support implementation.
Funding
The National Institute for Health Research Public Health Research programme.
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Affiliation(s)
- Lucy Platt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Sedona Sweeney
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Zoe Ward
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Lorna Guinness
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew Hickman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Vivian Hope
- Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Sharon Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Lisa Maher
- Viral Hepatitis Epidemiology and Prevention Program, Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Jenny Iversen
- Viral Hepatitis Epidemiology and Prevention Program, Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Noel Craine
- Health Protection Division, Public Health Wales, Cardiff, UK
| | - Avril Taylor
- School of Media Society and Culture, University of the West of Scotland, Paisley, UK
| | - Alison Munro
- School of Social Science, University of the West of Scotland, Paisley, UK
| | - John Parry
- Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Josie Smith
- Health Protection Division, Public Health Wales, Cardiff, UK
| | - Peter Vickerman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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A longitudinal and case-control study of dropout among drug users in methadone maintenance treatment in Haiphong, Vietnam. Harm Reduct J 2017; 14:59. [PMID: 28854943 PMCID: PMC5577787 DOI: 10.1186/s12954-017-0185-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 08/14/2017] [Indexed: 01/28/2023] Open
Abstract
Background Vietnam began providing methadone maintenance therapy (MMT) in 2008; as of June 2016, 44,479 persons who inject drugs (PWID) were in treatment in 57 provinces. However, 10–23% of patients were estimated to have dropped out of treatment during the first 2 years. We evaluated dropout and factors associated with quitting treatment. Methods We followed clients ≥ 18 years old enrolled in five MMT clinics in Haiphong for 3 years. Persons who missed a consecutive month of methadone treatment were considered to have dropped out and were not allowed to return; those who missed greater than five consecutive doses were considered to be non-compliant but were allowed to restart treatment at their initial dose. Clients who dropped out or who were non-compliant during their third year of MMT (cases) were traced and matched with two clients who remained in treatment (controls) by gender, age, and length of time in the program. Cases and controls were interviewed. Additional data on levels of yearly retention were abstracted from clinic records. Results Among the 1055 patients initially enrolled in MMT, dropout and non-compliance combined was 13.6% during the first year, 16.5% during the second year, and 22.3% during the third year. By 36 months, 33.3% of clients had dropped out, of whom 10.6% had died and 24% had been arrested. We traced and interviewed 81 clients who dropped out or who were non-compliant during year 3 as well as 161 controls. The primary reasons for dropping out included claiming no dependence on heroin (22.2%), conflict with work (21.0%), health problems (16.0%), and inability to afford the methadone co-payment of approximately 0.5 USD/day (14.8%). Independent factors associated with non-compliance included continuing to use heroin (aOR = 12.4, 95% CI 4.2–36.8) and missing greater than three doses during the previous 3 months (aOR = 18.5, 95% CI 7.4–47.1); receiving a daily dose of > 120 mg of methadone was associated with a lower odds ratio of dropping out (aOR = 0.3, 95% CI 0.1–0.9). Conclusion By 3 years, one third of all patients in treatment had permanently dropped out. Ensuring that methadone dosing is adequate and reducing or eliminating the co-payment fee for those who cannot afford it could improve retention.
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Shamsalinia A, Norouzi K, Fallahi-Khoshknab M, Farhoudian A, Ghaffari F. Experiences of substance abusers from methadone maintenance therapy. Med J Islam Repub Iran 2017; 31:45. [PMID: 29445674 PMCID: PMC5804444 DOI: 10.14196/mjiri.31.45] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Indexed: 02/03/2023] Open
Abstract
Background: Substance abusers are not able to withdraw drugs eternally despite the abundance of different treatments; therefore, withdrawal programs are not quite successful and notwithstanding all the successes of methadone maintenance therapy, there are some defects found in the manner this treatment is applied. Thus, this study was conducted to explore the experience of drug abusers regarding methadone maintenance therapy. Methods: This is a qualitative study using content analysis methodology. The research community includes drug abusers admitted to the treatment centers of the western cities of Mazandaran Province, Iran in 2016. The sampling was purposive and the data were collected by face-to-face single interviews with 20 patients. The interviews were continued up to data saturation. Finally, the Lundman and Grenheim method was used to analyze the interviews and the four criteria of Guba and Lincoln were applied to check data integrity. Results: "Buying time," "methadone dependence," and "looking from a narrow view to the patient" were the main three categories that fit the results. Conclusion: Governmental free services for drug abusers; paying attention to different aspects of treatment such as mental, emotional, and social recovery; lifelong support of the family and society members; and balance in prescribing and following the treatment process prescribed by health care providers can enhance both the quality and safety of the treatment process. Psychological consultation alongside social services can facilitate the recovery process in methadone maintenance therapy.
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Affiliation(s)
- Abbas Shamsalinia
- Ramsar Nursing Care Research Center, Babol University of Medical Sciences, School of Nursing and Midwifery. Babol, Mazandaran, Iran
| | - Kiyan Norouzi
- Nursing Department, University of Social Welfare and Rehabilitation Sciences. Tehran, Iran
| | | | - Ali Farhoudian
- Substance Abuse and Dependence Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Fatemeh Ghaffari
- Ramsar Nursing Care Research Center, Babol University of Medical Sciences, School of Nursing and Midwifery. Babol, Mazandaran, Iran
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Heikman PK, Muhonen LH, Ojanperä IA. Polydrug abuse among opioid maintenance treatment patients is related to inadequate dose of maintenance treatment medicine. BMC Psychiatry 2017; 17:245. [PMID: 28683783 PMCID: PMC5501578 DOI: 10.1186/s12888-017-1415-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/02/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Polydrug abuse is a known problem among opioid-dependent patients receiving opioid maintenance treatment (OMT). However, improved laboratory diagnostics is required to reveal polydrug abuse in its current scope. Furthermore, there are few studies focusing on the relationship between polydrug abuse and adequacy of the dose of OMT medicine. This study aimed to evaluate the polydrug abuse among opioid-dependent patients receiving OMT with inadequate (Group IA) and adequate (Group A) doses of OMT medicine as experienced by the patients. Craving for opioids and withdrawal symptoms were evaluated as indicators of the adequacy rating. METHODS This is a retrospective register-based study of 60 OMT patients on either methadone or sublingual buprenorphine/naloxone medication, whose polydrug abuse was studied from urine samples by means of a comprehensive high-resolution mass spectrometry method. RESULTS Inadequate doses of the OMT medicines were associated with higher subjective withdrawal scores and craving for opioids. Six groups of abused substances (benzodiazepines, amphetamines, opioids, cannabis, new psychoactive substances, and non-prescribed psychotropic medicines) were found among OMT patients. Group IA patients showed significantly more abuse of benzodiazepines and amphetamines than the Group A patients. All the new psychoactive substances and most of the non-prescribed psychotropic medicines were detected from the Group IA patients. There was no difference in the doses of the OMT medicine between Groups IA and A patients. CONCLUSIONS Polydrug abuse, detected by definitive laboratory methods, was widespread and more common among Group IA than Group A patients, emphasizing the requirement for individual OMT medicine dose adjustment.
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Affiliation(s)
- Pertti Kalevi Heikman
- University of Helsinki and Helsinki University Central Hospital, Psychiatry, P.O. Box 22, Välskärinkatu 12 A, FI-00014 Helsinki, Finland
| | - Leea Hellevi Muhonen
- University of Helsinki and Helsinki University Central Hospital, Psychiatry, P.O. Box 22, Välskärinkatu 12 A, FI-00014 Helsinki, Finland
| | - Ilkka Antero Ojanperä
- University of Helsinki, Forensic Medicine, P.O. Box 40, Kytösuontie 11, FI-00014 Helsinki, Finland
- National Institute for Health and Welfare, Forensic Toxicology Unit, P.O. Box 30, Mannerheimintie 166, FI-00271 Helsinki, Finland
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Mukherjee TI, Pillai V, Ali SH, Altice FL, Kamarulzaman A, Wickersham JA. Evaluation of a hepatitis C education intervention with clients enrolled in methadone maintenance and needle/syringe programs in Malaysia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 47:144-152. [PMID: 28652072 DOI: 10.1016/j.drugpo.2017.05.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 05/11/2017] [Accepted: 05/15/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Approximately 40%-90% of people who inject drugs (PWID) in Malaysia have hepatitis C (HCV). PWID continue to be disproportionately affected by HCV due to their lack of knowledge, perceived risk and interest in HCV treatment. Education interventions may be an effective strategy for increasing HCV knowledge in PWID, and harm reduction services are uniquely positioned to implement and deploy such interventions. METHODS We recruited 176 clients from methadone maintenance treatment (MMT: N=110) and needle/syringe programs (NSP: N=66) between November 2015 and August 2016. After baseline knowledge assessments, clients participated in a standardized, 45-min HCV education program and completed post-intervention knowledge assessments to measure change in knowledge and treatment interest. RESULTS Participants were mostly male (96.3%), Malay (94.9%), and in their early 40s (mean=42.6years). Following the intervention, overall knowledge scores and treatment interest in MMT clients increased by 68% and 16%, respectively (p<0.001). In contrast, NSP clients showed no significant improvement in overall knowledge or treatment interest, and perceived greater treatment barriers. Multivariate linear regression to assess correlates of HCV knowledge post-intervention revealed that optimal dosage of MMT and having had an HIV test in the past year significantly increased HCV knowledge. Having received a hepatitis B vaccine, however, was not associated with increased HCV knowledge after participating in an education session. CONCLUSION Generally, HCV knowledge and screening is low among clients engaged in MMT and NSP services in Malaysia. Integrating a brief, but comprehensive HCV education session within harm reduction services may be a low-cost and effective strategy in improving overall HCV knowledge and risk behaviors in resource-limited settings. In order to be an effective public health approach, however, education interventions must be paired with strategies that improve social, economic and political outcomes for PWID. Doing so may reduce HCV disparities by increasing screening and treatment interest.
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Affiliation(s)
- Trena I Mukherjee
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA
| | - Veena Pillai
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Siti Hafizah Ali
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Frederick L Altice
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, CT, USA
| | - Adeeba Kamarulzaman
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jeffrey A Wickersham
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
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Maremmani AGI, Pani PP, Rovai L, Bacciardi S, Maremmani I. Toward the Identification of a Specific Psychopathology of Substance Use Disorders. Front Psychiatry 2017; 8:68. [PMID: 28496418 PMCID: PMC5406468 DOI: 10.3389/fpsyt.2017.00068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 04/10/2017] [Indexed: 11/13/2022] Open
Abstract
Addiction is a mental illness in which psychiatric conditions imply a prominent burden. Psychopathological symptoms in substance use disorder (SUD) patients are usually viewed as being assignable to the sphere of a personality trait or of comorbidity, leaving doubts about the presence of a specific psychopathology that could only be related to the toxicomanic process. Our research group at the University of Pisa has shed light on the possible definition of a specific psychopathological dimension in SUDs. In heroin use disorder patients, performing an exploratory principal component factor analysis (PCA) on all the 90 items included in the SCL-90 questionnaire led to a five-factor solution. The first factor accounted for a depressive "worthlessness and being trapped" dimension; the second factor picked out a "somatic symptoms" dimension; the third identified a "sensitivity-psychoticism" dimension; the fourth a "panic-anxiety" dimension; and the fifth a "violence-suicide" dimension. These same results were replicated by applying the PCA to another Italian sample of 1,195 heroin addicts entering a Therapeutic Community Treatment. Further analyses confirmed the clusters of symptoms, independently of demographic and clinical characteristics, active heroin use, lifetime psychiatric problems, kind of treatment received, and, especially, other substances used by the patient such as alcohol or cocaine. Moreover, these clusters were able to discriminate patients affected by addiction from those affected by psychiatric diseases such as major depressive disorder. Our studies seem to suggest the trait-dependent, rather than the state-dependent, nature of the introduced psychopathology dimensions of SUDs.
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Affiliation(s)
- Angelo G. I. Maremmani
- V.P. Dole Dual Diagnosis Unit, Santa Chiara University Hospital, University of Pisa, Pisa, Italy
- Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Lucca, Italy
- Department of Psychiatry, North-Western Tuscany Region, Local Health Unit (Versilia Zone), Viareggio, Italy
| | - Pier Paolo Pani
- Social and Health Services, Cagliari Public Health Trust (ASL Cagliari), Cagliari, Italy
| | - Luca Rovai
- V.P. Dole Dual Diagnosis Unit, Santa Chiara University Hospital, University of Pisa, Pisa, Italy
- Department of Psychiatry, North-Western Tuscany Region, Local Health Unit, Massa, Italy
| | - Silvia Bacciardi
- V.P. Dole Dual Diagnosis Unit, Santa Chiara University Hospital, University of Pisa, Pisa, Italy
| | - Icro Maremmani
- V.P. Dole Dual Diagnosis Unit, Santa Chiara University Hospital, University of Pisa, Pisa, Italy
- Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Lucca, Italy
- G. De Lisio Institute of Behavioural Sciences, Pisa, Italy
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49
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Fuehrlein BS, Ross DA. Opioid Use Disorder: A Desperate Need for Novel Treatments. Biol Psychiatry 2017; 81:e43-e45. [PMID: 28283055 PMCID: PMC5712904 DOI: 10.1016/j.biopsych.2017.01.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/24/2017] [Accepted: 01/25/2017] [Indexed: 12/25/2022]
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50
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Bell J. Commentary on Nikoo et al. (2017): The role of research. Addiction 2017; 112:430-431. [PMID: 28168791 DOI: 10.1111/add.13704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 11/21/2016] [Indexed: 11/30/2022]
Affiliation(s)
- James Bell
- Acacia Cottage Dubbo Base Hospital, Dubbo, Australia
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