A comparison of 1-year substance abuse treatment outcomes in community syringe exchange participants versus other referrals

Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature

BACKGROUND

Syringe services programs (SSPs) provide a spectrum of health services to people who use drugs, with many providing referral and linkage to substance use disorder (SUD) treatment, and some offering co-located treatment with medications for opioid use disorder (MOUD). The objective of this study was to review the evidence for SSPs as an entry point for SUD treatment with particular attention to co-located (onsite) MOUD.

METHODS

We performed a scoping review of the literature on SUD treatment for SSP participants. Our initial query in PubMed led to title and abstract screening of 3587 articles, followed by full text review of 173, leading to a final total of 51 relevant articles. Most articles fell into four categories: (1) description of SSP participants' SUD treatment utilization; (2) interventions to link SSP participants to SUD treatment; (3) post-linkage SUD treatment outcomes; (4) onsite MOUD at SSPs.

RESULTS

SSP participation is associated with entering SUD treatment. Barriers to treatment entry for SSP participants include: use of stimulants, lack of health insurance, residing far from treatment programs, lack of available appointments, and work or childcare responsibilities. A small number of clinical trials demonstrate that two interventions (motivational enhancement therapy with financial incentives and strength-based case management) are effective for linking SSP participants to MOUD or any SUD treatment. SSP participants who initiate MOUD reduce their substance use, risk behaviors, and have moderate retention in treatment. An increasing number of SSPs across the United States offer onsite buprenorphine treatment, and a number of single-site studies demonstrate that patients who initiate buprenorphine treatment at SSPs reduce opioid use, risk behaviors, and have similar retention in treatment to patients in office-based treatment programs.

CONCLUSIONS

SSPs can successfully refer participants to SUD treatment and deliver onsite buprenorphine treatment. Future studies should explore strategies to optimize the implementation of onsite buprenorphine. Because linkage rates were suboptimal for methadone, offering onsite methadone treatment at SSPs may be an appealing solution, but would require changes in federal regulations. In tandem with continuing to develop onsite treatment capacity, funding should support evidence-based linkage interventions and increasing accessibility, availability, affordability and acceptability of SUD treatment programs.

Malmö Treatment Referral and Intervention Study (MATRIS)-36-month follow-up on retention and substance use among patients referred from needle exchange to opioid agonist treatment-The role of stimulant use at baseline

INTRODUCTION

Opioid use disorder (OUD) is the leading cause of overdose morbidity and mortality globally. Retention in opioid agonist treatment (OAT) is crucial as it effectively reduces overdose mortality among individuals suffering from OUD. Previous research on treatment retention among heroin-dependent individuals referred from needle exchange programs (NEP) to OAT is scarce, and with predictors for retention in OAT being somewhat inconclusive, further investigations into this subject is of great interest. The aim of our study was to assess 36-month treatment outcomes-defined as retention and illicit drug abstinence-and predictors of OAT discontinuation.

METHODS

This is a longitudinal cohort study of 71 study subjects successfully referred from a NEP to OAT. Participants were included between October 2011 and April 2013 and followed for 36 months. The study collected data from a structured baseline interview and from patient records, including laboratory data.

RESULTS

At the 36-month follow-up, retention was 51 % (n = 36), with mean days in treatment of 422 for those who discontinued treatment. Amphetamine use during the 30 days before inclusion was positively correlated with treatment discontinuation (AOR 1.22 [95 % CI 1.02-1.46]). No statistically significant association with retention was seen for gender, age, suicide attempt prior to treatment, or benzodiazepine use during 30 days prior to treatment. Opiate use and use of other substances were reduced over time, with major reductions occurring during the first 6 months.

CONCLUSIONS

Hitherto, baseline factors predicting retention in OAT have been insufficiently demonstrated. Active referral from NEP to OAT is effective when it comes to long-term retention and reduction of substance use while in treatment. Except from use of amphetamine, the use of other substances prior to OAT was not associated with treatment discontinuation. Further and in-depth analyses of baseline predictors are of importance for OAT retention.

Recruitment into a Clinical Trial of People Living with Uncontrolled HIV Infection Who Inject Drugs: a Site Case Report from the CTN 67 CHOICES Study

CHOICES was an open-label, randomized, comparative effectiveness trial of office-based extended-release naltrexone versus treatment as usual in people with untreated opioid use disorder and HIV. This study explored facilitators to recruitment in Miami, a successful recruiting site in the national trial. The mixed-methods study included quantitative surveys of randomized participants, medical record abstraction, and qualitative interviews with study staff. Miami recruited 47 (40.5%) of 116 randomized participants in the six-site national trial. In-depth interviews of study staff (n = 6) revealed that Miami had a recruitment approach consisting of street level outreach and a close relationship with the local syringe services program (SSP). Partnership with a local SSP provided access to people living with HIV who inject drugs in Miami. SSPs' fundamental trust within the community of people who inject drugs can be leveraged in studies aiming to improve health outcomes in this underserved and high-priority population.

Substance Use, Hospitalizations, and Co-Occurring Disorders among Patients Transferred from a Needle Exchange Program to Opioid Maintenance Treatment

Opioid use disorders (OUD) is a relapsing condition with high mortality. Opioid maintenance treatment (OMT) reduces heroin use, and overall morbidity and mortality. The prevalence of psychiatric and substance use disorders, potential baseline predictors for psychiatric hospitalization, and psychiatric diagnoses at follow-up were investigated and may give hints about possible preventative strategies. The medical records for 71 patients were reviewed 36 months following referral to OMT from a needle exchange program (NEP). Their psychiatric diagnoses and hospitalizations were identified. Their baseline characteristics were assessed for potential differences between hospitalized versus non-hospitalized patients and between patients with and without psychiatric diagnoses in a longitudinal observational study without controls. A regression analysis was performed to identify predictors for hospitalization when controlling for OMT status. Sixty-five percent of the patients were hospitalized at least once with a psychiatric diagnosis. Substance-related reasons were prevalent, and detoxification occurred among 59% of patients, with sedative- hypnotics (benzodiazepines, zopiclone, zolpidem, and pregabalin) being the substance used by 52% of patients. Baseline use of these drugs and/or buprenorphine predicted for hospitalization when controlling for OMT status. During the follow-up period, 72% of patients met the criteria for a psychiatric diagnosis other than OUD. The prevalence of non-substance use disorders overlapping with SUD was 41%, and that overlapping with anxiety disorder was 27% of all participants. Increased attention to psychiatric co-occurring disorders in the treatment of OUD is required and the importance of addressing sedative-hypnotics use when initiating OMT is highlighted.

Sexual-risk reduction following the referral of syringe exchange registrants to methadone maintenance: Impact of gender and drug use

This study evaluates the impact of enrolling syringe exchange registrants in methadone maintenance on change in sexual-risk behaviors. Baltimore Needle Exchange Program (BNEP) registrants (n = 210) participated in a parent study evaluating strategies for initiating methadone maintenance treatment and the study followed them for six months. Study staff administered the Risk Assessment Battery (RAB; Metzger, 1993) monthly throughout treatment. Staff conducted urinalysis testing weekly. Results showed that treatment enrollment reduced sexual-risk behaviors at month 1, though a longer treatment duration provided no further reductions in risky behaviors. Women reported higher levels of sexual risk throughout the observation period, and the use of cocaine diminished risk-reduction benefits. These findings demonstrate that participation in methadone maintenance reduces sexual-risk behaviors in syringe exchange registrants. Efforts to help more patients reduce cocaine use, and to help women address gender-specific psychosocial vulnerabilities, may further reduce risky behaviors during the treatment episode.

Reducing Risky Drug Use Behaviors by Enrolling Syringe Exchange Registrants in Methadone Maintenance

Referral of syringe exchange registrants with opioid use disorder to agonist treatment provides a pathway to further reduce drug use risk behaviors. Objective: This study evaluates the drug use risk reduction benefits of enrolling syringe exchange registrants in methadone maintenance, and the impact of continued illicit drug use on risk reduction. Method: Baltimore Needle Exchange Program (BNEP) registrants (n = 210) participated in a parent study evaluating treatment initiation strategies for methadone maintenance and were followed for six months. The Risk Assessment Battery (RAB; Metzger, 1993) was administered monthly to evaluate drug use risks; urinalysis testing was conducted weekly. Results: Treatment enrollment reduced drug use risk behaviors, and longer treatment episodes resulted in additional, though modest, risk reduction. Use of opioids or cocaine in treatment diminished risk-reduction benefits, though drug use risks declined over time and remained well below baseline levels. Conclusions: These findings demonstrate that methadone maintenance enhances the well-known risk-reduction benefits of syringe exchange participation. Improving coordination between syringe exchanges and treatment facilities may enhance the public health.

The Influence of Co-Occurring Substance Use on the Effectiveness of Opiate Treatment Programs According to Intervention Type

This systematic review describes the influence of co-occurring substance use on the effectiveness of opiate treatment programs. MEDLINE/PubMed, Embase, PsychINFO, and the Cumulative Index to Nursing and Allied Health Literature were searched from database inception to November 28, 2018, to identify eligible opioid treatment studies in the United States that assessed the relationship between co-occurring substance use and treatment outcome (i.e., opioid abstinence and treatment retention). A total of 34 eligible studies were included. Overall, co-occurring substance use was associated with negative treatment outcomes regardless of intervention type. However, patterns varied by substance and intervention type. In particular, co-occurring use of cocaine or marijuana with opioids was associated with reduced treatment retention and opioid abstinence regardless of intervention type. Co-occurring use of amphetamines, compared with no use or reduced use of amphetamines, decreased treatment retention. Co-occurring use of alcohol was both positively and negatively associated with treatment outcomes. One study reported a significant positive association between sedative use and opioid abstinence. Generally, findings suggest that combined interventions reported better health outcomes compared with pharmacological or behavioral intervention studies alone. The findings of this review emphasize the need to comprehensively study and address co-occurring substance use to improve opiate treatment programs.

Assessment of Co-Occurring Substance Use During Opiate Treatment Programs in the United States

The effectiveness of opiate treatment programs (OTPs) can be significantly influenced by co-occurring substance use, yet there are no standardized guidelines for assessing the influence of co-occurring substance use on treatment outcomes. In this review, we aim to provide an overview on the status of the assessment of co-occurring substance use during participation in OTPs in the United States. We searched 4 databases-MEDLINE/PubMed, EMBASE, PsychINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)-from database inception to November 2018 to select relevant publications on OTPs that assessed participants' co-occurring substance use. We used a standardized protocol to extract study, intervention, and co-occurring substance use characteristics. Methodological quality was assessed using the Quality in Prognosis Studies tool. Of the 3,219 titles screened, 614 abstracts and 191 full-text original publications were assessed, leaving 85 eligible articles. Co-occurring substance use was most often assessed during opioid treatments using combined (pharmacological and behavioral) (n = 57 studies) and pharmacological (n = 25 studies) interventions. Cocaine, alcohol, marijuana, and benzodiazepines were frequently measured, while amphetamines and tobacco were rarely assessed. Great variation existed between studies in the timing and measurement of co-occurring substance use, as well as definitions for substances and polysubstance/polydrug use. Inconsistencies in the investigation of co-occurring substance use make comparison of results across studies challenging. Standardized measures and consensus on research on co-occurring substance use is needed to produce the evidence required to develop personalized treatment programs for persons using multiple substances and to inform best-practice guidelines for addressing polydrug use during participation in OTPs.

Psychiatric and Substance Use Comorbidity in Treatment-Seeking Injection Opioid Users Referred From Syringe Exchange

OBJECTIVE

The present study evaluated rates of co-occurring current psychiatric and substance use disorders in a sample of opioid-dependent treatment-seeking injection drug users referred from syringe exchange.

METHODS

Participants (N = 208) completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV-R to assess current (within the past year) psychiatric and substance use disorders and the two most commonly diagnosed personality disorders (antisocial and borderline personality disorders).

RESULTS

Forty-eight percent of the sample had a current Axis I psychiatric disorder, and 67% had a co-occurring current substance use disorder. Posttraumatic stress disorder (21%), major depression (17%), and bipolar I (12%) were the most prevalent Axis I psychiatric disorders, and cocaine use disorder (53%) was the most commonly co-occurring substance use disorder. Women were more likely to have diagnoses of most anxiety disorders and less likely to have diagnoses of alcohol use disorder or antisocial personality disorder. The presence of a personality disorder was associated with higher rates of cocaine and sedative use disorder.

CONCLUSIONS

Findings suggest the importance of evaluating and treating co-occurring psychiatric and substance use disorders in the treatment of injection drug users with opioid dependence.

Treatment initiation strategies for syringe exchange referrals to methadone maintenance: A randomized clinical trial

This randomized clinical trial evaluated the efficacy of three treatment initiation strategies for improving retention to methadone maintenance for opioid-dependent individuals referred from a syringe exchange program (SEP). New admissions (n = 212) were randomly assigned to one of three 3-month initiation strategies: 1) Low Threshold (LTI), 2) Voucher Reinforcement (VRI), or 3) Standard Care (SCI). LTI was modeled on interim methadone maintenance to transition SEP admissions to the structure of medication-assisted treatment while maximizing exposure to methadone pharmacotherapy. VRI used monetary incentives to reinforce adherence to pharmacotherapy and adaptive counseling. SCI participants received standard methadone dosing and adaptive counseling. All participants were stabilized on methadone pharmacotherapy with a target dose of 80 mg. Following the initiation phase, participants in each condition received standard adaptive counseling from months 4-6. Results showed that most participants failed to achieve the target methadone dose. While no condition differences were observed in retention rates over the 3-month and 6-month observation periods, participants across conditions exhibited reductions in objective and self-report measures of drug use. Results support the benefits of referring syringe exchangers to methadone maintenance, and demonstrate the challenge of retaining these individuals in treatment.

Enrolment and retention of people who inject drugs in the Needle & Syringe Exchange Programme in Malaysia

Setting: Needle and Syringe Exchange Programme (NSEP) implemented by non-governmental organisations in Malaysia. Objectives: To determine enrolment, characteristics and retention in the NSEP of people who inject drugs (PWID) between 2013 and 2015. Design: Retrospective cohort study. Results: There were 20 946 PWID, with a mean age of 38 years. The majority were male (98%) and of Malay ethnicity (92%). Follow-up data were available for 20 761 PWID. Annual retention of newly enrolled PWID for each year was respectively 85%, 87% and 78% for 2013, 2014 and 2015, although annual enrolment over these years declined from 10 724 to 6288 to 3749. Total person-years (py) of follow-up were 27 806, with loss to follow-up of 40 per 100 py. Cumulative probability of retention in NSEP was 66% at 12 months, 45% at 24 months and 26% at 36 months. Significantly higher loss to follow-up rates were observed in those aged 15-24 years or ⩾50 years, females, transgender people and non-Malay ethnic groups. Conclusion: Annual retention of new PWID on NSEP was impressive, although enrolment declined over the 3 years of the study and cumulative loss to follow-up was high. A better understanding of these programmatic outcomes is required.

Malmö Treatment Referral and Intervention Study-High 12-Month Retention Rates in Patients Referred from Syringe Exchange to Methadone or Buprenorphine/Naloxone Treatment

BACKGROUND

Heroin dependence is associated with high mortality. Opioid agonist treatment (OAT) with methadone or buprenorphine has strong evidence for treatment of this relapsing condition. In our setting, OAT has been associated with strict and demanding intake procedures, often with requirements of social stability, but also high, approximately 80 percent 12-month retention rates. In a recent randomized controlled trial, we demonstrated high rates of successful rapid referral from a syringe exchange programme (SEP) to treatment with methadone or buprenorphine, including actual treatment initiation. The objectives of this study were to assess 12-month retention rates, in order to assess whether a novel referral program of current drug users at a SEP would achieve retention rates comparable to more traditional intake procedures.

METHODS

The present report is a 12-month follow-up of 71 patients who successfully started treatment with methadone or buprenorphine/naloxone. Patient data from baseline and at 12 months were collected.

RESULTS

Out of the 71 patients who started treatment, 58 (82%) were still in treatment after 12 months.

CONCLUSION

This was a population, referred from a SEP, with a high drug use severity on admission and no pretreatment requirement for social stability, but there were still high retention rates at 12 months comparable to regular opioid agonist clinics in our setting.

Buprenorphine/naloxone and methadone maintenance treatment outcomes for opioid analgesic, heroin, and combined users: findings from starting treatment with agonist replacement therapies (START)

OBJECTIVE

The objective of this secondary analysis was to explore differences in baseline clinical characteristics and opioid replacement therapy treatment outcomes by type (heroin, opioid analgesic [OA], or combined [heroin and OA]) and route (injector or non-injector) of opioid use.

METHOD

A total of 1,269 participants (32.2% female) were randomized to receive one of two study medications (methadone or buprenorphine/naloxone [BUP]). Of these, 731 participants completed the 24-week active medication phase. Treatment outcomes were opioid use during the final 30 days of treatment (among treatment completers) and treatment attrition.

RESULTS

Non-opioid substance dependence diagnoses and injecting differentiated heroin and combined users from OA users. Non-opioid substance dependence diagnoses and greater heroin use differentiated injectors from non-injectors. Further, injectors were more likely to be using at end of treatment compared with non-injectors. OA users were more likely to complete treatment compared with heroin users and combined users. Non-injectors were more likely than injectors to complete treatment. There were no interactions between type of opioid used or injection status and treatment assignment (methadone or BUP) on either opioid use or treatment attrition.

CONCLUSIONS

Findings indicate that substance use severity differentiates heroin users from OA users and injectors from non-injectors. Irrespective of medication, heroin use and injecting are associated with treatment attrition and opioid misuse during treatment. These results have particular clinical interest, as there is no evidence of superiority of BUP over methadone for treating OA users versus heroin users.

Older methadone patients achieve greater durations of cocaine abstinence with contingency management than younger patients

BACKGROUND AND OBJECTIVES

Contingency management (CM) interventions are efficacious in treating cocaine abusing methadone patients, but few studies have examined the effect of age on treatment outcomes in this population. This study evaluated the impact of age on treatment outcomes in cocaine abusing methadone patients.

METHODS

Data were analyzed from 189 patients enrolled in one of three randomized studies that evaluated the efficacy of CM versus standard care (SC) treatment.

RESULTS

Age was associated with some demographics and drug use characteristics including racial composition, education, and methadone dose. Primary drug abuse treatment outcomes did not vary across age groups, but CM had a greater benefit for engendering longer durations of abstinence in the middle/older and older age groups compared to the younger age groups. At the 6-month follow-up, submission of a cocaine positive urine sample was predicted by submission of a cocaine positive sample at intake, higher methadone doses, and assignment to SC rather than CM treatment.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

As substance abusers are living longer, examination of the efficacy of pharmacological and psychosocial treatments specifically within older age groups may lead to a better understanding of subpopulations for whom enhanced treatments such as CM are warranted.

Improving treatment enrollment and re-enrollment rates of syringe exchangers: 12-month outcomes

BACKGROUND

Developing bridges between community syringe exchange programs (SEPs) and substance abuse treatment could benefit syringe exchangers and the public health. Kidorf et al. (2009) showed that motivational approaches employed at an SEP site improved rates of treatment enrollment and reduced drug use over a 4-month observation window. The present study extends this report by evaluating rates of treatment enrollment and re-enrollment over a 12-month period.

METHODS

Opioid dependent individuals (n = 281) newly registered at an SEP were randomly assigned to one of three referral interventions: (1) 8 individual motivational enhancement sessions and 16 treatment readiness group sessions designed to improve treatment interest and readiness (motivated referral condition; MRC-only); (2) MRC-only with monetary incentives for attending sessions and enrolling in treatment (MRC+I); or (3) standard referral (SRC). MRC-only and MRC+I participants discharged from treatment could attend a treatment re-engagement group designed to facilitate return to treatment (MRC+I participants received incentives for attending sessions and re-enrolling in treatment).

RESULTS

The 4-month outcomes generally extended over 12 months. MRC+I participants were more likely to enroll in methadone maintenance than MRC-only or SRC participants, and to re-enroll in treatment following discharge. MRC+I participants also reported more days of treatment and less heroin and injection use.

CONCLUSIONS

The good harm reduction outcomes for many SEP participants can be enhanced through strategies designed to facilitate treatment enrollment and re-enrollment.

Traumatic event re-exposure in injecting drug users

Drug users have very high rates of lifetime exposure to traumatic events, leading to significant psychiatric complications. In spite of the high rate of lifetime exposure, very little is known about the rate of ongoing re-exposure to new traumatic events in drug users. We investigated the rate of traumatic event re-exposure in male and female injecting drug users using syringe exchange services in Baltimore (N = 197). Participants were assessed monthly for traumatic event re-exposure for 16 months. Averaged over the entire follow-up period, 27% of participants were re-exposed to a traumatic event each month and 72% were re-exposed over the 16-month study period. Women were over twice as likely to report any traumatic event re-exposure as men (adjusted odds ratio [AOR] = 2.48; 95% CI = 1.54-3.99), with the specific events of life-threatening illness, death of a loved one, and injury or illness of a loved one being more common in women than men. Traumatic event re-exposure occurs far more often than previously reported, with women injecting drug users at the highest risk. Reassessment of traumatic events may help to identify people most in need and encourage entry into treatment.

A treatment reengagement intervention for syringe exchangers

Poor sustained treatment engagement limits the effectiveness of all modalities of substance abuse treatment. This study evaluated the efficacy of a novel treatment reengagement intervention for a subset of syringe-exchange program (SEP) participants (N = 113) that had enrolled in treatment as part of a 4-month clinical trial (M. Kidorf et al., 2009). Three reengagement conditions for participants leaving treatment were compared. Motivational referral condition (MRC) participants (n = 31) could attend group sessions that focused on renewing treatment interest. MRC plus incentive (MRC + I) participants (n = 49) could receive modest monetary incentives for attending these sessions and reenrolling in treatment. Standard referral condition participants (n = 33) could not attend groups or receive incentives. Across a 1-year observation window, almost all study participants (86%) were discharged from treatment. MRC + I participants attended more group sessions than MRC participants and were considerably more likely to reenroll in treatment than participants in the other study conditions. Reengagement strategies can further enhance the public health benefits of SEPs by increasing rates of treatment participation over time.

Antecedents and correlates of methadone treatment entry: a comparison of out-of-treatment and in-treatment cohorts

BACKGROUND

The majority of opioid-dependent individuals in the US in need of drug treatment are not receiving it. It would be useful to understand the characteristics of individuals entering and failing to enter methadone treatment.

METHODS

Participants were opioid-dependent adults in Baltimore Maryland recruited from new admissions to one of six methadone treatment programs (n=351) and from the streets from among non-treatment seekers (n=164). At study enrollment, participants were administered the Addiction Severity Index, AIDS Risk Assessment, Community Assessment Inventory, Attitudes toward Methadone Scale, Motivation for Treatment Scale and a urine drug test. A series of logistic regression analyses were conducted to determine the best model to predict treatment entry.

RESULTS

The final logistic regression analysis showed that predictors of treatment entry included: being African-American, being on parole or probation, having lower rates of self-reported cocaine use and criminal activity, higher employment functioning, and greater perceptions of support from family and community for behavioral change. In addition, in-treatment participants were more likely to have a more extensive prior history of drug abuse treatment, greater desire to seek help in coping with their drug problem, and more positive view of methadone.

CONCLUSIONS

The distinctions between those entering and those not pursuing MTP entry have significance for the structure of outreach programs and reaffirm the need to supplement the current practices of voluntary and coerced treatment entry with one of encouraged treatment entry through outreach.

Benefits of concurrent syringe exchange and substance abuse treatment participation

Participation in syringe exchange programs (SEPs) is associated with many individual and public health benefits but may have little impact on reducing drug use without concurrent treatment engagement. This study evaluated rates of drug use, other risk behaviors, and illegal activities in newly registered SEP participants (N = 240) enrolled versus not enrolled in substance abuse treatment over a 4-month observation window and examined the effect of days in treatment on these outcomes. After controlling for baseline differences, SEP registrants enrolled in treatment (n = 113) reported less days of opioid and cocaine use, injection drug use, illegal activities, and incarceration than those not enrolled in treatment (n = 127). For those enrolled in treatment, days of treatment was strongly correlated with each of these outcomes. These findings provide good evidence for a dose-response effect of treatment in syringe exchangers and suggest that substance abuse treatment significantly expands the harm reduction benefits of SEP participation.

Drug interactions associated with methadone, buprenorphine, cocaine, and HIV medications: implications for pregnant women

Pregnancy in substance-abusing women with HIV/AIDS presents a complex clinical challenge. Opioid-dependent women need treatment with opioid therapy during pregnancy to protect the health of mother and developing fetus. However, opioid therapies, methadone and buprenorphine, may have drug interactions with some HIV medications that can have adverse effects leading to suboptimal clinical outcomes. Further, many opioid-dependent individuals have problems with other forms of substance abuse, for example, cocaine abuse, that could also contribute to poor clinical outcomes in a pregnant woman. Physiological changes, including increased plasma volume and increased hepatic and renal blood flow, occur in the pregnant woman as the pregnancy progresses and may alter medication needs with the potential to exacerbate drug interactions, although there is sparse literature on this issue. Knowledge of possible drug interactions between opioids, other abused substances such as cocaine, HIV therapeutics, and other frequently required medications such as antibiotics and anticonvulsants is important to assuring the best possible outcomes in the pregnant woman with opioid dependence and HIV/AIDS.

Lessons learned from a peri-urban needle exchange

Background

Injection drug users continue to be at high risk of HIV and HCV. Research has shown that needle exchange programs (NEP) decrease injection frequency, reduce syringe reuse, and reduce needle sharing, though some results have been mixed.

Methods

This evaluation of a small, peri-urban, legal NEP near Ypsilanti, Michigan describes the operation of the NEP and its clients. It uses interviews conducted with NEP participants between 2003 and 2006, describing the population served by the program, and draws on limited comparisons between matched baseline and follow-up measures as well as aggregate baseline and follow-up comparisons.

Results

The HIV/AIDS Resource Center (HARC) Harm Reduction NEP serves a diverse population from a wide geographical area. NEP participants at follow-up reused their syringes significantly fewer times before getting new ones, were significantly less likely to report giving another IDU a previously used syringe, and were more likely to clean their skin with alcohol either before or after injecting than the baseline comparison group.

Conclusions

The limited data presented here suggest that a NEP can be an effective method of harm reduction even in low-volume, non-urban settings and are an important venue for intervention in peri-urban areas.

Impact of one-year methadone maintenance treatment in heroin users in jiangsu province, china

CONTEXT

Although the effectiveness of methadone maintenance treatment (MMT) is well-established in many countries, it is a relatively new therapy for heroin users in China. Jiangsu Province, a relatively wealthy province, set up 4 MMT clinics in February 2006. No previous studies have evaluated the impact of MMT in a wealthy Chinese province.

OBJECTIVE

The aim of this study is to evaluate the impact of a 1-year MMT among heroin users in Jiangsu Province. We investigated the impact of the treatment by examining the following outcomes: 1) reduction of heroin use, 2) increase of appropriate sexual intercourse, 3) reduction of antisocial behavior, 4) increase of better social and family relationships, and 5) HIV prevalence among heroin users in MMT clinics.

DESIGN AND SETTING

Repeated cross-sectional surveys were conducted before and after heroin users in Jiangsu Province received at least 1-year of treatment in the MMT clinics. A questionnaire survey was implemented for those who agreed to participate from March to April 2006, before the initiation of MMT (N = 554). The second survey was from August to September 2007 and was administered to those who received MMT for more than 1 year (N = 804). One hundred and ninety-six patients who were investigated in both surveys were included in a longitudinal study to evaluate the factors attributable to behavior change.

RESULTS

MMT helped in reducing the percentage of heroin injection and also improved social and familial relationships. Antisocial behavior, including theft, prostitution, and dealing in heroin, decreased after 1-year treatment in the MMT clinics. However, the percentage of patients using condoms was not statistically significant. No case was found to be HIV-positive among those who received more than 1 year MMT. In the longitudinal study of 196 patients who participated in both surveys, no specific demographic variables were found to be associated with heroin use, anti-social behaviors after 1-year MMT.

CONCLUSIONS

MMT was thought to reduce heroin use, antisocial behaviors and HIV prevalence, and increased appropriate sexual intercourse behaviors and better social and family relationships among heroin users in a wealthy province in China, which was true regardless of gender, age, marital status, or working status.

Methadone patients in the therapeutic community: a test of equivalency

BACKGROUND

Residential therapeutic communities (TCs) have demonstrated effectiveness, yet for the most part they adhere to a drug-free ideology that is incompatible with the use of methadone. This study used equivalency testing to explore the consequences of admitting opioid-dependent clients currently on methadone maintenance treatment (MMT) into a TC.

METHODS

The study compared 24-month outcomes between 125 MMT patients and 106 opioid-dependent drug-free clients with similar psychiatric history, criminal justice pressure and expected length of stay who were all enrolled in a TC. Statistical equivalence was expected between groups on retention in the TC and illicit opioid use. Secondary hypotheses posited statistical equivalence in the use of stimulants, benzodiazepines, and alcohol, as well as in HIV risk behaviors.

RESULTS

Mean number of days in treatment was statistically equivalent for the two groups (166.5 for the MMT group and 180.2 for the comparison group). At each assessment, the proportion of the MMT group testing positive for illicit opioids was indistinguishable from the proportion in the comparison group. The equivalence found for illicit opioid use was also found for stimulant and alcohol use. The groups were statistically equivalent for benzodiazepine use at all assessments except at 24 months where 7% of the MMT group and none in the comparison group tested positive. Regarding injection- and sex-risk behaviors the groups were equivalent at all observation points.

CONCLUSIONS

Methadone patients fared as well as other opioid users in TC treatment. These findings provide additional evidence that TCs can be successfully modified to accommodate MMT patients.