Quality of life under maintenance treatment with heroin versus methadone in patients with opioid dependence

Quality of life of patients treated with opium tincture or methadone: A randomized controlled trial

OBJECTIVE

Quality of life (QoL) is an increasingly recognized patient-centered treatment outcome in individuals with opioid use disorder. There is a gap in literature on the impact of opium tincture (OT) on patients' QoL compared to standard treatment options such as methadone. This study aimed to compare the QoL of participants with opioid use disorder receiving OAT using OT or methadone and identify the factors associated with their QoL during treatment.

METHODS

The opium trial was a multicenter non-inferiority randomized clinical trial in four private OAT outpatient clinics in Iran. The study assigned patients to either OT (10 mg/ml) or methadone sirup (5 mg/ml) for a follow-up of 85 days. QoL was assessed using the brief version of the World Health Organization Quality of Life instrument (WHOQOL- BREF).

RESULTS

A total of 83 participants, 35 (42.2%) in the OT arm and 48 (57.8%) in the methadone arm, completed the WHOQOL-BREF in full and were included in the primary analysis. The mean score of patients' QoL showed improvement compared to baseline, but differences were not statistically significant between OT and methadone arms (p = 0.786). Improvements were mainly observed within the first 30 days of receiving treatment. Being married and lower psychological distress were associated with an improved QoL. Within the social relationships domain, male gender showed significantly higher QoL compared to females.

CONCLUSION

OT shows promise as an OAT medication, comparable to methadone in improving patients' QoL. There is a need to incorporate psychosocial interventions to further sustain and improve the QoL in this population. Identifying other social determinants of health which affect QoL and the cultural adaptation of assessments for individuals from various ethnocultural backgrounds are critical areas of inquiry.

Exploring the Relationship between Drug Addiction and Quality of Life in Herat, Afghanistan: A Cross-sectional Study

BACKGROUND

Addiction is a global public health problem, with over 36 million people suffering from drug-use disorders. Afghanistan, the world's leading opium producer, has high rates of drug use owing to the easy access to drugs in this country. This study aimed to investigate drug users' quality of life in Herat, Afghanistan, and identify the factors affecting it.

METHODS

This cross-sectional study examined health-related quality of life at six rehabilitation camps in Herat, Afghanistan, from March to July 2019, using the short form-36 questionnaire (SF-36). Data collected through interviews were analyzed using SPSS software (version 25).

FINDINGS

A total of 240 participants from six rehabilitation camps in Herat, Afghanistan participated in this study. The majority of participants (80%) rated their overall health as "good" or "very good". Men had higher average scores for mental health and vitality than women and those aged 30-39 had the highest quality of life. Statistically significant differences were found in bodily pain (P=0.038), vitality (P=0.042), and social functioning (P=0.046) among users of different types of drugs. Opium abusers had the highest scores for the physical and mental components, followed by heroin, methamphetamine, hashish, and crack abusers.

CONCLUSION

This study explored the relationship between drug addiction and quality of life in Herat, Afghanistan. The findings showed that young adults were more vulnerable to drug use and male addicts and opium users had the highest quality of life. This study can inform the development of effective rehabilitation programs but more research is needed for addiction treatment strategies.

Iteration is not solving the opioid crisis, it's time for transformation

Opioid use disorder (OUD) produces exceedingly high rates of morbidity and mortality in the United States and throughout the world. Almost 90% of persons qualifying for treatment do not enter treatment and 72% of those who initiate treatment leave within 60 days. This Perspective posits that over the past decade our OUD treatment system has produced only small iterative gains in treatment access because, in part, it is founded in a series of top-down regulatory policies dating back more than 100 years. These policies prioritized restricting persons with OUD from having access to opioid agonists over empirical discovery of treatment best practice. It further suggests that for persons who are not already responding positively to our existing treatments, we may need to fundamentally transform care to enact true, meaningful change. Four potential considerations are outlined: expanding beyond long-acting opioids for treatment, embracing safe use as a viable therapeutic target, ending closed medication distribution systems, and partnering with our patients. The overarching aim of this discussion is to motivate broader thinking about new solutions for the patients for whom the existing strategies are not working and who may benefit from more transformative approaches. Though efforts to-date to expand existing treatment systems and find new ways to promote existing MOUDs have been important, these efforts have represented iterative changes. For us to meet our goal of substantially reducing opioid-related harms, it may be time to consider strategies that represent true transformation.

Psychological distress and quality of life among Opioid Agonist Treatment service users with a history of injecting and non-injecting drug use: A cross-sectional study in Kathmandu, Nepal

BACKGROUND

Opioid use disorder is a serious public health problem in Nepal. People who use opioids often experience psychological distress and poor quality of life. Opioid agonist Treatment (OAT) is central in managing opioid dependence. This study aimed to examine factors associated with quality of life and serious psychological distress among OAT service users in the Kathmandu Valley, Nepal and compare those who had injected opioids prior to OAT and those who had not.

METHODS

A cross-sectional study with 231 was conducted using a semi-structured questionnaire, the Nepalese versions of the Kessler 6 psychological distress scale and World Health Organization Quality of Life scale (WHOQOL-BREF). Bivariate and multivariate analyses were undertaken to examine factors associated with quality of life and serious psychological distress.

RESULTS

Most participants were males (92%) and about half had injected opioids before initiating OAT. Serious psychological distress in the past four weeks was significantly more prevalent among participants with a history of injecting (32.2%) than those who did not inject (15.9%). In the adjusted linear regression model, those who had history of injecting were likely to have lower physical quality of life compared to non-injectors. Those self-reporting a past history of mental illness were more than seven times and those with medical comorbidity twice more likely to have serious psychological distress over last four weeks. Lower socioeconomic status and a history of self-reported mental illness in the past were found to be significantly associated with lower quality of life on all four domains.

CONCLUSION

Those who had history of injecting were younger, had frequent quit attempts, higher medical comorbidity, lower socioeconomic status and remained longer in OAT services. Alongside OAT, the complex and entangled needs of service users, especially those with a history of injecting drugs, need to be addressed to improve quality of life and lessen psychological distress.

Barriers to accessing opioid substitution treatment for opioid use disorder: A systematic review from the client perspective

OBJECTIVES

To update the existing evidence to identify specific barriers to initiation of opioid substitution therapy (OST) for those with opioid use disorder (OUD).

METHODS

The review follows Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) guidelines. Six databases were initially searched in November 2019, with the search updated on 11 November 2020, for qualitative or quantitative studies reporting the barriers to initiating OST from the client with OUD perspective. Thematic analysis of the barriers to OST was undertaken to determine barrier themes and subthemes.

RESULTS

There were 37 studies included in the review; 18 were qualitative, 15 were quantitative and four were mixed methods. The barrier themes identified were stigma and fear, regulatory, logistical, attitudinal and social factors. Within these barrier themes 19 barrier subthemes were identified. The most reported OST barrier subthemes were negative treatment perceptions, cost, stigma and lack of flexibility.

CONCLUSION

This review discusses important barriers to OST and examines reported barriers from the client perspective. OST guidelines and programs would benefit by introducing programs that reduce stigma, increase treatment knowledge and health literacy, reduce treatment costs, increase treatment flexibility and allow for easier treatment access.

Impact of opioid agonist treatment on mental health in patients with opioid use disorder: a systematic review and network meta-analysis of randomized clinical trials

Background: There is a knowledge gap in systematic reviews on the impact of opioid agonist treatments on mental health.Objectives: We compared mental health outcomes between different opioid agonist treatments and placebo/waitlist, and between the different opioids themselves.Methods: This meta-analysis of randomized clinical trials (RCTs) was pre-registered at PROSPERO (CRD42018109375). Embase, MEDLINE, PsychInfo, CINAHL Complete, and Web of Science Core Collection were searched from inception to May 2020. RCTs were included if they compared opioid agonists with each other or with placebo/waitlist in the treatment of patients with opioid use disorder and reported at least one mental health outcome after 1-month post-baseline. Studies with psychiatric care, adjunct psychotropic medications, or unbalanced psychosocial services were excluded. The primary outcome was overall mental health symptomatology, e.g. Symptom Checklist 90 total score, between opioids and placebo/waitlist. Random effects models were used for all the meta-analyses.Results: Nineteen studies were included in the narrative synthesis and 15 in the quantitative synthesis. Hydromorphone, diacetylmorphine (DAM), methadone, slow-release oral morphine, buprenorphine, and placebo/waitlist were among the included interventions. Based on the network meta-analysis for primary outcomes, buprenorphine (SMD (CI95%) = -0.61 (-1.20, -0.11)), DAM (-1.40 (-2.70, -0.23)), and methadone (-1.20 (-2.30, -0.11)) were superior to waitlist/placebo on overall mental health. Further direct pairwise meta-analysis indicated that overall mental health improved more in DAM compared to methadone (-0.23 (-0.34, -0.13)).Conclusions: Opioid agonist treatments used for the treatment of opioid use disorder improve mental health independent of psychosocial services.

Substitution treatment for opioid dependence with slow-release oral morphine: Retention rate, health status, and substance use after switching to morphine

INTRODUCTION

Since April 2015, slow-release oral morphine (SROM) has been approved for opioid agonist treatment (OAT) in Germany. Experimental studies show that benefits of SROM over methadone include less heroin craving, better tolerability, and higher patient satisfaction and mental stability. The SROMOS study (Efficacy and Tolerability of Slow-Release Oral Morphine in Opioid Substitution Treatment) aims to investigate the long-term effects (effectiveness and safety) of morphine substitution under routine care in Germany.

MATERIAL AND METHODS

This is a prospective, noninterventional, naturalistic, observational study. Between July 2016 and November 2017, this study recruited patients in OAT who decided to switch to SROM from 23 outpatient addiction treatment centers in Germany. The study collected data on mental health (Brief Symptom Inventory - BSI-18), substance use, somatic health (Opiate Treatment Index Health-Symptoms-Scale - OTI-HSS), opioid craving (visual analogue scale), and withdrawal symptoms (Short Opiate Withdrawal Scale) at baseline (t0) and after 3 (t3), 6 (t6) and 12 (t12) months. Physicians documented side effects as adverse events (AEs) and adverse drug reactions (ADRs).

RESULTS

Three-quarters of the enrolled study participants (N = 180) were male. The average age was 44.4 years. Patients were opioid-dependent for 23 years and had been in OAT for almost seven years on average. After 12 months, 60.6% were still being treated with SROM. Mental health improved significantly under SROM treatment between t0 and t12. The intention-to-treat (ITT), as well as the per-protocol (PP) analysis, shows a statistically significant improvement of the mean Global Severity Index (GSI) of the BSI-18 value of 20% (ITT) and 24% (PP). Physical health also improved significantly under SROM treatment. There were no statistically significant changes in the use of cannabis, cocaine, amphetamines, and tranquillizers in the past 30 days, but heroin use, intravenous consumption, and the number of drinking days significantly decreased.

CONCLUSIONS

This study provides some of the first long-term data on OAT with SROM under routine care conditions. SROM treatment is an effective alternative for a subgroup of opioid-dependent patients with an unsatisfactory course of OAT or in cases where undesirable side effects due to alternative substances have occurred.

ETHICAL STATEMENT

The study protocol was approved by the Ethics Committee of the Chamber of Physicians in Hamburg in March 2016 (No. PV5222). The study was conducted by following the Declaration of Helsinki and is registered with the German Register of Clinical Trials (DRKS, ID: DRKS00010712).

Evaluating comparative effectiveness of psychosocial interventions adjunctive to opioid agonist therapy for opioid use disorder: A systematic review with network meta-analyses

BACKGROUND

Guidelines recommend that individuals with opioid use disorder (OUD) receive pharmacological and psychosocial interventions; however, the most appropriate psychosocial intervention is not known. In collaboration with people with lived experience, clinicians, and policy makers, we sought to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy (OAT) among persons with OUD.

METHODS

A review protocol was registered a priori (CRD42018090761), and a comprehensive search for randomized controlled trials (RCT) was conducted from database inception to June 2020 in MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Established methods for study selection and data extraction were used. Primary outcomes were treatment retention and opioid use (measured by urinalysis for opioid use and opioid abstinence outcomes). Odds ratios were estimated using network meta-analyses (NMA) as appropriate based on available evidence, and in remaining cases alternative approaches to synthesis were used.

RESULTS

Seventy-two RCTs met the inclusion criteria. Risk of bias evaluations commonly identified study limitations and poor reporting with regard to methods used for allocation concealment and selective outcome reporting. Due to inconsistency in reporting of outcome measures, only 48 RCTs (20 unique interventions, 5,404 participants) were included for NMA of treatment retention, where statistically significant differences were found when psychosocial interventions were used as an adjunct to OAT as compared to OAT-only. The addition of rewards-based interventions such as contingency management (alone or with community reinforcement approach) to OAT was superior to OAT-only. Few statistically significant differences between psychosocial interventions were identified among any other pairwise comparisons. Heterogeneity in reporting formats precluded an NMA for opioid use. A structured synthesis was undertaken for the remaining outcomes which included opioid use (n = 18 studies) and opioid abstinence (n = 35 studies), where the majority of studies found no significant difference between OAT plus psychosocial interventions as compared to OAT-only.

CONCLUSIONS

This systematic review offers a comprehensive synthesis of the available evidence and the limitations of current trials of psychosocial interventions applied as an adjunct to OAT for OUD. Clinicians and health services may wish to consider integrating contingency management in addition to OAT for OUD in their settings to improve treatment retention. Aside from treatment retention, few differences were consistently found between psychosocial interventions adjunctive to OAT and OAT-only. There is a need for high-quality RCTs to establish more definitive conclusions.

TRIAL REGISTRATION

PROSPERO registration CRD42018090761.

Daily heroin injection and psychiatric disorders: A cross-sectional survey among People Who Inject Drugs (PWID) in Haiphong, Vietnam

BACKGROUND

Psychiatric comorbidities are frequent among people who inject drugs, they are associated with a poorer prognosis and need to be addressed. Their interaction with daily heroin injection requires clarification.

METHODS

A cross-sectional survey was conducted among PWID recruited in the city of Haiphong, Vietnam, by respondent-driven sampling. The inclusion criteria were age 18 or older and current injection drug use, verified by skin marks and positive urine tests for heroin or methamphetamine. Data on socio-demographic characteristics, drug use, sexual behaviour and access to treatment were collected using face-to-face questionnaires by trained interviewers. PWID were screened by trained psychiatrists for depression, psychotic disorder and suicidality, using the MINI questionnaire.

RESULTS

418 participants were included in the analyses. All were injected heroin users, 21 % were diagnosed with a current major depressive disorder, 15 % with a current psychotic disorder and 12 % presented a suicide risk. In the bivariate analyses, regular meth use, cannabis use and ketamine use were positively associated with presenting at least one psychiatric condition while daily heroin injection and being currently treated with methadone were negatively associated. In the multivariate model, poly-substance use was positively associated with depression (methamphetamine and drinking in addition to heroin) and psychotic disorder (methamphetamine and/or hazardous drinking in addition to heroin) while daily heroin injection and current methadone treatment were negatively and independently associated with depression and psychotic syndrome.

CONCLUSIONS

Our survey confirms the burden of methamphetamine use and the protective effect of methadone but also a possible protective effect of daily heroin injection.

Fifteen years of heroin-assisted treatment in a Swiss prison-a retrospective cohort study

Background

In the context of the current US opioid crisis and the compelling fact that a quarter to a third of all those addicted to heroin pass through its prisons and jails each year, the care of incarcerated opioid-using individuals (OUI) needs to be improved.

Aims

Little has been published on the effectiveness or outcomes of heroin-assisted treatment (HAT), a treatment option for severely dependent OUI delivered in a prison setting. The aim of this study was therefore to evaluate such treatment since its implementation. The primary objective was to investigate whether heroin-assisted treatment was associated with severe detrimental health outcomes. The secondary objective was to compare the heroin-assisted treatment group with the general prison population in terms of occupational functioning.

Design

Retrospective cohort study

Setting

An open prison with 120 places

Subjects

Data on 1885 male prisoners with a total of 2239 imprisonment periods between 2000 and 2015 was available. Ninety-seven inmates in heroin-assisted treatment were compared with 1788 inmates from the general prison population (reference group).

Measurements

Mortality, medical complications (including overdoses), and work performance (days worked, sick days, and monthly wages earned).

Findings

Inmates receiving HAT were on average 1 year younger (33.8 vs. 34.9 years), had longer prison stays (7.3 vs. 3.0 months), were more often of Swiss nationality (68.0% vs. 28.9%), and had committed more drug- and property-related offenses (49.5% vs. 23.2% and 63.9% vs. 38.3%, respectively) compared to the reference group. No serious heroin-related medical complication occurred during the 15-year window of observation among inmates with heroin-assisted treatment. Their work performance was comparable to that of the reference group.

Conclusions

This study shows that heroin-assisted treatment can be a valuable treatment option for severely dependent OUI during imprisonment, can be delivered safely by prison health staff over extended periods of time, and allows OUI in treatment to achieve work performance rates comparable to that of the general prison population.

Health-related quality of life of long-term patients receiving opioid agonist therapy: a nested prospective cohort study in Norway

Background

Opioid dependence carries the highest disease burden of all illicit drugs. Opioid agonist therapy (OAT) is an evidence-based medical intervention that reduces morbidity and mortality. There is limited knowledge on the health-related quality of life (HRQoL) of long-term patients in OAT. This study measures HRQoL and self-perceived health of long-term patients on OAT, compares the scores to a Norwegian reference population, and assesses changes in these scores at 1-year follow up.

Methods

We conducted a nested prospective cohort study among nine OAT outpatient clinics in Norway. 609 OAT patients were included, 245 (40%) followed-up one year later. Data on patient characteristics, HRQoL, and self-perceived health was collected. HRQoL was assessed with the EQ-5D-5L, which measures five dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) on a five-point Likert scale (from “no problems” to “extreme problems”). An UK value set was applied to calculate index values (from 0 to 1) for the EQ-5D-5L and compare them to a Norwegian reference population. Self-perceived health was measured with EQ-VAS (from 0 to 100).

Results

Mean (standard deviation (SD)) EQ-5D-5L index value at baseline was 0.699 (0.250) and EQ-VAS 57 (22) compared to 0.848 (0.200) and 80(19) for the Norwegian reference population. There were large variations in EQ-5D-5L index values, where 43% had > 0.8 and 5% had < 0.2 at baseline. The lowest EQ-5D-5L index values were observed for female patients, age groups older than 40 years and for methadone users. At follow-up, improvements in HRQoL were observed across almost all dimensions and found significant for mobility and pain/discomfort. Mean (SD) overall index value and EQ-VAS at follow up were 0.729 (0.237) and 59 (22) respectively.

Conclusion

The average HRQoL and self-perceived health of OAT patients is significantly lower than that of the general population, and lower than what has been found among other severe somatic and psychiatric conditions. Around 34% had very good HRQoL, higher than average Norwegian values, and around 5% had extremely poor HRQoL.

Comparison of Treatment Options for Refractory Opioid Use Disorder in the United States and Canada: a Narrative Review

Amidst the opioid overdose crisis, there are increased efforts to expand access to medications for opioid use disorder (MOUD). Hospitalization for the complications of substance use in the United States (US) provides an opportunity to initiate methadone, buprenorphine, and extended release naltrexone and link high-risk, not otherwise engaged, patients into outpatient care. However, treatment options for patients are quickly exhausted when these medications are not desired, tolerated, or beneficial. As an example, we discuss the case of a man who was hospitalized 27 times over 2 years for complications related to his opioid use disorder (OUD), including recurring methicillin-resistant Staphylococcus aureus vertebral osteomyelitis, increasing antimicrobial resistance, new infections, and multiple overdoses in and out of the hospital. The patient suffered these complications despite efforts to treat his OUD with methadone and buprenorphine while hospitalized, and repeated attempts to link him to outpatient care. We use this case to review evidence-based treatments for refractory OUD, which are not approved in the US, but are available in Canada. If hospitalized in Vancouver, Canada, this patient could have been offered slow-release oral morphine and injectable opioid agonist therapy, as well as access to sterile syringes and injection equipment at an in-hospital supervised injection facility. Each of these approaches is supported by evidence and has been implemented successfully in Canada, yet none are available in the US. In order to combat the multiple harms from opioids, it is critical that we consider every evidence-based tool.

Validation and psychometric properties of the drug users' quality of life scale in Iranian population

INTRODUCTION

Drug dependence and the resultant problems notably decrease the quality of life (QOL). Measuring the QOL in persons who use drugs (PWUD_s) and planning to improve it can be helpful for rehabilitation programs. Given the absence of a standard tool to measure the quality of life of PWUD, the present study is an attempt to validate psychometric and cultural characteristics of non-injection drug users' QOL scale.

METHOD

The study was carried out as a validation and methodological work. The study population consisted of 273 PWUDs in Kermanshah-based drug clinics including outgoing and hospitalized patients. The participants were selected through convenient-quota sampling. After securing the required permission from the copyright owner of the tool, it was forward/backward translated. Face validity and content validity were determined quantitatively and qualitatively. To examine construct validity of the tool, explorative factor analysis and confirmatory factor analysis were used. Internal consistency was measured using Cronbach's alpha and statistical analyses were performed using SPSS (v.25) and LISREL (v.8).

RESULTS

Explorative factor analysis (EFA) and confirmatory factor analysis (CFA) results supported the tool with one factor and 22 items. The R2 index in the model was equal to 0.99, which means that 99% of the variation of dependent variable (total score of QOL) is attributed to independent variable (22 statements). In other words, 99% of the variation of dependent variable is due to the independent variables in the model. The main indices of the model based on CFA all were higher than 0.9, which indicates goodness of fit of the model (χ2/DF = 2.18, CFI, NFI, TLI = 0.93 GF = 0.84, REMSEA = 0.066, R2 = 0.99). The correlative coefficient was significant (p < 0.05). The reliability of the tool based on internal consistency (Cronbach's alpha) for the subscales ranged from 0.84 to 0.85 and equal to 0.84 for the whole tool.

CONCLUSION

The Farsi version of non-injection drug users' QOL scale had acceptable indices and it was applicable to assess QOL in the target population. The tool can be used in different fields of drug addiction.

Effectiveness of Religious-Spiritual Group Therapy on Spiritual Health and Quality of Life in Methadone-treated Patients: A Randomized Clinical Trial

Background

Spirituality is one of the most important factors that can contribute to the recovery of substance use disorder (SUD). The objective of this study is to evaluate the efficacy of the religious-spiritual group therapy on the spiritual health and the quality of life in methadone-treated patients.

Methods

This study was carried out in Qom City, Iran, in 2018. 72 methadone-treated patients were randomly selected and assigned in two groups: the experimental group (which received religious-spiritual therapy) and control group (which received no treatment). At the beginning of the study (pre-test), eight weeks after the start of the study (post-test), and three months after the start of the study (follow-up test), all participants completed the World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire and the Spiritual Well-Being Scale (SWBS). Participants in the experimental group received 8 sessions (90 minutes for each session) of spiritual and religious training, while the control group received no religious-spiritual intervention; it just was trained with general information on addiction. Data were analyzed using SPSS software and descriptive and inferential statistics methods.

Findings

The results of repeated measures analysis of variance (ANOVA) showed that there was no significant difference between the intervention and control groups in the pretest, but religious-spiritual training significantly increased spiritual health and the patients' quality of life (P < 0.001).

Conclusion

Religious-spiritual education can improve the quality of life and spiritual well-being in methadone-treated patients. The findings suggest that religious -spiritual education can be considered as an inexpensive, accessible, useful, and effective treatment for SUD treatment.

Comparison of the effectiveness of a 12 step substance use recovery program on quality of life

Substance-related disorders can adversely impact quality of life. This study assessed a 12 step program on health-related quality of life for Iranian individuals seeking to recover from substance use. The study used a quasi-experimental, two group, three stage, pre- and post-test design and collected data at baseline, and at 1 and 3 months' post-intervention. The treatment group comprised 35 participants in a 12 step program with a non-equivalent comparison group of individuals admitted to addiction treatment centers. Physical and mental health quality-of-life domains were assessed using the Short Form 36 Health Survey Questionnaire. The treatment group improved in all aspects of health-related quality of life. The treatment group improved compared to the comparison group for two of eight quality of life dimensions - physical functioning and role limitations due to emotional problems - at 1 month post-intervention. There were additional improvements at 3 months' follow up in six of eight quality-of-life subscales compared to the comparison group. The benefits to quality of life related to mental health recovery extended beyond the treatment program, indicating that the program principles were effectively implemented in daily life.

Intact responses to non-drug rewards in long-term opioid maintenance treatment

Disruption of non-drug reward processing in addiction could stem from long-term drug use, addiction-related psychosocial stress, or a combination of these. It remains unclear whether long-term opioid maintenance treatment (OMT) disrupts reward processing. Here, we measured subjective and objective reward responsiveness in 26 previously heroin-addicted mothers in >7 years stable OMT with minimal psychosocial stress and illicit drug use. The comparison group was 30 healthy age-matched mothers (COMP). Objective reward responsiveness was assessed in a two-alternative forced-choice task with skewed rewards. Results were also compared to performance from an additional 968 healthy volunteers (meta-analytic approach). We further compared subprocesses of reward-based decisions across groups using computational modelling with a Bayesian drift diffusion model of decision making. Self-reported responsiveness to non-drug rewards was high for both groups (means: OMT = 6.59, COMP = 6.67, p = 0.84, BF₁₀ = 0.29), yielding moderate evidence against subjective anhedonia in this OMT group. Importantly, the mothers in OMT also displayed robust reward responsiveness in the behavioral task (t₁₉ = 2.72, p = 0.013, BF₁₀ = 3.98; d = 0.61). Monetary reward changed their task behavior to the same extent as the local comparison group (reward bias OMT = 0.12, COMP = 0.12, p = 0.96, BF₁₀ = 0.18) and in line with data from 968 healthy controls previously tested. Computational modelling revealed that long-term OMT did not even change decision subprocesses underpinning reward behavior. We conclude that reduced sensitivity to rewards and anhedonia are not necessary consequences of prolonged opioid use.

Association of current and past opioid use disorders with health-related quality of life and employment among US adults

BACKGROUND

To examine the association of current and past Opiate Use Disorder (OUD) with measures of HRQOL and employment in a nationally representative sample of adults.

METHODS

The 2012-2013 National Epidemiological Survey on Alcohol and Related Conditions III (NESARC III) surveyed a nationally representative sample of non-institutionalized civilian adults (≥18 years) in the US (n = 36,309 unweighted). Using DSM-5 criteria, adults without history of OUD were compared to those with current and past OUD. Using the SF-12 items, standard measures of the mental and physical component scores of HRQOL and of quality-adjusted life years (QALYs) were constructed. Employment in the past year (yes/no) was also assessed. Multivariable-adjusted regression analyses were used to adjust for covariates.

RESULTS

Overall, 0.9% of the study sample, representing 2.1 of 235.4 million adults, met criteria for current OUD; 1.2%, representing 2.7 million adults, met criteria for past OUD. Adults with current or past OUD had large and moderately reduced mental component (MCS) and physical health component (PCS) summary scores compared to adults who never had OUD (p < 0.001, respectively). Current OUD was associated with lower odds of being employed compared to never experiencing OUD (Adjusted odds ratio = 0.65; 95% CI: 0.48, 0.88; p = 0.005), as was past OUD. Adjustment for potentially confounding factors reduced the independent association of OUD and HRQOL by about 40-50% but did not change employment comparisons.

CONCLUSION

Adults with current OUD are associated with large reductions in HRQOL and likelihood of not being employed, and adults with past OUD also have considerable residual impairment.

Factors associated with health-related quality of life in a large national sample of patients receiving opioid substitution treatment in Germany: A cross-sectional study

BACKGROUND

Knowledge of health-related quality of life (HRQOL) of patients receiving opioid substitution treatment (OST) is limited and fragmented. The present study examines the HRQOL of a large national sample of OST patients in Germany and sociodemographic and clinical correlates.

METHODS

Cross-sectional data on the HRQOL of 2176 OST patients was compared with German general population norms. Patients were recruited from 63 OST practices across Germany. To identify correlates of HRQOL, as measured with the SF-12, we performed bi- and multivariate analyses with sociodemographic and clinical variables, including patient- and clinician-reported outcomes on physical and mental health.

RESULTS

Patients' HRQOL was significantly poorer than in the general population, especially their mental HRQOL. Factors associated with lower physical HRQOL were older age, longer duration of opioid dependence, hepatitis C virus infection, and HIV infection. Benzodiazepine use was associated with lower mental HRQOL, and amphetamine use with higher physical HRQOL, compared to non-use of these substances. For both mental and physical HRQOL, the factor with the strongest positive association was employment and the factors with the strongest negative associations were physical and mental health symptom severity, psychiatric diagnosis, and psychopharmacological medication.

CONCLUSIONS

Compared to the general population, we found substantially lower HRQOL in OST patients, especially in their mental HRQOL. OST programs can benefit from further improvement, particularly with regard to mental health services, in order to better serve their patients' needs. Clinicians may consider the use of patient-reported outcome measures to identify patients' subjective physical and psychological needs. Further research is needed to determine if employment is a cause or consequence of improved HRQOL.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02395198 , retrospectively registered 16/03/2015.

Health Related Quality of Life in Individuals Transferred from a Needle Exchange Program and Starting Opioid Agonist Treatment

Background

Opioid agonist treatment (OAT), for the treatment of heroin dependence, has been reported to improve overall health and lower mortality. Drug use and retention in treatment have often been used as measures of treatment success. More recently, however, researchers have suggested that measurements of quality of life should be an outcome in substance use treatment evaluations. In a recent randomized controlled trial we demonstrated high rates of successful rapid referral from a needle exchange program (NEP) to OAT. The aim of this study was to see whether an improvement in health related quality of life (HRQoL) could be seen at 3-month follow-up after starting OAT and whether it was associated with any baseline characteristics. We also wanted to compare our sample to a sample from the general population with regard to HRQoL.

Methods

This was a 3-month follow-up of 71 patients who started OAT. Measurements of HRQoL with EQ-5D (an instrument developed by the EuroQol group) were made at baseline and at three months.

Results

Mean EQ-5D VAS (visual analogue scale) for the study sample at baseline was 47.3, which was lower than a Swedish reference population reporting 83.3. Individuals reporting being prescribed a drug for a psychiatric condition had significantly lower EQ-5D index values. Improvement in EQ-5D index score was significantly less for individuals reporting previous overdoses (-0.10, p=0.025). Individuals reporting previous suicide attempts had significantly lower EQ-5D VAS score at baseline. A significant increase of the EQ-5D VAS difference over time was found with a mean difference of 10.94 (p=0.008) for the total sample.

Conclusion

To our knowledge this is the first time HRQoL as an outcome is reported in a population transferred from a NEP to OAT. Our results indicate that OAT can result in increased HRQoL, even with this type of rapid low-threshold referral.

Impacts of GRIN3A, GRM6 and TPH2 genetic polymorphisms on quality of life in methadone maintenance therapy population

Opioid addiction is a major public health issue worldwide. Methadone maintenance treatment (MMT) is used to detoxify users of illicit opiates, but drug relapse is common and associated with poor quality of life (QoL). This study investigated the associations between the GRIN3A, GRM6, and TPH2 genetic variants and QoL in the MMT population. A total of 319 participants were included in the study, and genotyping of GRIN3A, GRM6, and TPH2 genes was performed using the Sequenom iPLEX. Associations between genotypes and the domains of QoL were examined through posthoc analysis with LSMEANS syntax using SAS 9.1.3. The single nucleotide polymorphisms rs9325202 and rs1487275 in the TPH2 gene were significantly associated with the QoL domain of physical functioning. The least absolute shrinkage and selection operator regression model revealed that the risk allele rs1487275-G was significantly correlated with the domain of physical functioning when clinical characteristics were considered as covariates. The results of the present study illuminate the importance of the genetic basis of QoL in the MMT population, and suggest that genotypes should be considered as a potential QoL indicator.

Characterizing the subjective, observer-rated, and physiological effects of hydromorphone relative to heroin in a human laboratory study

BACKGROUND

This study compared the effects of the several doses of the opioid agonists heroin and hydromorphone across two routes of administration in humans. The goal was to guide development of human laboratory studies of opioid effects and inform subsequent injection pharmacotherapy trials of hydromorphone-assisted treatment.

METHODS

A within-subject (N = 16), double-blind, double-dummy, placebo-controlled, evaluation of acute doses of heroin and hydromorphone was completed at four dose levels (placebo, low, medium, high) across two routes of administration (intravenous, subcutaneous) in non-physically dependent, opioid-experienced individuals. Subject and observer ratings, as well as physiological outcomes, were assessed.

RESULTS

Within each route of administration, heroin and hydromorphone produced effects that were qualitatively similar on most variables across the doses examined. All effects were dose-dependent. The drugs produced different effects on VAS ratings of "Feels Like Heroin," a Heroin Identification Test, observer agonist ratings, and oxygen saturation levels. Drug-dependent differences emerged at the highest doses in all cases. Few significant main effects of Route were identified and their pattern was not uniform. Relative potency calculations across all subject, observer, and physiological outcomes that met analysis criteria revealed similar profiles and resulted in mean heroin:hydromorphone potencies of 3.35:1 and 2.88:1 for the intravenous and subcutaneous routes, respectively, and intravenous:subcutaneous potencies of 0.47:1 and 0.49:1 for heroin and hydromorphone, respectively.

CONCLUSIONS

Hydromorphone produced similar subjective and physiological effects as heroin, but was more potent than heroin. The current findings support the use of hydromorphone as a model for heroin in human laboratory and clinical treatment studies, and help identify appropriate hydromorphone dose conversion ratios to produce effects qualitatively similar to heroin.

RELATIONSHIP OF ASSESS SELF-ESTEEM AND LOCUS OF CONTROL WITH QUALITY OF LIFE DURING TREATMENT STAGES IN PATIENTS REFERRING TO DRUG ADDICTION REHABILITATION CENTERS

Objective:

Thus, the present research was carried out aimed at determining the relationship between self-esteem and locus of control and quality of life during treatment stages in the patients referring to drug addiction rehabilitation centers of Borujen city, Iran.

Methods:

The current study was a sectional research of descriptive correlation type. The research sample was 150 individuals of patients referring to addiction rehabilitation centers of Borujen city. For data gathering, Rosenberg Self-esteem Scale, Rotter’s Locus of Control Scale, and SF36 Quality of Life Questionnaire were used. Following collection of questionnaires, the data were analyzed using SPSS/16 software.

Results:

According to the results, in the 12^th day of treatment, 96 patients exhibited moderate self-esteem, 102 patients had internal locus of control, and the score of their overall quality of life was 40.43±12.71. Furthermore, Pearson’s correlation coefficient indicated that a significant and positive relationship was observed between locus of control and quality of life during different treatment stages.

Conclusion:

It seems that quality of life improves during addiction treatment stages due to improvement of personality traits including locus of control and self-esteem. Therefore, consultation methods as a very crucial priority in addiction rehabilitation centers shall be taken into account by the health sector authorities and managers and can play an essential role in enhancing quality of life.

Characterizing Long-Term Health Related Quality of Life Trajectories of Individuals With Opioid Use Disorder

OBJECTIVES

Health related quality of life (HRQoL) has been increasingly considered an endpoint in evaluations of treatment for substance use disorders. We aimed to characterize longitudinal patterns of HRQoL in individuals with opioid use disorder (OUD) and with a history of opioid agonist treatment (OAT) with methadone.

METHODS

The EuroQol EQ-5D, a preference-weighted measure of HRQoL, was assessed in individuals with OUD and with a history of OAT enrolled in three prospective cohort studies between December 2011 and May 2014, with a maximum of five biannual assessments. We used latent class growth analysis to identify HRQoL trajectory classes and their association with self-reported current OAT receipt. Class assignment was derived from posterior probabilities and we explored time-invariant and time-varying determinants of trajectory class membership.

RESULTS

Our study included 443 individuals (median age 47, 37% female); 24.6% reported use of illicit opioids at every follow-up, 69.1% during at least one follow-up. We identified three latent HRQoL trajectory classes that were stable regardless of current OAT receipt: stably high (n=107, 24.2%), stably moderate (n=260, 58.7%) and stably low HRQoL (n=76, 17.2%). A history of either a physical disability or of a mental health illness increased the probability of membership assignment to a lower HRQoL class.

CONCLUSIONS

The non-significant association of OAT with HRQoL may suggest that the modest immediate HRQoL gains after OAT engagement, observed in short-term studies, may not persist over time. Implications for cost-effectiveness analysis and clinical practice are discussed.

Short term health-related quality of life improvement during opioid agonist treatment

BACKGROUND

Opioid dependence is associated with high levels of morbidity, yet sparse data exists regarding the health-related quality of life (HRQoL) of individuals with opioid dependence, particularly following treatment initiation. To inform cost-effectiveness analyses of treatment modalities, this study investigates short-term changes in HRQoL following enrollment into opioid agonist treatment (OAT), across treatment modalities and patient subgroups.

METHODS

Data was analyzed from the Starting Treatment with Agonist Replacement Therapies (START) and Prescription Opioid Addiction Treatment Studies (POATS) randomized controlled trials. Participants included individuals dependent on prescription opioids (POs) or heroin, receiving limited-term or time-unlimited treatment. PO- or heroin-users in START received buprenorphine/naloxone (BUP/NX) or methadone (MET) over 24 weeks. PO-users in POATS received psychosocial care and short-term (4-week) taper with BUP/NX, with non-responders offered subsequent extended (12-week) stabilization and taper. HRQoL was assessed using the short-form SF-6D while in and out of OAT, with distinction between MMT and BUP/NX in START. Linear mixed effects regression models were fitted to determine the independent effects of OAT on HRQoL and characterize HRQoL trajectories.

RESULTS

Treatment had a similar immediate and modest positive association with HRQoL in each patient subgroup. The association of OAT on HRQoL was statistically significant in each model, with effect sizes between 0.039 (heroin-users receiving BUP/NX) and 0.071 (PO-users receiving MET). After initial improvement, HRQoL decreased slightly, or increased at a diminished rate.

CONCLUSIONS

OAT, whether delivered in time-limited or unlimited form, using BUP/NX or MET, is associated with modest immediate HRQoL improvements, with diminishing benefits thereafter.

Quality of Life in Methadone Maintenance Treated Patients in Iran

BACKGROUND

Measurement of life quality as an index of health status has a widespread application in health care domain.

OBJECTIVES

The current study aimed to determine the quality of life of referents to addiction cessation centers of Iran.

PATIENTS AND METHODS

In this cross-sectional study, 988 addicts who had referred to addiction cessation centers in Shahroud were studied through SF-36 questionnaire. The data were analyzed using linear regression in structural equation modeling and STATA 12 statistical software.

RESULTS

The mean ± SD age of the participants was 41.2 ± 11.8 years. Most of the referents used smoking followed by eating method of opium abuse. The mean ± SD score of life quality was 67.8 ± 17.2, the mean ± SD score of life quality in physical health dimension was 76.9 ± 26.7, and the mean ± SD score in mental health dimension was 64.5 ± 18.4. Univariate analysis showed a significant relationship between life quality and gender, place of residence, education, occupation, marital status, and income (P ≤ 0.05). However, in multivariate analysis a significant relationship was observed only between gender, socioeconomic status, and quality of life score.

CONCLUSIONS

Although most studies have reported low and weak quality of life in addicts, the findings of this study shows that the life quality score of addicts is rather good. It seems that the maintenance treatment that addicts receive in addiction cessation centers has been effective in improving the quality of life of the patients. Hence, expanding methadone treatment centers can play a leading role in the improvement of life quality in addicts.

Heroin on trial: systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction†

BACKGROUND

Supervised injectable heroin (SIH) treatment has emerged over the past 15 years as an intensive treatment for entrenched heroin users who have not responded to standard treatments such as oral methadone maintenance treatment (MMT) or residential rehabilitation.

AIMS

To synthesise published findings for treatment with SIH for refractory heroin-dependence through systematic review and meta-analysis, and to examine the political and scientific response to these findings.

METHOD

Randomised controlled trials (RCTs) of SIH treatment were identified through database searching, and random effects pooled efficacy was estimated for SIH treatment. Methodological quality was assessed according to criteria set out by the Cochrane Collaboration.

RESULTS

Six RCTs met the inclusion criteria for analysis. Across the trials, SIH treatment improved treatment outcome, i.e. greater reduction in the use of illicit 'street' heroin in patients receiving SIH treatment compared with control groups (most often receiving MMT).

CONCLUSIONS

SIH is found to be an effective way of treating heroin dependence refractory to standard treatment. SIH may be less safe than MMT and therefore requires more clinical attention to manage greater safety issues. This intensive intervention is for a patient population previously considered unresponsive to treatment. Inclusion of this low-volume, high-intensity treatment can now improve the impact of comprehensive healthcare provision.

Drug use, health and social outcomes of hard-to-treat heroin addicts receiving supervised injectable opiate treatment: secondary outcomes from the Randomized Injectable Opioid Treatment Trial (RIOTT)

AIMS

The Randomized Injectable Opioid Treatment Trial (RIOTT) compared supervised injectable heroin (SIH) and supervised injectable methadone (SIM) with optimized oral methadone (OOM) (ISRCTN0133807). Heroin addicts (previously unresponsive to treatment) made significant reductions in street heroin use at 6 months when treated with SIH. We now examine secondary outcomes.

DESIGN

Multi-site randomized controlled trial (RCT) comparing SIH versus OOM and SIM versus OOM.

SETTING

Three supervised injectable opiate clinics in England.

PARTICIPANTS

Chronic refractory heroin addicts continuing to inject street heroin virtually daily despite oral substitution treatment (n = 127), randomized to either SIH(n = 43), SIM(n = 42) or OOM(n = 42). All received high levels of medical and psychosocial support.

SECONDARY OUTCOMES

wider drug use, crime, health and social functioning at 6 months.

FINDINGS

At 6 months, no significant differences were found between treatment groups in wider drug use (crack/cocaine, benzodiazepines, alcohol), physical and mental health (SF-36) or social functioning. Within each treatment group, significant reductions were observed in crime [SIH = odds ratio (OR) 0.05; P < 0.001; SIM = OR 0.11; P = 0.002; OOM = OR 0.11; P = 0.003] and money spent per week on illicit drugs (SIH = mean change £-289.43; P < 0.001; SIM = mean change £-183.41; P < 0.001; OOM = mean change £-162.80; P < 0.001), with SIH significantly more likely to have reduced money spent on illicit drugs versus OOM (mean difference £-92.04; P < 0.001). Significant improvements were seen in physical health for SIH and SIM (SIH = mean change 3.97; P = 0.008; SIM = mean change 4.73; P = 0.002) and mental health for OOM (mean change 6.04; P = 0.013).

CONCLUSIONS

Supervised injectable heroin treatment and supervised injectable methadone treatment showed no clearly identified benefit over optimized oral methadone in terms of wider drug use, crime, physical and mental health within a 6-month period, despite reducing street heroin use to a greater extent. However, all interventions were associated with improvements in these outcomes.

The reductions in monetary cost and gains in productivity with methadone maintenance treatment: one year follow-up

While methadone maintenance treatment (MMT) is beneficial for heroin dependence, there is little information regarding the reductions in monetary cost and gains in productivity following MMT. The aim of this study was to evaluate the changes in the monetary cost of heroin addiction and productivity after one year of MMT. Twenty-nine participants from an MMT clinic were included. The monetary cost, productivity, quality of life (QOL) and mental health status were assessed at both baseline and one year follow-up. The average annual total cost was approximately US$26,485 (1.43 GDP per capita in 2010) at baseline, and decreased by 59.3% to US$10,784 (0.58 GDP) at follow-up. The mean number of months of unemployment dropped from 6.03 to 2.79, the mean income increased to exceed the basic salary, but only reached 45.3% of the national average monthly earnings. The participants׳ mental health improved, but their QOL scores did not increase significantly. After one year of MMT, the monetary cost of heroin addiction fell, both the productivity and mental health of the participants׳ improved, but limited gains were seen with regard to their QOL.

The relationship between recovery and health-related quality of life

Building upon recommendations to broaden the conceptualization of recovery and to assess its relationship with health-related quality of life (HRQoL), this study addressed three primary aims. These included: 1) testing the model fit of a hypothesized latent measure of recovery, 2) examining the extent to which this multidimensional measure of recovery was associated with concurrently measured HRQoL, and 3) examining the extent to which this multidimensional measure of recovery predicted changes in HRQoL during the subsequent year. Data were from 1,008 adults who completed follow-up assessments at 15 and 16 years post-intake. Confirmatory factor analysis indicated a good fit for a hypothesized recovery measure (CFI=.98; RMSEA=.06). Additionally, structural equation modeling suggested that this recovery measure was not only concurrently associated with HRQoL (β=.78, p<.001), but was also a significant predictor of changes in HRQoL during the subsequent year (β=.25, p<.001).

Accessibility versus quality of care plus retention: the formula for service delivery in Australian opioid replacement therapy?

The aim of this paper is to investigate how Australian Opioid Replacement Therapy (ORT) policy influences access to ORT treatment, including the resources required for implementation. In doing so, we also compare the accessibility of ORT treatment in Australia (AU) with ORT in the United Kingdom (UK) and United States (US). A review of government data and policy that influence service delivery was undertaken. When comparing across AU, the UK, and the US, we found several differences. To improve access to treatment in Australia more general practitioners need to provide ORT. Additionally, criteria for quality care, a centralised intake system, a national ORT treatment outcome measure, and a shift towards a recovery focus are recommended.

Impact of methadone maintenance on health utility, health care utilization and expenditure in drug users with HIV/AIDS

BACKGROUND

This study assessed the impact of methadone maintenance treatment (MMT) on health utility, health care service utilization, and out-of-pocket (OOP) health expenditure in drug users with HIV/AIDS in Vietnam.

METHODS

Using the 2012 Vietnam HIV Service Users Survey data, a post-evaluation was designed to compare 121 MMT patients with 347 non-MMT patients who were matched using propensity scores of MMT covariates. Health utility was measured using the EuroQOL - five dimensions - five levels (EQ-5D-5L) and a visual analogue scale (EQ-VAS).

RESULTS

The mean EQ-5D-5L single index and EQ-VAS score of MMT patients were 0.68 (95% CI=0.64-0.73) and 71.5% (95% CI=68.2-74.9). Compared with the control group, the adjusted differences in health utility were 0.08 and 4.43% (p=0.07), equivalent to 12.1% and 6.5% increases during MMT. There was a 45.9% decrease in the frequency of health care service utilization that was attributable to MMT. Although, antiretroviral treatment and MMT services were free-of-charge, MMT and non-MMT patients still paid their OOP for health care for averagely US$ 16.3/month and US$ 28.9/month. The adjusted difference between the two groups was US$ 19.3/month ($ 231.6/year) that equivalents to a reduction of 66.7% in OOP health expenditure related to MMT.

CONCLUSION

MMT was associated with a clinically important difference in health utility, large reductions in health care service utilization and OOP health expenditure in HIV-positive drug users. Scaling up MMT in large drug-using population could help improve the outcomes of HIV/AIDS interventions and reduce economic vulnerability of affected households.

Can heroin-dependent individuals benefit from a methadone maintenance treatment program before they drop out against medical advice? A 12-month follow-up study

AIM

Little is known about whether heroin-dependent individuals receiving methadone maintenance treatment (MMT) who were discharged involuntarily and against medical advice (DAMA) get benefits before they left. The aims of this 12-month follow-up study were to examine whether the effects of MMT on depressive symptoms, heroin dependence and quality of life (QOL) are different among the non-DAMA group, the DAMA group, and the involuntarily discharged group, as well as the time effect of receiving MMT on changes in these three outcome indicators.

METHOD

A total of 266 individuals receiving MMT were divided into the non-DAMA group, the DAMA group, and the involuntarily discharged group. Participants were interviewed at baseline and at 3, 6, 9, and 12 months of treatment for levels of depressive symptoms, heroin dependence and QOL.

RESULTS

The levels of depressive symptoms, heroin dependence and QOL in all three groups improved after receiving MMT for 3 months and the improvement was maintained during the MMT period. There were no significant differences in the three outcome indicators among the three groups.

CONCLUSION

The results support the concept that heroin-dependent individuals benefit from MMT, even if they do not want to stay in the program or drop out involuntarily.

Prospective patterns and correlates of quality of life among women in substance abuse treatment

BACKGROUND

Quality of life (QOL) is increasingly recognized as central to the broad construct of recovery in substance abuse services. QOL measures can supplement more objective symptom measures, identify specific service needs and document changes in functioning that are associated with substance use patterns. To date however, QOL remains an under investigated area in the addictions field, especially in the United States.

METHODS

This study examines patterns and predictors of QOL at 1 and 6 months post treatment intake among 240 women enrolled in substance abuse treatment in Cleveland, Ohio. The World Health Organization Quality of Life (WHOQOL-BREF) measure was used to assess physical, psychological, social and environmental domains. Hierarchical multiple regressions were conducted to identify correlates of QOL at 6 months post treatment intake.

RESULTS

All QOL domains across the follow up time points improved significantly. However, QOL scores across domains remained below those of healthy population norms. Trauma symptoms significantly predicted Physical and Psychological QOL. Among treatment process variables, alcohol use was the sole significant factor associated with QOL and only for Environmental QOL. Recovery support and friends support for abstinence were consistently associated with QOL across all four domains.

IMPLICATIONS

This study suggests the usefulness of the WHOQOL measure as an indicator of functioning in substance abusing populations. Findings underline the importance of helping women deal with trauma symptoms and develop support for recovery. Further research is needed on the longitudinal relationship between QOL and substance use patterns.

Exercise as an adjunct treatment for opiate agonist treatment: review of the current research and implementation strategies

Opiate dependence is a significant public health concern linked to poor quality of life, comorbid psychiatric disorders, and high costs to society. Current opiate agonist treatments are an effective but limited intervention. Adjunctive interventions could improve and augment opiate agonist treatment outcomes, including drug abstinence, quality of life, and physical health. This article reviews exercise as an adjunctive intervention for opiate agonist treatment, especially in regards to improving mood and overall quality of life, while reducing other substance use. Poor adherence and dropout frequently prevent many individuals from garnering the many physical and mental health benefits of exercise. Strategies for implementing an exercise intervention, including safety considerations, are discussed.

Attitudes toward opioid substitution therapy and pre-incarceration HIV transmission behaviors among HIV-infected prisoners in Malaysia: implications for secondary prevention

BACKGROUND

Pre-incarceration HIV transmission behaviors and current attitudes toward opioid substitution therapy (OST) among HIV-infected male prisoners in Malaysia have important implications for secondary HIV prevention efforts.

METHODS

In June 2007, 102 HIV-infected male prisoners within 6 months of community-release were anonymously surveyed in Kota Bharu, Malaysia.

RESULTS

Nearly all subjects (95%) met criteria for opioid dependence. Overall, 66% of participants reported sharing needles, and 37% reported unprotected sex in the 30 days prior to incarceration. During this period, 77% reported injection drug use, with 71% injecting daily and 65% injecting more than one substance. Injection of buprenorphine (28%), benzodiazepines (28%) and methamphetamines (49%) was reported. Nearly all (97%) of those reporting unprotected sex did so with someone not known to be HIV-infected. While 51% believed that opioid substitution therapy (OST) would be helpful, only 33% believed they needed it to prevent relapse after prison release. Most participants (70%) expressed interest in learning more about OST. Those reporting the highest injection risks were more likely to believe OST would be helpful (p<0.05), to believe that it was needed to prevent relapse post-release (p<0.05), and to express interest in learning more about OST (p<0.01).

CONCLUSIONS

Secondary HIV prevention among prisoners in Malaysia is crucial to reduce community HIV transmission after release. Effectively reducing HIV risk associated with opioid injection will require OST expansion, including social marketing to improve its acceptability and careful monitoring. Access to sterile injection equipment, particularly for non-opioid injectors, and behavioral interventions that reduce sexual risk will also be required.

Clinical characteristics and risk behavior as a function of HIV status among heroin users enrolled in methadone treatment in northern Taiwan

Background

Methadone treatment was introduced in Taiwan in 2006 as a harm-reduction program in response to the human immunodeficiency virus (HIV), which is endemic among Taiwanese heroin users. The present study was aimed at examining the clinical and behavioral characteristics of methadone patients in northern Taiwan according to their HIV status.

Methods

The study was conducted at four methadone clinics. Participants were patients who had undergone methadone treatment at the clinics and who voluntarily signed a consent form. Between August and November 2008, each participant completed a face-to-face interview that included questions on demographics, risk behavior, quality of life, and psychiatric symptoms. Data on HIV and hepatitis C virus (HCV) infections, methadone dosage, and morphine in the urine were retrieved from patient files on the clinical premises, with permission of the participants.

Results

Of 576 participants, 71 were HIV positive, and 514 had hepatitis C. There were significant differences between the HIV-positive and HIV-negative groups on source of treatment payment, HCV infection, urine test results, methadone dosage, and treatment duration. The results indicate that HIV-negative heroin users were more likely to have sexual intercourse and not use condoms during the 6 months prior to the study. A substantial percent of the sample reported anxiety (21.0%), depression (27.2%), memory loss (32.7%), attempted suicide (32.7%), and administration of psychiatric medications (16.1%). There were no significant differences between the HIV-positive and HIV-negative patients on psychiatric symptoms or quality of life.

Conclusions

HIV-positive IDUs were comorbid with HCV, indicating the need to refer both HIV- and HCV-infected individuals for treatment in methadone clinics. Currently, there is a gap between psychiatric/psychosocial services and patient symptoms, and more integrated medical services should be provided to heroin-using populations.