The impact of benzodiazepine use on methadone maintenance treatment outcomes

Clinical Outcomes of Benzodiazepine Prescribing for People Receiving Opioid Agonist Treatment: A Systematic Review of the Evidence

Many countries are experiencing an increased use of unregulated benzodiazepines in combination with opioids and other drugs, which contributes to drug-related harm. This descriptive review identifies and synthesises the outcomes of studies co-prescribing benzodiazepines and opioids. A systematic review was undertaken in Medline, CINAHL, PsychInfo, Embase, and the Cochrane databases covering publications from 1 January 1991 to 18 November 2021. Inclusion criteria were peer reviewed, English language studies of adults prescribed opioid agonist treatment (OAT) and a concurrent benzodiazepine, and reporting outcome data. Of the 4370 titles screened, 18 papers were included. The main outcomes identified covered all-cause mortality (ACM) (n = 5); overdose death (n = 3); retention in treatment (n = 7); and hospitalisation/emergency department encounters (n = 2). Other outcomes included QTc interval, cognitive function, illicit drug use, and mental health. The prescription of benzodiazepines alongside OAT increased the ACM by 75-90%, while evidence on overdose death was less robust but indicative of increased risk (40-334%). There was an indicative positive effect on treatment retention, with increased retention in those prescribed a benzodiazepine with OAT compared to those not prescribed or taking non-prescribed benzodiazepines. In conclusion, methodologically robust epidemiological studies found increased ACM and overdose death but possibly improved retention. However confounders (e.g., psychiatric comorbidity) exist, so a trial is recommended.

Association between benzodiazepine coprescription and mortality in people on opioid replacement therapy: a population-based cohort study

OBJECTIVE

To investigate the association between opioid replacement therapy (ORT) and benzodiazepine (BZD) coprescription and all-cause mortality compared with the prescription of ORT alone.

DESIGN

Population-based cohort study.

SETTING

Scotland, UK.

PARTICIPANTS

Participants were people prescribed ORT between January 2010 and end of December 2020 aged 18 years or above.

MAIN OUTCOME MEASURES

All-cause mortality, drug-related deaths and non-drug related deaths.

SECONDARY OUTCOME

ORT continuous treatment duration.

ANALYSIS

Cox regression with time-varying covariates.

RESULTS

During follow-up, 5776 of 46 899 participants died: 1398 while on coprescription and 4378 while on ORT only. The mortality per 100 person years was 3.11 during coprescription and 2.34 on ORT only. The adjusted HR for all-cause mortality was 1.17 (1.10 to 1.24). The adjusted HR for drug-related death was 1.14 (95% CI, 1.04 to 1.24) and the hazard for death not classified as drug-related was 1.19 (95% CI, 1.09 to 1.30).

CONCLUSION

Coprescription of BZDs in ORT was associated with an increased risk of all-cause mortality, although with a small effect size than the international literature. Coprescribing was also associated with longer retention in treatment. Risk from BZD coprescription needs to be balanced against the risk from illicit BZDs and unplanned treatment discontinuation. A randomised controlled trial is urgently needed to provide a clear clinical direction.

TRIAL REGISTRATION NUMBER

NCT04622995.

Effects of a Two-Month Exercise Training Program on Concurrent Non-Opiate Substance Use in Opioid-Dependent Patients during Substitution Treatment

BACKGROUND

This randomized controlled trial aimed to evaluate the effects of a two-month exercise intervention on the concurrent non-opiate substance use (alcohol, cocaine, cannabis, and benzodiazepines) in opioid users during their medication treatment.

METHODS

Ninety opioid users (41 females) in methadone and buprenorphine medication treatment were randomly divided into four groups: (a) buprenorphine experimental (BEX; n = 26, aged 41.9 ± 6.1 yrs); (b) buprenorphine control (BCON; n = 25, aged 41.9 ± 5.6 yrs); (c) methadone experimental (MEX; n = 20, aged 46.7 ± 6.6 yrs); and (d) methadone control (MCON; n = 19, aged 46.1 ± 7.5 yrs). The experimental groups (BEX and MEX) followed an aerobic exercise training program on a treadmill for 20 min at 70% HRmax, 3 days/week for 8 weeks. Socio-demographic, anthropometric, and clinical characteristics, as well as non-opioid drug use in days and quantity per week, were assessed before and after the intervention period.

RESULTS

Following the exercise training, the weekly non-opioid substance consumption (days) decreased (p < 0.05) in both exercise groups and was lower in BEX compared to MEX, while no differences were observed (p > 0.05) between the control groups (BCON vs. MCON) or compared to their baseline levels. Similarly, the daily amount of non-opiate substance intake was reduced (p < 0.05) post-training in BEX and MEX, whereas it did not differ (p > 0.05) in BCON and MCON compared to the baseline.

CONCLUSIONS

The two-month exercise intervention reduced the non-opioid drug use in both the methadone and buprenorphine substitution groups compared to the controls, suggesting that aerobic exercise training may be an effective strategy for treating patients with OUDs.

Association of random and observed urine drug screening with long-term retention in opioid treatment programs

BACKGROUND

In the US, opioid treatment providers (OTPs) have wide latitude to perform urine drug screening (UDS) and discharge clients for positive results. OTP clients have identified randomized and directly observed UDS as potentially stigmatizing, but little research has examined the association between UDS modality and retention in OTPs.

METHODS

This cross-sectional study uses the 2016-2017 NDATSS wave among OTPs that administered methadone. The exposure was a 4-level variable based on whether OTPs had a high percentage (≥ 90% of clients) who experienced randomized, observed, both, or neither modality of UDS. The outcome was the proportion of clients retained in treatment 1 year or longer (long-term retention). Analyses were conducted using fractional logit regression with survey weighting and presented as percentages and 95% confidence intervals. We also present how policies for involuntary clinic discharge modify these effects.

RESULTS

150 OTPs were eligible with a median of 310 clients. 40 (27%) OTPs did not highly utilize either randomized or observed UDS, 22 (15%) only highly utilized observed UDS, 42 (28%) only highly utilized randomized UDS and 46 (31%) utilized both practices on ≥ 90% of clients. Adjusted estimates for long-term retention ranged from 57.7% in OTPs that conducted both randomized and observed UDS on ≥ 90% of clients and 70.4% in OTPs that did not highly utilize these practices. Involuntary discharge may moderate this relationship.

CONCLUSION

Findings showed an association between high utilization of randomized and observed UDS and decreased long-term retention, suggesting that UDS modality may impact long-term OTP retention.

Risks of returning to opioid use at treatment entry and early in opioid use disorder treatment: Role of non-opioid substances

OBJECTIVE

Patients in treatment with medications for opioid use disorder (MOUD) often report use of other substances in addition to opioids. Few studies exist that examine the relationship between use at treatment entry and early non-opioid use in opioid treatment outcome.

METHODOLOGY

We combined and harmonized three randomized, controlled MOUD clinical trials from the National Institutes of Drug Abuse (NIDA) Clinical Trials Network (CTN) (N=2197) and investigated the association of non-opioid substance use at treatment entry and during early treatment with a return to opioid use. The trials compared MOUD treatment (buprenorphine, methadone, extended-release naltrexone) in populations with opioid use disorder (OUD). Non-opioid substances were identified through harmonizing self-reported use. The primary outcomes were markers of return to opioid use by 12 weeks.

RESULTS

When treatment cohorts were adjusted, no association between self-reported treatment entry use of non-opioid substances and week-12 opioid use was detected. During the first month of treatment, higher use of cocaine (OR 1.41 [1.18-1.69]) and amphetamine (OR 1.70 [1.27-2.26]) was found to be associated with higher likelihood of illicit opioid use by week 12. Exploratory analyses of potential treatment cohort-by-predictor interactions showed that those with heavier cocaine use had a lower rate of returning to opioid use in the extended-release naltrexone group than in the methadone group.

CONCLUSION

Substance use other than opioids at treatment entry is not associated with relapse. Use of cocaine or amphetamines during the first few weeks of MOUD treatment may signal a worse outcome, suggesting a need for additional interventions.

Understanding polysubstance use at the daily and event levels: protocol for a mixed-methods qualitative and ecological momentary assessment study in a community-based sample of people who use illicit drugs in Oakland, California, USA

INTRODUCTION

Polysubstance use is extremely common among people who use illicit opioids in the USA. It is associated with poor substance use treatment outcomes, infectious disease risk and alarming rates of drug overdose. Nearly all extant literature examines polysubstance use over broad time frames, such as 30 days or 6 months. However, both substance use and overdose risk are episodic. To build a stronger understanding of polysubstance use and overdose risk, we need to expand the knowledge base to include daily-level and event-level data that examine how substances are used together, in which combinations and in which contexts. The study described in this protocol will use qualitative and ecological momentary assessment (EMA) methods to examine polysubstance use and overdose risk on a daily and event level.

METHODS AND ANALYSIS

This is a mixed-methods observational study with three phases. The first phase is formative, consisting of qualitative interviews with people who use multiple substances (N=20), to inform the development of items for the EMA component. The second phase is EMA data collection with people who use multiple substances (N=120), three times daily for 28 days. The third phase consists of mixed-methods inquiries with a subset of participants (N=20), using participant-level EMA data and qualitative techniques to build a nuanced understanding of the motivations and contexts of polysubstance use in everyday life. Analytical induction methods will be used to interpret qualitative data. Hierarchical linear modelling methods will be used to analyse EMA data.

ETHICS AND DISSEMINATION

This research has been reviewed and approved by the Institutional Review Board at RTI International (#MOD00001782 for EMA procedures and #MOD00001241 for qualitative procedures). Participants engage in an informed consent procedure for each component of the study. Data will be managed and shared per the National Institutes of Health extramural data sharing policy.

New Perspective for Drug-Drug Interaction in Perioperative Period

In this review, we aim to discuss current information on drug interactions in the perioperative period. During this period, patients receive several drugs that may interact with each other and affect the efficacy and safety of the treatment. There are three types of drug interactions: pharmacodynamic, pharmacokinetic, and pharmaceutical. It is important to recognize that drug interactions may increase the toxicity of the drug or reduce its efficacy, increasing the risk of complications in the perioperative period. This review describes the most commonly used perioperative drugs approved by the FDA and some of the described interactions between them. Thoroughly reviewing a patient's medication list and identifying potential interactions are essential steps in minimizing risks. Additionally, vigilant monitoring of patients during and after surgery plays a pivotal role in early detection of any signs of drug interactions. This article emphasizes the significance of addressing DDIs in the perioperative period to ensure patient well-being and advocates for the implementation of careful monitoring protocols to promptly identify and manage potential interactions.

Benzodiazepine use, quality of life and psychiatric symptom burden in oral and injectable opioid agonist treatment: a cross-sectional study

BACKGROUND

Use of benzodiazepines (BZD) in patients receiving opioid agonist treatment (OAT) is common and associated with a variety of negative health and social outcomes. This cross-sectional study investigates the impact of BZD use in OAT patients on their quality of life (QoL).

METHODS

A convenience sample of patients receiving oral OAT or heroin-assisted treatment in two outpatient centres in Basel, Switzerland was investigated. Participants (n = 141) completed self-report questionnaires on psychiatric symptoms and psychological distress (The Symptom Checklist 27, SCL-27), depressive state (German version of the Center for Epidemiological Studies Depression Scale), quality of life (Lancashire Quality of Life Profile, LQOLP) and use of BZD and other drugs (self-report questionnaire). Substance use was assessed by urine toxicology testing.

RESULTS

In bivariate analysis, total QoL scores were significantly lower for lifetime, current, and prolonged BZD users compared to participants without the respective use patterns. There was no significant relationship between BZD dose and QoL. In multivariable linear regression models controlling for psychiatric symptom load and depressive state, only lifetime use predicted lower QoL, whereas other BZD use patterns were not significantly associated.

CONCLUSIONS

The association of lower QoL and BZD use in OAT patients is strongly confounded by co-occurring depressive state and psychiatric symptoms. Careful diagnosis and treatment of co-occurring mental disorders in OAT is paramount to improve QoL in this patient population and may also help reduce BZD use.

Co-use of Opioid Medications and Alcohol Prevention Study (COAPS)

While there is limited research in the field regarding the various dimensions of co-use of alcohol and opioid medication, particularly related to co-use and levels of severity, our research has shown 20% to 30% of community pharmacy patients receiving opioid pain medications are engaged in co-use. Co-use of alcohol and opioid medications is a significant risk factor for opioid-related overdose. Community pharmacy is a valuable yet underutilized resource and setting for addressing the US opioid epidemic, with an untapped potential for identification of and intervention for risks associated with co-use of alcohol and opioids. This commentary describing the "Co-use of Opioid Medications and Alcohol Prevention Study (COAPS)" offers an innovative and promising approach to mitigating serious risks associated with co-use of alcohol (risk and non-risk use) and opioids in community pharmacy. COAPS aim 1involves adapting an existing opioid misuse intervention to target co-use of alcohol and opioid mediations. COAPS aim 2 involves testing the adapted intervention within a small-scale pilot randomized controlled trial (N = 40) to examine feasibility, acceptability and preliminary efficacy of the intervention versus standard care. COAPS aim 3 involves conducting key informant interviews related to future implementation of larger scale studies or service delivery in community pharmacy settings.

Drug prescriptions preceding opioid-related deaths-a register study in forensic autopsy patients

BACKGROUND/AIM

Opioid overdose deaths have increased in Sweden and other developed countries in recent decades, despite increased treatment efforts and harm-reduction interventions. Further knowledge in this field is needed if this trend is to be reversed. Previous research suggests that mental health and patterns of prescription of opioids and other prescription drugs are associated with increased opioid-related mortality. The present study therefore aimed to investigate what drugs were prescribed during the last six months of life to individuals with a history of illicit substance use who died with opioids present in their blood, the relationship between drugs prescribed and drugs found in blood at time of death, and if prescription of specific drugs was temporally associated with death.

METHODS

This was a retrospective, register-based observational study that utilized data from the National Board of Forensic Medicine, the Prescribed Drug Registry, regional health care services, and municipal social services. We used conditional logistic regression to find temporal associations between the prescription and dispensing of drugs and time of death.

RESULTS

Prescription and dispensing of alprazolam and diazepam were temporally associated with death. The most frequently dispensed drugs were zopiclone, pregabalin, methylphenidate, diazepam and oxycodone. Methadone, alprazolam, and buprenorphine were the drugs most often found in the blood. Opioids and tranquilizers in combination were found in a vast majority of deaths, and prescription data suggested that the use of these drugs was illicit in a majority of cases.

CONCLUSION

Prescription of certain drugs, especially alprazolam and diazepam, should be made with great caution to patients with a history of illicit substance use or concurrent use of opioids.

Assessing Motivations for Nonprescribed Buprenorphine Use Among Rural Appalachian Substance Users

OBJECTIVE

Buprenorphine (Suboxone) is an effective treatment for opioid use disorder (OUD). However, there have been widespread reports of diversion and misuse. This study examined motivations for nonprescribed buprenorphine use among rural residents.

METHODS

Eligible participants (N = 200) were at least 18 years old, had used any illegal or prescription drugs to get high, and had ever used nonprescribed buprenorphine. A questionnaire administered by a trained interviewer assessed demographic characteristics, substance use, and motivations for use.

RESULTS

Primary motivations for first nonprescribed buprenorphine use included avoiding withdrawal and getting high, while at most recent nonprescribed use, motivations shifted toward maintaining abstinence from other drugs. In adjusted logistic regression analyses, past month use of stimulants decreased odds of nonprescribed buprenorphine use for the purposes of self-treatment by 68% (adjusted odds ratio, 0.26; 95% confidence interval, 0.11-0.61), whereas history of treatment for OUD more than doubled odds of use for self-treatment (adjusted odds ratio, 2.71; 95% confidence interval, 1.11-6.63).

CONCLUSIONS

Results indicate that many individuals used buprenorphine without a prescription, motivated largely by behaviors consistent with self-treatment, and diversion of buprenorphine may be driven by these motivations more than desire to get high. While many participants attempted to access treatment, many were still using nonprescribed buprenorphine for self-treatment, and many were dissatisfied with care they had received as part of a treatment program. Thus, increasing quantity of providers may not be adequate to address the opioid epidemic, but particular attention should be paid to providing care targeted to the needs of those with OUD in rural areas.

The impact of benzodiazepine exposure on treatment retention in an open-access methadone program: A retrospective cohort study

BACKGROUND

Open-access opioid treatment programs (OTP) offer same-day access to methadone without an appointment and aim to minimize treatment barriers that often reduce admission and/or retention. We explored whether patients with benzodiazepine exposure at treatment entry would have similar 12-month retention compared to those without benzodiazepine exposure.

METHODS

We conducted a retrospective cohort study of 2968 patients consecutively initiated on methadone between January 2015 and February 2017 at an open-access OTP. The sample was stratified into benzodiazepine-exposed and nonexposed groups based on intake urine toxicology. Group comparison of 12-month retention was conducted. Kaplan Meier analysis compared time to methadone treatment discontinuation between groups with a log-rank test. Multivariable Cox regression was performed to compare retention by baseline benzodiazepine exposure with adjustment for confounders.

RESULTS

Overall, 31% of patients with benzodiazepine exposure (n = 171) and 31% without exposure (n = 2423) were retained at 12 months (p = 0.95). Median treatment duration was 182 days (95% CI, 152-239) and 175 days (95% CI, 156-196) for patients with and without benzodiazepine exposure, respectively. Kaplan-Meier analysis showed no significant difference in treatment duration between groups (log-rank test p = 0.73). Cox regression found no difference in treatment retention between groups (adjusted Hazard Ratio= 1.03, 95% CI, 0.91-1.16).

CONCLUSIONS

In this cohort of patients receiving methadone at an open-access OTP, benzodiazepine exposure at intake was not observed to impact 12-month treatment retention or duration. These findings support U.S. Food and Drug Administration (FDA) recommendations to not withhold medications for opioid use disorder from patients taking benzodiazepines.

Self-Administration of Fentanyl-Alprazolam Combinations by Rhesus Monkeys Responding under a Progressive-Ratio Schedule

This study evaluated the reinforcing effects of fentanyl, alone or in combination with the benzodiazepine alprazolam, in rhesus monkeys (3 females, 3 males). Subjects were trained to self-administer the opioid remifentanil (0.3 µg/kg/injection) under a progressive-ratio schedule of reinforcement. The reinforcing effects of fentanyl (0.1-10 µg/kg/injection) or alprazolam (1.0-100 µg/kg/injection) alone, or in combinations of fixed proportions (1:1, 1:3, and 3:1 fentanyl:alprazolam, with 1:1 based on the potencies of drugs alone) were evaluated in single-day test sessions (with double determinations). Dose-equivalence analysis was used to determine the extent to which fentanyl and alprazolam combinations differed from additivity. Fentanyl functioned as a positive reinforcer in all monkeys, while alprazolam was a reinforcer in 3 of 6 monkeys only. Therefore, drug combination data were grouped as "alprazolam-taking" and "non-alprazolam-taking" monkeys. For alprazolam-taking monkeys, we observed additive effects for the 3:1 and 1:3 combinations, and a significant supra-additive interaction for the 1:1 combination of fentanyl and alprazolam. For 2 of the 3 non-alprazolam-taking monkeys, the combination of fentanyl and alprazolam resulted in enhanced reinforcing effects relative to either drug alone. However, the one monkey showed primarily inhibitory, or suppressive effects, with the 3:1 dose combination resulting in a relatively modest rightward shift in the fentanyl dose-response function. In summary, our findings show that combining fentanyl and alprazolam generally result in proportion-dependent additive or supra-additive enhancements. These data raise the possibility that the prevalence of opioid-benzodiazepine polydrug abuse may reflect a unique enhancement of these drugs' reinforcing effects, although individual differences may exist. SIGNIFICANCE STATEMENT: Addressing the critical question of the degree to which benzodiazepines can modulate the abuse-related effects of opioids may provide improved pathways to treatment of this common form of polydrug addiction. In the present study, we show that combinations of the opioid fentanyl and the benzodiazepine alprazolam can be more reinforcing than either drug alone in a rhesus monkey model, suggesting that enhancement of reinforcement processes may underlie this prevalent form of polydrug use disorder.

Evaluating the association between urine drug screening frequency and retention in opioid agonist treatment in Ontario, Canada: a retrospective cohort study

OBJECTIVE

The objective of this study was to evaluate how urine drug screening (UDS) frequency is associated with retention in opioid agonist treatment (OAT).

METHODS

Data for this retrospective cohort study of 55 921 adults in OAT in Ontario, Canada, were derived from administrative sources between 1 January 2011 and 31 December 2015. All patient information was linked anonymously across databases using encrypted health card numbers. Descriptive statistics were calculated for comparing UDS frequency groups using standardised differences (d) where d less than 10% indicated a statistically significant difference. A logistic regression model was then used to calculate ORs adjusting for baseline covariates, including sex, age, location of residence, income quintile, mental disorders, HIV status and deep tissue infections.

RESULTS

Over 70% of the cohort had four or more UDS tests per month (weekly or more UDS). Significant associations were observed between UDS frequency and 1-year treatment retention in OAT biweekly (adjusted OR (aOR)=3.20, 95% CI 2.75 to 3.75); weekly UDS (aOR=6.86, 95% CI 5.88 to 8.00) and more than weekly (aOR=8.03, 95% CI 6.87 to 9.38) using the monthly or less groups as the reference.

CONCLUSION

This study identified an association between weekly UDS and 1-year treatment retention in OAT. There is an active discussion within Canada about the utility of UDS. The lack of evidence for the impact of UDS on retention has left it open to some to argue they simply provide a barrier to patient engagement. Therefore, it is timely of this study to demonstrate that more frequent urine testing is not associated with a reduction in treatment retention.

A transition of power in opioid substitution treatment: Clinic managers' views on the consequences of a patient choice reform

Objectives: Opioid substitution treatment (OST) is often described as a strict and highly regulated treatment method, in which patients have limited influence over their treatment. In 2014, a reform was introduced by the regional council of Skåne in southern Sweden, which allowed OST patients to choose their treatment provider, thus transferring power from care providers to patients. The aim of this study was to examine what this increase in patient influence has meant for the clinics that provide OST in Skåne, and how these clinics have dealt with the new competitive situation that has arisen following the introduction of the reform. Methods: The study is based on two waves of semi-structured interviews with clinic managers at all OST clinics in Skåne. Results: The clinic managers described the increase in patient influence as a positive change, which had led to the patients being treated with more respect. The competition among clinics was expressed, among other things, in the form of differing views on the prescription of benzodiazepines, which initially gave rise to dissatisfaction among clinics with a more restrictive approach to such prescriptions. The reform did not lead to any clear diversity between clinics, apart from different approaches to the prescription of benzodiazepines. The incentive for competition-based diversity is, however, limited by the strict national regulatory system and by the reimbursement system, which restricts the ways in which clinics can conduct treatment activities. Conclusion: OST-clinic managers were largely positive about the increased patient empowerment and the shift in power balance associated with the patient choice reform. The introduction of the reform did not lead to any clear diversity between treatment providers, apart from differing views on the prescription of benzodiazepines, which by some managers was regarded as unfair competition.

Risky alcohol use among patients dispensed opioid medications: A clinical community pharmacy study

BACKGROUND

Included among the significant risk factors for opioid overdose is concomitant use of other central nervous system depressants, particularly alcohol. Given the continued expansion of community pharmacy in the continuum of care, it is imperative to characterize alcohol use among pharmacy patients dispensed opioids in order to establish a foundation for identification and intervention in these settings.

METHODS

This secondary analysis utilized data from a one-time, cross-sectional health assessment conducted among patients dispensed opioid medications in 19 community pharmacies in Indiana and Ohio. Adult, English speaking, patients not receiving cancer care who were dispensed opioid medications were asked to self-report alcohol and substance use, behavioral and physical health, and demographic information. Descriptive and logistic regression analyses were employed to characterize alcohol use/risky alcohol use and patient characteristics associated therewith.

RESULTS

The analytical sample included 1494 individuals. Participants were on average 49 years of age (Standard Deviation=14.9)-with 6% being persons of color (n = 89). Weekly drinking was reported by 18.1% (n = 204) and daily drinking was reported by 6.8% (n = 77) of the study sample, with a total of 143 (9.6%) participants reporting moderate/high risk drinking. Males (Adjusted Odds Ratio [AOR]=1.94, 95% CI=1.3,2.9), those with higher pain interference (AOR=1.44, 95% CI=1.0,2.0), overdose history (AOR=1.93, 95% CI=1.1,3.5), sedative use (AOR=2.11, 95% CI=1.3,3.5), and tobacco use (AOR=2.41, 95% CI=1.6,3.7) had increased likelihood of moderate/high risk alcohol use (all p < 0.05).

CONCLUSIONS

Medication labeling and clinical guidelines clearly indicate that patients should abstain from concomitant use of opioids and alcohol. This study has identified rates and associated risk factors of risky alcohol use among a clinical sample of community pharmacy patients dispensed opioid medications. Continuing this line of research and potential clinical service development has the ability to improve patient safety through addressing a significant gap within the current opioid epidemic.

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.

Polysubstance Overdose Deaths in the Fentanyl Era: A Latent Class Analysis

OBJECTIVES

To elucidate the main latent classes of substances detected among overdose decedents, and latent class associations with age, sex, race, and jurisdiction of death in Maryland.

METHODS

We used toxicology data from the Office of the Chief Medical Examiner of Maryland for all decedents. We analyzed all cases of drug overdose deaths that occurred from 2016 to 2018 (N = 6566) using latent class analysis and regression.

RESULTS

Drug overdose deaths were concentrated in 2 of 24 counties in Maryland (Baltimore City and County). Fentanyl was involved in 71% of all drug overdose deaths, and the majority (76%) of these deaths included multiple substances. Three latent classes emerged: (1) fentanyl/heroin/cocaine (64%); (2) fentanyl/alcohol (18%); and (3) prescription drugs including opioids, benzodiazepines and antidepressants (18.0%). The fentanyl/heroin/cocaine class members were significantly younger (<30 years), female and White compared to the fentanyl/alcohol class, but more male and non-White than the prescription drugs class (all P < 0.05). Deaths in Baltimore City/County were more likely than in other locations to involve fentanyl/alcohol (P < 0.05).

CONCLUSIONS

The majority of fentanyl-involved overdose deaths in Maryland involved multiple substances, and several demographic and geographic differences in these patterns emerged. Geographically-targeted interventions that are tailored to reduce the harms associated with polysubstance use (including cocaine, alcohol, and prescription drugs) for different demographic groups are warranted.

Drug addiction: from bench to bedside

Drug addiction is responsible for millions of deaths per year around the world. Still, its management as a chronic disease is shadowed by misconceptions from the general public. Indeed, drug consumers are often labelled as "weak", "immoral" or "depraved". Consequently, drug addiction is often perceived as an individual problem and not societal. In technical terms, drug addiction is defined as a chronic, relapsing disease resulting from sustained effects of drugs on the brain. Through a better characterisation of the cerebral circuits involved, and the long-term modifications of the brain induced by addictive drugs administrations, first, we might be able to change the way the general public see the patient who is suffering from drug addiction, and second, we might be able to find new treatments to normalise the altered brain homeostasis. In this review, we synthetise the contribution of fundamental research to the understanding drug addiction and its contribution to potential novel therapeutics. Mostly based on drug-induced modifications of synaptic plasticity and epigenetic mechanisms (and their behavioural correlates) and after demonstration of their reversibility, we tried to highlight promising therapeutics. We also underline the specific temporal dynamics and psychosocial aspects of this complex psychiatric disease adding parameters to be considered in clinical trials and paving the way to test new therapeutic venues.

Factors associated with opioid overdose during medication-assisted treatment: How can we identify individuals at risk?

BACKGROUND

Due to the loss of tolerance to opioids during medication-assisted treatment (MAT), this period may represent a time of heightened risk for overdose. Identifying factors associated with increased risk of overdose during treatment is therefore paramount to improving outcomes. We aimed to determine the prevalence of opioid overdoses in patients receiving MAT. Additionally, we explored factors associated with opioid overdose during MAT and the association between length of time enrolled in MAT and overdose.

METHODS

Data were collected prospectively from 2360 participants receiving outpatient MAT in Ontario, Canada. Participants were divided into three groups by overdose status: no history of overdose, any lifetime history of overdose, and emergency department visit for opioid overdose in the last year. We used a multivariate multinomial regression model to assess demographic and clinical factors associated with overdose status.

RESULTS

Twenty-four percent of participants reported a lifetime history of overdose (n = 562), and 8% reported an emergency department (ED) visit for opioid overdose in the last year (n = 179). Individuals with a recent ED visit for opioid overdose were in treatment for shorter duration (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.87, 0.97, p = 0.001). Individuals with a lifetime or recent history of overdose were more likely to be younger in age (OR 0.93, 95% CI 0.89, 0.98, p = 0.007 and OR 0.84, 95% CI 0.77, 0.92, p < 0.001, respectively), report more physical symptoms (OR 1.02, 95% CI 1.01, 1.03, p = 0.005 and OR 1.03, 95% CI 1.01, 1.05, p = 0.005, respectively), and had higher rates of non-prescription benzodiazepine use (OR 1.87, 95% CI 1.32, 2.66, p < 0.001 and OR 2.34, 95% CI 1.43, 3.81, p = 0.001, respectively) compared to individuals with no history of overdose.

CONCLUSIONS

A considerable number of patients enrolled in MAT have experienced overdose. Our study highlights that there are identifiable factors associated with a patient's overdose status that may represent areas for intervention. In particular, longer duration in MAT is associated with a decreased risk of overdose.

Effects of treatment status and life quality on anxiety in MMT patients

Background

Anxiety, an important factor that affects the therapeutic effect and preservation rate of methadone maintenance treatment, has a high prevalence among MMT patients. This study aims to investigate the effects of treatment status and life quality on anxiety in MMT patients.

Methods

One hundred and Seventy-seven methadone maintenance treatment users in Guangzhou, China were evaluated. The socio-demographic, duration and MMT-related characteristics were documented. Anxiety level and quality of life were evaluated by Beck Anxiety inventory (BAI) and the Quality of Life-Drug Addiction (QOL-DA) respectively. The correlation between different factors and BAI score was also analyzed.

Results

The BAI total score and the QOL-DA score were 7.1±8.2, 163.5±21.4 respectively. 30.5% of the subjects showed mild to severe anxiety. Treatment interruption and QOL-DA score had strong correlations with the score of BAI, with correlation coefficients of 0.17 and − 0.08 respectively.

Conclusions

Anxiety symptoms were commonly presented in MMT patients. Treatment interruption and quality of life are two major factors affecting anxiety of MMT patients.

Common Opioids Involved in Drug Poisoning Presenting to the Emergency Department: A Cross-sectional Study

Objective:

Opioids poisoning is of the most important cause of mortality. The objective of the study was to compare the demographic factors, clinical manifestations, and outcomes of the most common opioids involved in drug overdose presenting to the Emergency Department.

Methods:

This cross-sectional study was conducted from October 2016 to March 2017 in the Clinical Toxicology Department of the main referral center of the university. All poisoning cases with common opioids were included in the study. Demographic factors, clinical manifestations, and outcome were recorded in a check list. ANOVA, Chi-square or Fisher's exact test, and binary logistic regression analysis were used for outcome prediction.

Findings:

Two hundred and thirty six patients with opioids poisoning were evaluated during the study period. The most common opioids involved in poisoning were methadone (47.9%), tramadol (24.2%), and opium (21.6%). Patients with opium poisoning were older than others (P < 0.0001). The rate of suicide was more in the tramadol group, while the past history of psychological problems was more observed in the methadone group (P < 0.0001). Increasing age (odds ratio [OR], 1.05; 95% confidence interval [CI]: 1.02–1.09; P = 0.05) and addiction (P = 0.01; OR, 7; 95% CI: 1.55–31.52) was associated with an increased complications or death. Also patients with somatic disease had more chance of complications/death (P = 0.04; OR, 3.71; 95% CI: 1.06–12.97). Kind of opioids was not a predictive factor in the outcome of the patients with acute poisoning.

Conclusion:

Age, addiction, and somatic disease should be considered as more important factors in outcome prediction with opioids poisoning, including opium, tramadol, and methadone.

Negative Impact of Amphetamine-Type Stimulant Use on Opioid Agonist Treatment Retention in Ontario, Canada

Objective: The objective of this study was to evaluate epidemiological trends of co-use patterns of amphetamine-type stimulants and opioids and the impact of co-use patterns on Opioid Agonist Treatment (OAT) retention in Ontario, Canada. The secondary objective was to assess geographical variation in amphetamine-type stimulant use in Northern Rural, Northern Urban, Southern Rural and Southern Urban Areas of Ontario. Methods: A retrospective cohort study on 32,674 adults receiving OAT from ~70 clinics was conducted between January 1, 2014, and December 31, 2020, in Ontario, Canada. Patients were divided into four groups base on the proportion of positive urine drug screening results for amphetamine-type stimulants during treatment: group 1 (0-25%), group 2 (25-50%), group 3 (50-75%), and groups 4 (75-100%). A Fractional logistic regression model was used to evaluate differences over time in amphetamine-type stimulant use with urine drug screening results. A Cox Proportional Hazard Ratio model was used to calculate the impact of amphetamine-type stimulant use on retention in OAT and adjusted for sociodemographic characteristics, drug use and clinical factors. Lastly, a logistic regression model was used on a subgroup of patients to assess the impact of geography on amphetamine-type stimulant use in Northern Rural, Northern Urban, Southern Rural and Southern Urban Areas of Ontario. Results: There were significant differences in amphetamine-type stimulant positive urine drug screening results year-over-year from 2015 to 2020. Significant differences were observed between amphetamine-type stimulant groups with regards to sociodemographic, clinical and drug use factors. Compared to those with no amphetamine-type stimulant use, the number of days retained in OAT treatment for amphetamine-type stimulant users was reduced (hazard ratio 1.19; 95% confidence interval = 1.07-1.17; p < 0.001). Lastly, an adjusted logistic regression model showed a significant increase in the likelihood of amphetamine-type stimulant use in Northern Rural regions compared to Southern Urban areas. Conclusion: There was a significant increase in amphetamine-type stimulant use among individuals in OAT from 2014 to 2020, associated with decreased OAT retention. Research is required to determine if tailored strategies specific to individuals in OAT who use amphetamine-type stimulants can improve OAT outcomes.

Pay for Performance and Treatment Outcome in Agonist Treatment for Opioid Use Disorder

BACKGROUND AND OBJECTIVES

Pay for performance (P4P) models have become more popular in reimbursement for medical services, including treatment for substance use disorders. However, studies have not examined whether P4P has an impact on treatment outcome in the individual in opioid agonist treatment (OAT). Thus, the present study was conducted at the individual level, rather than the programmatic level, to determine whether meeting the P4P early engagement criteria (four services in the initial 14 days of treatment and/or eight services within the initial 30 days of treatment) resulted in reduced opioid, benzodiazepine, and cocaine use.

METHODS

We performed a retrospective study of 63 patients enrolled in OAT for opioid use disorder. χ² analyses were conducted crossing P4P early engagement criteria status and urine drug screen (UDS) results for opioid, cocaine, and/or benzodiazepine use at 6 and 12 months postadmission. Methadone dosage and treatment retention were also considered. The odds ratio was used to determine the directionality of significant results.

RESULTS

Significant relationships were revealed between patients meeting 30-day P4P early engagement criteria and opioid negative UDS, and with retention in treatment at 6 and 12 months. Methadone dosage was significant at a 6-month follow-up.

DISCUSSION AND CONCLUSIONS

Since significant associations between opioid use and P4P as well as opioid use and methadone dose were revealed, findings partially supported hypothesis.

SCIENTIFIC SIGNIFICANCE

P4P and methadone dosage may have some benefit to individuals in OAT in attaining short-term abstinence from opioids. P4P may be less useful in helping individuals achieve abstinence from other substances of abuse. (Am J Addict 2020;00:00-00).

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.

Potentially addictive drugs dispensing to patients receiving opioid agonist therapy: a register-based prospective cohort study in Norway and Sweden from 2015 to 2017

OBJECTIVES

To compare the use of benzodiazepines, z-hypnotics, gabapentinoids, opioids and centrally acting stimulants (CAS) among patients who had received opioid agonist therapy (OAT) in Norway and Sweden during the period 2015 - 2017.

DESIGN

A register-based prospective cohort study using information about dispensed drugs from the Norwegian Prescription Database and Swedish Prescribed Drug Register.

SETTING

Patients who were dispensed OAT opioids from pharmacies.

PARTICIPANTS

A total of 7176 Norwegian and 3591 Swedish patients on OAT were included.

OUTCOME MEASURES

The number and frequency of potentially addictive drugs dispensed were calculated for the two countries. The mean daily doses of dispensed benzodiazepines and z-hypnotics were summarised by calculating benzodiazepines in diazepam equivalents and z-hypnotics in zopiclone equivalents.

RESULTS

In 2017, 46% of patients in Norway, and 15% in Sweden, were dispensed a benzodiazepine. Moreover, 14% in Norway and 26% in Sweden received z-hypnotics. Gabapentinoids were dispensed to 10% of patients in Norway and 19% of patients in Sweden. In Norway, 6% and 12% of the patients received strong and weak non-OAT opioids, respectively, whereas in Sweden 10% were dispensed strong non-OAT opioids and 5% weak non-OAT opioids . CAS were dispensed to 4% in Norway and 18% in Sweden. The mean daily doses of benzodiazepines were 16 and 17 mg diazepam equivalents in Norway and Sweden, respectively. For z-hypnotics, the mean daily dose was 8 mg zopiclone equivalents in both countries. 'Benzodiazepines and z-hypnotics' was the most dispensed drug combination in 2017. Similar results were found in 2015 and 2016.

CONCLUSIONS

Nearly half of those patients who were dispensed an OAT opioid in Norway and Sweden were dispensed potentially addictive drugs. The differences identified between Norway and Sweden might be related to differences in eligibility guidelines and restrictions with respect to OAT.

Evaluating the Impact of Prescribed Versus Nonprescribed Benzodiazepine Use in Methadone Maintenance Therapy: Results From a Population-based Retrospective Cohort Study

Objectives:

Benzodiazepine (BZD) use is common in patients who are engaged in methadone as a treatment for opioid use disorder. BZD prescribing is generally discouraged for this patient population due to the increased risk of BZD dependence and BZD use disorder, medication-assisted treatment (MAT) discontinuation, and opioid-overdose death. However, some patients have concurrent mental health disorders, where BZD use may be clinically indicated. This study evaluates the impact of prescribed BZD on MAT outcomes.

Methods:

Linking urine drug screening data (UDS) and prescribing information from single-payer health records, we conducted a retrospective Kaplan–Meier analysis between patients using prescribed and nonprescribed BZD with methadone treatment retention as the primary outcome. Data are from a network of 52 outpatient clinics in Ontario, Canada, between January 1, 2006 and June 30, 2013.

Results:

We identified 3692 patients initiating methadone-assisted treatment for the first time; 76% were BZD−/UDS− (no BZD prescription and <30% screens positive for BZD); 13% were BZD+/UDS−; 6% BZD−/UDS+; and 6% BZD+/UDS+. Using 1-year treatment retention as a primary outcome, patients using nonprescribed BZD (BZD−/UDS+) were twice as likely (adjusted odds ratio 0.38, 95% confidence interval 0.27–0.53) to discontinue treatment as those not using BZD (BZD−/UDS−), or those using BZD in a prescribed manner (BZD+/UDS+).

Conclusions:

Our findings suggest that prescribed BZD can be used during methadone MAT without impacting a patient's retention in MAT, but nonprescribed BZD use is predictive of treatment discontinuation. Importantly, we urge both the physician and patient to seek alternative clinical options to BZD prescribing, due to the potential for developing physical dependence (and BZD use disorder) to BZD and the risks of negative interactions with opioids.

Retention of patients in opioid substitution treatment: A systematic review

Background

Retention in opioid substitution (OST) treatment is associated with substantial reductions in all cause and overdose mortality. This systematic review aims to identify both protective factors supporting retention in OST, and risk factors for treatment dropout.

Methods

A systematic search was performed using MEDLINE, Embase, PsycInfo, CINAHL and Web of Science (January 2001 to October 2019). Randomised controlled trials (RCTs) and observational cohort studies reporting on retention rates and factors associated with retention in OST were included. Factors associated with treatment retention and dropout were explored according to the Maudsley Addiction Profile. A narrative synthesis is provided.

Results

67 studies were included in this review (4 RCTs and 63 observational cohort studies; N = 294,592), all assessing factors associated with retention in OST or treatment dropout. The median retention rate across observational studies was approximately 57% at 12 months, which fell to 38.4% at three years. Studies included were heterogeneous in nature with respect to treatment setting, type of OST, risk factor assessment, ascertainment of outcome and duration of follow-up. While the presence of such methodological heterogeneity makes it difficult to synthesise results, there is limited evidence to support the influence of a number of factors on retention, including age, substance use, OST drug dose, legal issues, and attitudes to OST.

Conclusions

Younger age, substance use particularly cocaine and heroin use, lower doses of methadone, criminal activity/incarceration, and negative attitudes to MMT appear to be associated with reduced retention in OST. A consensus definition of retention is required to allow for comparability across future studies.

Dispensations of benzodiazepines, z-hypnotics, and gabapentinoids to patients receiving opioid agonist therapy; a prospective cohort study in Norway from 2013 to 2017

Background

Dispensations of benzodiazepines, z-hypnotics, and gabapentinoids to patients on opioid agonist therapy (OAT) are common and have pros and cons. The objectives of the current study are to define the dispensation rates of these potentially addictive drugs, and whether the number and the mean daily doses of dispensed OAT opioids and discontinuing OAT, are associated with being dispensed benzodiazepines, z-hypnotics and gabapentinoids among patients on OAT in Norway in the period 2013 to 2017.

Methods

Information about all dispensed opioids, benzodiazepines, z-hypnotics and gabapentinoids were recorded from the Norwegian Prescription Database (NorPD). A total of 10,371 OAT patients were included in the study period. The dispensation rates were defined as the number of patients who were dispensed at least one of the potentially addictive drugs divided among the number of patients who have dispensed an OAT opioid per calendar year. Mean daily doses were calculated, and for benzodiazepines and z-hypnotics, stated in diazepam equivalents. The association between dispensed potentially addictive drugs, and the number and the type of dispensed OAT opioids were calculated by using logistic regression models.

Results

Half of the OAT patients received at least one dispensation of a benzodiazepine or z-hypnotic, and 11% were dispensed at least a gabapentinoid in 2017. For dispensed benzodiazepines or z-hypnotics, the mean daily dose was reduced from 21 mg (95% confidence interval (CI): 20–23) diazepam equivalents in 2013 to 17 mg (95% CI: 16–17) in 2017. The mean daily dose of pregabalin increased from 365 mg (95% CI: 309–421) in 2013 to 386 mg (95% CI: 349–423) in 2017. Being dispensed a gabapentinoid (adjusted odds ratio (aOR) = 2.5, 95% CI: 2.1–3.0) or a non-OAT opioid (aOR = 3.0, 95% CI: 2.6–3.5) was associated with being dispensed a benzodiazepine or z-hypnotic. Discontinuing OAT did not affect the number of dispensations and the doses of potentially addictive drugs.

Conclusion

The dispensation rates of potentially addictive drugs are high in the OAT population. Treatment indications, as well as requirements for prescription authority, need to be debated and made explicit. Randomized controlled trials evaluating the benefits and risks of such co-prescription are required.

Exploring gender differences among treatment-seekers who use opioids versus alcohol and other drugs

Identifying clinical differences between opioid users (OU) and alcohol and other drug users (AOD) may help to tailor treatment to OU, particularly among the majority of OU who are not on opioid agonist treatments. Given the dearth of research on these differences, this study explored gender differences in demographic and clinical characteristics between OU and AOD. Participants (N = 506) were from a multisite, randomized controlled clinical trial of an Internet-delivered psychosocial intervention conducted in 2010-2011. Logistic regression models explored differences in demographic and clinical characteristics by substance use category within and between women and men. Women OU were more likely to be younger, White, employed, benzodiazepine users, and less likely to have children or use cocaine and cannabis than women AOD. Men OU, compared to men AOD, were more likely to be younger, White, younger at first abuse/dependence, benzodiazepine users, and reported greater psychological distress, but were less likely to be involved in criminal justice or use stimulants. Interactions by gender and substance use were also detected for age of first abuse/dependence, employment, and criminal justice involvement. These findings provide a nuanced understanding of gender differences within substance use groups to inform providers for OU seeking treatment.

Drug Abuse and Behavioral Transgressions during Methadone Maintenance Treatment (MMT) are Related to High Psychopathy Levels

Introduction: Studies which used the Psychopathy Checklist-Revised (PCL-R) among methadone maintenance treatment (MMT) patients focused mostly on methodological issues, without addressing its relationship to patients' misconduct during treatment. This paper tests the hypothesis that high PCL-R scores are related to high rates of drug abuse, and high numbers of behavioral transgressions in MMT during a 7-year period. Material and Methods: 107 MMT patients were recruited from a MMT clinic in Israel, and were administered the PCL-R. The questionnaires results as well as routine drug test findings were recorded between 7/2007 and 11/2007. Seven years later (7/2014), repeated drug test results were analyzed, and the number of behavioral transgressions during the entire period was computed. Results: High levels of psychopathy were related to drug test results indicating any illicit drug use, cocaine use and benzodiazepines misuse at the beginning of study, and limited to benzodiazepines misuse among patients who stayed in treatment at the 7-year follow-up. However, higher scores on different PCL-R facets were significantly associated with different types of drugs. The PCL-R's total score and all but the antisociality facet were positively correlated with a higher number of behavioral transgressions (such as, threats and/or verbal and physical aggression). Conclusions: Administration of the PCL-R during MMT may help identify patients with high illicit drug use levels and a higher chance of committing behavioral transgressions during treatment.

Specificity of personality relationships to particular forms of concurrent substance use among methadone maintenance therapy clients

OBJECTIVE

A mainstay treatment for opioid addiction in North America is methadone maintenance therapy (MMT) - a form of opiate agonist therapy (OAT). While efficacious for treating opioid addiction, MMT fails to address the concurrent polysubstance use that is common among opioid dependent clients. Moreover, psychosocial approaches for addressing polysubstance use during MMT are lacking. Our study's goals were to validate the use of the four-factor personality model of substance use vulnerability in MMT clients, and to demonstrate theoretically-relevant relationships of personality to concurrent substance use while receiving MMT.

METHOD

Respondents included 138 daily-witnessed MMT clients (65.9% male, 79.7% Caucasian), mean age (SD) 40.18 (11.56), recruited across four Canadian MMT clinics. Bayesian confirmatory factor analysis was used to establish the structural validity of the four-factor personality model of substance use vulnerability (operationalized with the Substance Use Risk Profile Scale [SURPS]) in MMT clients. SURPS personality scores were then used as predictors for specific forms of recent (past 30-day) substance use.

RESULTS

Using a latent hierarchal model, hopelessness was associated with recent opioid use; anxiety sensitivity with recent tranquilizer use; and sensation seeking with recent alcohol, cannabis, and stimulant use.

CONCLUSION

Personality is associated with substance use patterns and may be an appropriate target for intervention for those undergoing MMT to reduce opioid use, and potentially dangerous concurrent use of other drugs, while receiving methadone.

Evaluation of the treatment failure ratio in individuals receiving methadone maintenance therapy via the network scale up method

BACKGROUND

The network scale up (NSU) method is an indirect size estimation method that has received remarkable attention in estimating the sensitive behaviors. Using methadone maintenance therapy (MMT), which is a treatment for opioid use disorder, is a sensitive topic in many societies. The aim of this manuscript was to estimate the number of MMT users and its failure ratio using the NSU method in the city of Kerman, Iran, in 2016.

METHODS

In this cross-sectional study, 1275 men and 1275 women which were aged >18 years and who had lived in the city of Kerman for at least 5 years were recruited via multistage sampling. Data was collected via face-to-face interviews using a questionnaire that was included questions for estimating the network size of the residents of Kerman as well as the number of MMT users and the existing failure among them.

RESULTS

In total, the average network size of the citizens of Kerman was 235; among them, 97 were men and 138 were women. Overall, the numbers of MMT users and failures were estimated at about 5289 and 2731, respectively, leading to a failure ratio about 52%. The treatment failure ratio in the women and men was equal to 55% and 51%, respectively. Among the men, the failure ratio in all age groups was equal to ˜50%. Among the women, the failure ratio in those who were aged <18 years was equal to 76%.

CONCLUSION

The considerable failure ratio indicates the need for conducting studies on MMT services in order to understand the reasons which exist regarding this failure. This is of particular importance in specific groups, such as in young women. Further, the comparable results with other direct methods indicate that the NSU method could be used in the size estimation of MMT failure ratios.

Sociodemographic factors and social determinants associated with toxicology confirmed polysubstance opioid-related deaths

BACKGROUND AND AIMS

While prescribed and illicit opioid use are primary drivers of the national surges in overdose deaths, opioid overdose deaths in which stimulants are also present are increasing in the U.S. We determined the social determinants and sociodemographic factors associated with opioid-only versus polysubstance opioid overdose deaths in Massachusetts. Particular attention was focused on the role of stimulants in opioid overdose deaths.

METHODS

We analyzed all opioid-related overdose deaths from 2014 to 2015 in an individually-linked population database in Massachusetts. We used linked postmortem toxicology data to identify drugs present at the time of death. We constructed a multinomial logistic regression model to identify factors associated with three mutually exclusive overdose death groups based on toxicological results: opioid-related deaths with (1) opioids only present, (2) opioids and other substances not including stimulants, and (3) opioids and stimulants with or without other substances.

RESULTS

Between 2014 and 2015, there were 2,244 opioid-related overdose deaths in Massachusetts that had accompanying toxicology results. Toxicology reports indicated that 17% had opioids only, 36% had opioids plus stimulants, and 46% had opioids plus another non-stimulant substance. Persons older than 24 years, non-rural residents, those with comorbid mental illness, non-Hispanic black residents, and persons with recent homelessness were more likely than their counterparts to die with opioids and stimulants than opioids alone.

CONCLUSIONS

Polysubstance opioid overdose is increasingly common in the US. Addressing modifiable social determinants of health, including barriers to mental health services and homelessness, is important to reduce polysubstance use and overdose deaths.

The epidemiology of benzodiazepine misuse: A systematic review

BACKGROUND

Benzodiazepine misuse is a growing public health problem, with increases in benzodiazepine-related overdose deaths and emergency room visits in recent years. However, relatively little attention has been paid to this emergent problem. We systematically reviewed epidemiological studies on benzodiazepine misuse to identify key findings, limitations, and future directions for research.

METHODS

PubMed and PsychINFO databases were searched through February 2019 for peer-reviewed publications on benzodiazepine misuse (e.g., use without a prescription; at a higher frequency or dose than prescribed). Eligibility criteria included human studies that focused on the prevalence, trends, correlates, motives, patterns, sources, and consequences of benzodiazepine misuse.

RESULTS

The search identified 1970 publications, and 351 articles were eligible for data extraction and inclusion. In 2017, benzodiazepines and other tranquilizers were the third most commonly misused illicit or prescription drug in the U.S. (approximately 2.2% of the population). Worldwide rates of misuse appear to be similar to those reported in the U.S. Factors associated with misuse include other substance use, receipt of a benzodiazepine prescription, and psychiatric symptoms and disorders. Benzodiazepine misuse encompasses heterogeneous presentations of motives, patterns, and sources. Moreover, misuse is associated with myriad poor outcomes, including mortality, HIV/HCV risk behaviors, poor self-reported quality of life, criminality, and continued substance use during treatment.

CONCLUSIONS

Benzodiazepine misuse is a worldwide public health concern that is associated with a number of concerning consequences. Findings from the present review have implications for identifying subgroups who could benefit from prevention and treatment efforts, critical points for intervention, and treatment targets.

Exploring health-care providers’ experiences in the care of clients on opioid agonist treatment in two western Canadian clinics

Introduction

Prescribing methadone as part of opioid agonist therapy is a common treatment approach to manage opioid use disorder. Unfortunately, many clients prematurely discontinue opioid agonist therapy because of restrictions attached to the therapy.

Purpose

The purpose of this study was to explore health-care provider experiences as they worked with clients on opioid agonist therapy in a western Canadian city.

Methods

In this descriptive, qualitative study, we interviewed 18 health-care providers working in an opioid agonist therapy setting. The focus of the interviews was on the organization of opioid agonist therapy care at their clinic, their personal experiences and challenges faced when providing care to their clients. Interviews were recorded electronically and transcribed verbatim and thematic analysis was completed using NVIVO software.

Results

The following three themes emerged from the data relate to the care organization and health care provider (HCP)-clients dynamics. These are: (1) fragmentation of care for a complex problem, (2) enforcing compliance to treatment, and (3) the importance of a therapeutic alliance to improve overall care.

Conclusion

The opioid agonist therapy model is biocentric and emphasizes abstinence which can create tension between providers and clients. Making the model of care more patient centred might help to improve client retention rates and successful treatment outcomes.

The Role of Patient Payment Method in Premature Discharge from Methadone Maintenance Treatment

BACKGROUND

Premature discharge is a pervasive problem in methadone maintenance treatment (MMT), and is associated with numerous adverse outcomes. Although a number of demographic variables have consistently been found to impact MMT retention, method of payment has received considerably less attention. A notable limitation of prior work is that most studies classify all patients who leave treatment early, irrespective of reason, as treatment dropouts and fail to account for specific reasons.

OBJECTIVE

This study sought to determine whether method of payment for MMT services was associated with differential reasons for premature discharge.

METHODS

The sample was comprised of 4158 patients prematurely discharged from 33 MMT facilities located throughout the U.S. from 2009 to 2012. Patients were classified into two groups based on their method of payment: self-pay and insurance (largely Medicaid). Patients were studied through retrospective electronic chart review.

RESULTS

Binary logistic regression indicated that insurance patients who were prematurely discharged were significantly more likely to be discharged due to a program-initiated reason (administrative), while self-pay patients were more likely to be discharged due to a patient-initiated reason (against medical advice) after controlling for significant intake demographic and clinical covariates.

CONCLUSIONS

Further research is needed to determine whether insurance patients may require different supports in place compared to self-pay patients in order to improve compliance with program guidelines (e.g. behavioral contracts providing a detailed description of rules both at admission and throughout treatment with an emphasis on the potential consequences of noncompliance), and whether self-pay patients may benefit from motivational incentives and interventions to remain engaged in treatment.

Nonmedical prescription sedative/tranquilizer use in alcohol and opioid use disorders

AIMS

Nonmedical prescription sedative/tranquilizer (e.g., benzodiazepines) use (NMSTU) increases risk of overdose when combined with opioids and/or alcohol. Yet, little is known about NMSTU among those with alcohol and opioid use disorders. We aimed to characterize NMSTU and sedative/tranquilizer use disorder among adults with alcohol use disorder (AUD) and/or opioid use disorder (OUD) in a general population sample.

METHODS

We conducted analyses of 2008-2014 National Survey on Drug Use and Health data; adults with past-year AUD-only (n = 27,416), OUD-only (n = 2142), and co-occurring AUD and OUD (n = 1483) were included (total N = 31,041). Multivariable logistic regression models were utilized to examine correlates of past-month NMSTU and past-year sedative/tranquilizer use disorder. Focal independent variables were polysubstance use (i.e., number of substances used in the previous year) and psychiatric distress.

RESULTS

Among those with AUD-only, 27.1% reported lifetime NMSTU, 7.6% reported past-year NMSTU, 2.7% reported past-month NMSTU, and 0.6% met criteria for past-year sedative/tranquilizer use disorder. Corresponding prevalence rates among those with OUD-only were 69.5%, 43.0%, 22.6%, and 11.3%. Those with co-occurring AUD and OUD displayed the highest rates of NMSTU (e.g., 27.5% with past-month NMSTU) and sedative/tranquilizer use disorder (20.2%). Across groups, more severe polysubstance use and psychiatric distress were associated with increased risk of NMSTU and sedative/tranquilizer use disorder.

CONCLUSIONS

Results of this analysis indicate that >25% of adults with AUD and approximately 70% of those with OUD report lifetime NMSTU. Among these populations, individuals with more polysubstance use and greater psychiatric distress might benefit from targeted interventions to reduce NMSTU.

Expectations about alcohol, cocaine, and benzodiazepine abstinence following inpatient heroin withdrawal management

BACKGROUND AND OBJECTIVES

Polysubstance use is associated with relapse and poor treatment outcomes among people dependent on heroin. Despite the high prevalence of polysubstance use among patients detoxifying from heroin, little is known about patients' expectations to abstain or use non-opiate substances. The current study examined factors associated with expectations about abstaining from alcohol, cocaine, and benzodiazepines (BZDs) following heroin withdrawal management.

METHODS

Between May and December of 2015, we surveyed 417 patients (71.9% male, 31.7 [±8.39] mean years old) initiating short-term inpatient heroin withdrawal management who reported alcohol, cocaine, or BZD use in the past 30 days. We used logistic regression to evaluate the adjusted associations of background characteristics with expectations about using each substance following discharge.

RESULTS

Approximately half of respondents reported past month alcohol (52%), cocaine (47.0%), or BZD (47.0%) use, and 25.9% reported using all three substances. Approximately half of those reporting drinking, 6.6% reporting cocaine use, and 27% of reporting BZD use expected to abstain from using that substance following heroin withdrawal. Prior opioid withdrawal was associated with a lower likelihood of expecting to stop using alcohol and BZDs, and more days of BZD use was associated with a greater likelihood of expecting to abstain from BZDs following discharge.

CONCLUSION

Persons with opioid use disorder often do not expect to stop using other substances following withdrawal management, with very few planning cocaine cessation.

SCIENTIFIC SIGNIFICANCE

Inpatient heroin withdrawal programs need to address and educate patients about how polysubstance use complicates recovery from heroin use. (Am J Addict 2019;28:36-42).

Polydrug use patterns, risk behavior and unmet healthcare need in a community-based sample of women who use cocaine, heroin or methamphetamine

BACKGROUND

The use of multiple illicit drugs (polydrug use) is associated with health-related harms and elevated risk of drug overdose. Polydrug use in common among women who use 'hard' drugs, such as cocaine, heroin or methamphetamine.

METHODS

Quantitative data collection was conducted with a community-recruited sample of 624 women who used heroin, methamphetamine or cocaine in Oakland, CA during 2014-2015. We conducted latent class analysis to classify polydrug use patterns. We assessed associations between classes of polydrug use and infectious disease risk behaviors, health care utilization and unmet health care need.

RESULTS

We identified four distinct classes of drug use: (1) predominantly crack (52% of women); (2) powder cocaine & non-heroin opioids (8%); (3) moderate polydrug use (25%); (4) heavy polydrug use (15%). Odds of sexual risk, injection drug use and unmet healthcare need were twice as high in the heavy polydrug use class as the predominantly crack class (p > 0.01 for each outcome). The rate of binge drinking (as days per month) was also significantly higher in the heavy polydrug class (p = 0.01). The moderate polydrug use class had higher odds of injection drug use and drug treatment participation, compared to the mainly crack class (p < 0.001 for each outcome). There were no differences between classes in health insurance or health care utilization.

DISCUSSION

Reduction of polydrug use could be an effective harm reduction strategy to address sexual and injection risk among women. The use of both opioids and stimulants in three of the four classes suggests that multi-modal substance abuse treatment approaches may be most appropriate.

Prescription Opioid Quality Measures Applied Among Pennsylvania Medicaid Enrollees

BACKGROUND

The Pharmacy Quality Alliance (PQA) recently developed 3 quality measures for prescribing opioids: high dosages, multiple providers and pharmacies, and concurrent use of opioids and benzodiazepines.

OBJECTIVE

To examine the prevalence of the PQA measures and identify the patient demographic and health characteristics associated with the measures.

METHODS

We conducted a cross-sectional analysis using Pennsylvania Medicaid data (2013-2015). We limited our analyses to noncancer patients who were aged 18-64 years and not dual-eligible for Medicare/Medicaid. Per PQA specifications, patients were required to possess ≥ 2 opioid prescriptions for ≥ 15 days annual supply each year. Outcome measures included (a) high dosages, defined as > 120 morphine milligram equivalents for ≥ 90 consecutive days; (b) multiple providers/pharmacies, defined as receiving opioid prescriptions from ≥ 4 providers and ≥ 4 pharmacies; and (c) concurrent use of opioids and benzodiazepines, defined as ≥ 30 cumulative days of overlapping opioids and benzodiazepines among individuals having ≥ 2 opioid and ≥ 2 benzodiazepine fills. Patient characteristics assessed included demographics; other medication use; and physical, mental, and behavioral health comorbidities. We present descriptive and multivariable statistical analyses of the data to describe trends in quality measure prevalence and associations with enrollee health characteristics.

RESULTS

Numbers of enrollees meeting inclusion criteria ranged from 73,082 in 2013 to 85,710 in 2015. From 2013 to 2015, high dosage prevalence increased from 5.1% to 5.5%; the use of multiple providers/pharmacies decreased from 7.1% to 5.0%; and concurrent use of opioids and benzodiazepines decreased from 29.1% to 28.4% (all P < 0.05). A substantial portion of patients with > 1 PQA measure from 2013 to 2015 was eligible for Medicaid because of disability (41.8%-81.9%). Enrollees with opioid use disorder were more likely to have high dosages (adjusted odds ratio [AOR] = 2.01, 95% CI = 1.83-2.21). Enrollees with anxiety and mood disorders were more likely to have multiple providers/pharmacies (anxiety: AOR = 1.54, 95% CI = 1.43-1.65; mood: AOR = 1.15, 95% CI = 1.06-1.25) and concurrent use of opioids and benzodiazepines (anxiety: AOR = 3.50, 95% CI = 3.38-3.63; mood: AOR = 1.42, 95% CI = 1.36-1.48).

CONCLUSIONS

Given high levels of eligibility based on disability and the prevalence of mood, anxiety, and opioid use disorders among those identified by the quality measures, providers may require additional support to care for this patient population.

DISCLOSURES

This project was supported by a grant from the Centers for Disease Control and Prevention and was also supported by an intergovernmental agreement between the Pennsylvania Department of Human Services and the University of Pittsburgh. Lo-Ciganic was supported by the University of Arizona Health Sciences Career Development Award. The other authors have nothing to disclose. The conclusions, findings, and opinions expressed by authors contributing to this article do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the Commonwealth of Pennsylvania. A portion of these results was presented at the Association for Medical Education and Research in Substance Abuse 41st National Conference; November 2-4, 2017; Washington, DC.

Clinical characteristics of poly-drug abuse among heroin dependents and association with other psychopathology in compulsory isolation treatment settings in China

OBJECTIVE

To investigate clinical characteristics and associations of polydrug abuse among heroin-dependent patients in compulsory isolation settings in China.

METHODS

Structured interviews were conducted in 882 heroin-dependent patients in two compulsory isolation settings in Changsha, China. Descriptive statistics were employed to report prevalence and general information of polydrug abuse among the participants. Bivariate associations were examined between polydrug abuse and variables regarding demographics, heroin use profile and psychopathology. Multivariate logistic regressions were conducted to determine independent factors associated with polydrug abuse.

RESULTS

Of all the participants, 40.6% reported abuse of/dependence on at least one other type of drug/alcohol than heroin/opioids during the month preceding admission, with benzodiazepines and alcohol being the most common type of drugs abused apart from heroin. Antisocial and depressive personality disorders, as well as more severe heroin use patterns, including younger age at initiate use and larger amount used per day, were found to be independently associated with polydrug abuse.

CONCLUSIONS

The prevalence of polydrug abuse and its associated severe heroin use patterns and personality disorders suggests an urgent need of promoting treatment policies and strategies for heroin patients in China to address these issues.

Initial treatment dropout in patients with substance use disorders attending a tertiary care de-addiction centre in north India

Background & objectives:

Dropout from substance use disorders treatment is associated with poor outcomes. Although many factors have been associated with an early dropout of patients, the reasons for dropping out of treatment prematurely remain poorly understood particularly in the Indian context. This study was aimed to study socio-demographic and clinical variables predicting initial dropout of patients attending a tertiary care de-addiction treatment centre in north India.

Methods:

Information was extracted from the records of consecutive newly registered patients from January 2011 to December 2014. The patients who did not come for follow up within 30 days of the first contact were defined as initial dropouts.

Results:

Data of 7991 patients could be retrieved. Majority of the sample consisted of male, married and employed individuals. Of them, 4907 patients (61.3%) were considered initial dropouts. Multivariate analysis revealed that after controlling for other factors, greater age, being employed, lower educational status, lesser duration of substance use, use of alcohol, opiate, tobacco, cannabis or sedative-hypnotic use but the absence of multi-substance use predicted initial drop out.

Interpretation & conclusions:

This study identified some socio-demographic and clinical variables which might predict treatment attrition in substance use disorders. Clinician's awareness towards these factors and tailor-made intervention might improve initial treatment retention. Future research could be directed to find the validity of this assumption.

Tranquilizer misuse among active cocaine users: Predictors of initiation

INTRODUCTION AND AIMS

Tranquilizer use is associated with negative health outcomes among people who use drugs. This paper aims to estimate the incidence rate (initiation) and identify predictors of tranquilizer misuse (TM) among cocaine users.

DESIGN AND METHODS

A prospective cohort study was conducted in Montreal, Canada. Interviewer-administered questionnaires were carried out at 3-month intervals. Initiation was defined as misusing a tranquilizer for the first time during follow-up. 'Lasting-initiation', defined as reporting TM at the next visit following first use, was also examined. Cox proportional hazard regression analyses were carried out to assess predictors of initiation to TM.

RESULTS

Among the 245 participants who were eligible for the initiation analyses, 123 started TM during follow-up for an incidence rate of 40.49 per 100 person-years (95% confidence interval, CI: 33.80-48.15). Of the 123 initiates, 35.7% were still using at the interview following initiation for an incidence rate of 14.70 per 100 person-years (95% CI: 10.82-19.56). Multivariate models showed that independent predictors of initiation and 'lasting initiation' were identical as having had a criminal activity as the main source of income, having been recently in treatment for a substance use disorder (SUD) and reporting non-medical use of prescription opioids.

DISCUSSION AND CONCLUSIONS

The incidence rate of TM initiation was high among a sample of cocaine users. Initiation was predicted by a problematic drug use pattern involving polydrug use, involvement in the street economy and having been in treatment for a SUD. These findings have implications for prevention and harm reduction strategies.

Associations between substance use and type of crime in prisoners with substance use problems - a focus on violence and fatal violence

Aim

The present study aimed to study the associations between substance use patterns and types of crimes in prisoners with substance use problems, and specifically whether substance use patterns were different in violent offenders.

Methods

Interview data of prisoners with substance use problems (N=4,202, mean age 33.5 years, SD 9.8), derived from the Addiction Severity Index, were run against criminal register data on main types of crimes in the verdict.

Results

In binary analyses, compared to those with acquisitive and drug crimes, violent offenders had lower prevalence of illicit drugs and homelessness, but higher prevalence of binge drinking, and higher prevalence of sedative use than clients sentenced with drug crimes. Clients with violent crime had lower prevalence of injecting drug use, compared to all other crimes. In logistic regression, binge drinking and sedatives were positively associated with violent crime (as opposed to non-violent crime), whereas heroin, amphetamine, cocaine, and injecting drug use were negatively associated with violent crime. Among violent offenders only, sedatives tended to be associated with fatal violence (p=0.06), whereas amphetamine, homelessness, age, and (marginally significant, p=0.05) heroin were negatively associated with fatal violence, as opposed to non-fatal violence.

Conclusion

Treatment and risk assessment in violent perpetrators with substance use may need to address sedatives and alcohol specifically. Limitations of the study are due to self-reported and cross-sectional data and because a large majority of the prison sample studied here are men.

Perception of unmet needs and association with benzodiazepine misuse among patients on a methadone maintenance treatment programme

Aims and method

To examine patients' perceptions of unmet needs during methadone maintenance treatment (MMT), and to explore the relationship between co-occurring benzodiazepine misuse and severity of needs. A cross-sectional survey was carried out at an MMT programme in Dublin, Ireland. All patients were invited to participate on a voluntary basis. Of the 191 eligible patients, 107 agreed to participate and completed the Camberwell Assessment of Need questionnaire.

Results

Unmet needs for substance misuse treatments, daytime activities, socialisation, money management and psychological distress were high. Fifty-two respondents (49%) reported using non-prescribed benzodiazepines during the past month. Compared with non-users of benzodiazepines, benzodiazepine users reported higher ratings of total and unmet needs (P < 0.05). The number of days using benzodiazepines predicted the severity of needs.

Clinical implications

The findings highlight the importance of addressing coexisting psychological needs, and further support enhancing treatment interventions for benzodiazepine misuse or dependence among patients on MMT.