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

Ageing and older people who use illicit opioids, cocaine or methamphetamine: a scoping review and literature map

AIMS

To provide an overview of research literature on ageing and older people who use illicit opioids and stimulants by documenting the conceptual frameworks used and content areas that have been investigated.

METHODS

We conducted a scoping review of literature relating to ageing and older people who use illicit stimulants and opioids, defining 'older' as 40 years and above. Primary studies, secondary studies and editorials were included. Searches were conducted in PubMed and Embase in July 2020 and March 2021; the Cochrane library was searched in November 2021. Charted data included methodological details, any conceptual frameworks explicitly applied by authors and the content areas that were the focus of the publication. We developed a hierarchy of content areas and mapped this to provide a visual guide to the research area.

RESULTS

Of the 164 publications included in this review, only 16 explicitly applied a conceptual framework. Seven core content areas were identified, with most publications contributing to multiple content areas: acknowledgement of drug use among older people (n = 64), health status (n = 129), health services (n = 109), drug use practices and patterns (n = 84), social environments (n = 74), the criminal legal system (n = 28) and quality of life (n = 15).

CONCLUSIONS

The literature regarding older people who use illicit drugs remains under-theorized. Conceptual frameworks are rarely applied and few have been purposely adapted to this population. Health status and health services access and use are among the most frequently researched topics in this area.

Substance Use Disorders in Later Life: A Review and Synthesis of the Literature of an Emerging Public Health Concern

Substance use disorders (SUDs) among older persons are among the fastest growing health problems in the United States. The number of older persons is projected to exceed 72.1 million persons by 2030, following a trend of general population growth in the mid-1940s to 1960s. The generation, known as "baby boomers," who refashioned drug use during their 20-30s, are increasingly continuing drug habits into later life. This review aims to assess the epidemiology, impact, and treatment of geriatric SUDs. Academic databases including PubMed, PsychInfo, Ovid, and Medline, were queried up to December 2018 for terms of "geriatric," "older," "elderly," "substance abuse," "drug," "drug use," "drug abuse," "drug dependency," "illicit drugs," and "geriatric psychiatry." Articles identified included 17 government documents, 29 studies based upon government documents, 43 studies not related to US government surveys, 19 review articles, 9 commentary pieces, 4 newspaper articles, 2 textbooks, and 1 published abstract. Evaluated studies and documents together suggest that older individuals are using illicit drugs and meeting criteria for SUDs at higher rates than previous geriatric cohorts resulting in substantial negative impacts on medical and psychiatric conditions. These findings represent a novel trend since previous cohorts of older individuals were thought to rarely use illicit substances. Current treatment models are inadequate to address the new wave of older individuals with SUDs. The fields of geriatrics, addiction, and geriatric psychiatry must work together to establish comprehensive care models and treatment modalities for addressing this emerging public health concern.

Considerations for Implementing Contingency Management in Substance Abuse Treatment Clinics: The Veterans Affairs Initiative as a Model

Contingency management (CM) is an efficacious intervention for the treatment of substance use disorders that is widely applicable across a range of client populations and characteristics. Despite its strong evidence base, CM remains underutilized in real world practice. This article introduces CM for clinicians interested in adopting CM and briefly reviews this research evidence. In addition, CM protocols are described, with emphasis on the specific design considerations important to CM's efficacy. The recent Department of Veterans Affairs (VA) initiative, which represents the first successful large-scale implementation effort, is presented. It provides a model for the training and supervision components that may be critical to implementation with fidelity. Continued research in this area, as well as further demonstrations of successful dissemination and implementation, will be critical for improving the adoption of this intervention in clinical, nonresearch settings.

"I's" on the prize: A systematic review of individual differences in Contingency Management treatment response

Contingency Management is an evidence-based treatment for substance use disorders with strong potential for measurement-based customization. Previous work has examined individual difference factors in Contingency Management treatment response of potential relevance to treatment targeting and adaptive implementation; however, a systematic review of such factors has not yet been conducted. Here, we summarize and evaluate the existing literature on patient-level predictors, mediators, and moderators of Contingency Management treatment response in stimulant and/or opioid using outpatients - clinical populations most frequently targeted in Contingency Management research and clinical practice. Our search strategy identified 648 unique, peer-reviewed publications, of which 39 met full inclusion criteria for the current review. These publications considered a variety of individual difference factors, including (1) motivation to change and substance use before and during treatment (8/39 publications), (2) substance use comorbidity and chronicity (8/39 publications), (3) psychiatric comorbidity and severity (8/39 publications), (4) medical, legal, and sociodemographic considerations (15/39 publications), and (5) cognitive-behavioral variables (1/39 publications). Contingency Management was generally associated with improved treatment outcomes (e.g., longer periods of continuous abstinence, better retention), regardless of individual difference factors; however, specific patient-level characteristics were associated with either an enhanced (e.g., more previous treatment attempts, history of sexual abuse, diagnosis of antisocial personality disorder) or diminished (e.g., complex post-traumatic stress symptoms, pretreatment benzodiazepine use) response to Contingency Management. Overall, the current literature is limited but existing evidence generally supports greater benefits of Contingency Management in patients who would otherwise have a poorer prognosis in standard outpatient care. It was also identified that the majority of previous work represents a posteriori analysis of pre-existing clinical samples and has therefore rarely considered pre-specified, hypothesis-driven individual difference factors. We therefore additionally highlight patient-level factors that are currently understudied, as well as promising future directions for measurement-based treatment adaptations that may directly respond to patient traits and states to improve Contingency Management effectiveness across individuals and over time.

Interest and preferences for contingency management design among addiction treatment clientele

BACKGROUND

Despite strong support for its efficacy, debates persist about how dissemination of contingency management is most effectively undertaken. Currently-promoted contingency management methods are empirically-validated, yet their congruence with interests and preferences of addiction treatment clientele is unknown. Such client input is a foundational support for evidence-based clinical practice.

OBJECTIVE

This study documented interest in incentives and preferences for fixed-ratio vs. variable-ratio and immediate vs. distal distribution of earned incentives among clients enrolled at three community programs affiliated with the National Institute on Drug Abuse Clinical Trials Network.

METHODS

This multi-site study included anonymous survey completion by an aggregate sample of 358 treatment enrollees. Analyses first ruled out site differences in survey responses, and then tested age and gender as influences on client interest in financial incentives, and preferences for fixed-ratio vs. variable-ratio reinforcement and immediate vs. distal incentive distribution.

RESULTS

Interest in different types of $50 incentives (i.e. retail vouchers, transportation vouchers, cash) was highly inter-correlated, with a mean sample rating of 3.49 (0.83) on a five-point scale. While consistent across client gender, age was an inverse predictor of client interest in incentives. A majority of clients stated preference for fixed-ratio incentive magnitude and distal incentive distribution (67% and 63%, respectively), with these preferences voiced by a larger proportion of females.

CONCLUSION

Sample preferences contradict currently-promoted contingency management design features. Future efforts to disseminate contingency management may be more successful if flexibly undertaken in a manner that incorporates the interests and preferences of local client populations.

Initial abstinence status and contingency management treatment outcomes: does race matter?

OBJECTIVE

Limited research has evaluated African American substance users' response to evidence-based treatments. This study examined the efficacy of contingency management (CM) in African American and White cocaine users.

METHOD

A secondary analysis evaluated effects of race, treatment condition, and baseline cocaine urine sample results on treatment outcomes of African American (n = 444) and White (n = 403) cocaine abusers participating in one of six randomized clinical trials comparing CM to standard care.

RESULTS

African American and White patients who initiated treatment with a cocaine-negative urine sample remained in treatment for similar durations and submitted a comparable proportion of negative samples during treatment regardless of treatment type; CM was efficacious in both races in terms of engendering longer durations of abstinence in patients who began treatment abstinent. Whites who began treatment with a cocaine positive sample remained in treatment longer and submitted a higher proportion of negative samples when assigned to CM than standard care. African Americans who initiated treatment with a cocaine positive sample, however, did not remain in treatment longer with CM compared with standard care, and gains in terms of drug use outcomes were muted in nature relative to Whites. This interaction effect persisted through the 9-month follow-up period.

CONCLUSIONS

CM is not equally effective in reducing drug use among all subgroups, specifically African American patients who are using cocaine upon treatment entry. Future research on improving treatment outcomes in this population is needed.

Police bribery and access to methadone maintenance therapy within the context of drug policy reform in Tijuana, Mexico

AIMS

In 2009, Mexico passed legislation to decriminalize drug possession and improve access to addiction treatment. We undertook research to assess the implementation of the reform among a cohort of people who inject drugs (PWID) in Tijuana. This study specifically sought to determine whether discretionary policing practices like extortion impact access to methadone maintenance therapy (MMT) in Tijuana, a city characterized by high levels of drug-related harms.

METHODS

Generalized estimating equation analyses were used to construct longitudinal confounding models to determine the association between paying a police bribe and MMT enrolment among PWID in Tijuana enrolled in a prospective cohort study. Outcome of interest was MMT enrolment in the past six months. Data on police interactions and MMT enrolment were also obtained.

RESULTS

Between October, 2011 and September, 2013, 637 participants provided 1825 observations, with 143 (7.8%) reports of MMT enrolment during the study period. In a final confounding model, recently reporting being forced to pay a bribe to police was significantly associated with an increased likelihood of accessing MMT (adjusted odds ratio=1.69, 95% confidence interval: 1.02-2.81, p=0.043). However, in 56 (39.2%) cases, MMT enrolment ceased within six months. The majority of participant responses cited the fact that MMT was too expensive (69.1%).

DISCUSSION

Levels of MMT access were low. PWID who experienced police extortion were more likely to access MMT at baseline, though this association decreased during the study period. Coupled with the costs of MMT, this may compromise MMT retention among PWID.

Treatment use, perceived need, and barriers to seeking treatment for substance abuse and mental health problems among older adults compared to younger adults

BACKGROUND

This study examined age group differences in and correlates of treatment use and perceived treatment need for substance use disorders (SUD) and mental health (MH) problems as well as self-reported barriers to treatment among people 65+ years old vs. 26-34, 35-49, and 50-64 years old.

METHODS

Data are from the 2008 to 2012 National Survey on Drug Use and Health (NSDUH) (N = 96,966). Age group differences were examined using descriptive bivariate analyses and binary logistic regression analyses.

RESULTS

The 65+ age group was least likely to use treatment and perceive treatment need, but the 50-64 age group was more similar to the younger age groups than the 65+ age group. Controlling for age, other predisposing, and enabling factors, alcohol and illicit drug dependence and comorbid SUD and MH problems increased the odds of SUD treatment use. Of MH problems, anxiety disorder had the largest odds for MH treatment use. Bivariate analyses showed that lack of readiness to stop using and cost/limited insurance were the most frequent barriers to SUD and MH treatment, respectively, among older adults, and they were less likely than younger age groups to report stigma/confidentiality concerns for MH treatment.

CONCLUSIONS

Older adults will become a larger portion of the total U.S. population with SUD and/or MH problems. Healthcare providers should be alert to the need to help older adults with SUD and/or MH problems obtain treatment.

Maintenance treatments for opiate -dependent adolescents

BACKGROUND

The scientific literature examining effective treatments for opioid-dependent adults clearly indicates that pharmacotherapy is a necessary and acceptable component. Nevertheless, no reviews have been published that systematically assess the effectiveness of pharmacological maintenance treatment in adolescents.

OBJECTIVES

To assess the effectiveness of any maintenance treatment alone or in combination with psychosocial intervention compared to no intervention, other pharmacological intervention or psychosocial interventions for retaining adolescents in treatment, reducing the use of substances and improving health and social status.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group's Trials Register (January 2014), the Cochrane Central Register of Controlled Trials (2014, Issue 1), PubMed (January 1966 to January 2014), EMBASE (January 1980 to January 2014), CINAHL (January 1982 to January 2014), Web of Science (1991 to January 2014) and reference lists of articles.

SELECTION CRITERIA

Randomised and controlled clinical trials of any maintenance pharmacological interventions either alone or associated with psychosocial intervention compared with no intervention, placebo, other pharmacological intervention, pharmacological detoxification or psychosocial intervention in adolescents (13 to 18 years).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included two trials involving 189 participants. One study, with 35 participants, compared methadone with levo-alpha-acetylmethadol (LAAM) for maintenance treatment lasting 16 weeks, after which patients were detoxified. The other study, with 154 participants, compared maintenance treatment with buprenorphine-naloxone and detoxification with buprenorphine. We did not perform meta-analysis because the two studies assessed different comparisons.In the study comparing methadone and LAAM, the authors declared that there was no difference in the use of a substance of abuse or social functioning (data not shown). The quality of the evidence was very low. No side effects, such as nausea, vomiting, constipation, weakness or fatigue, were reported by study participants.In the comparison between buprenorphine maintenance and buprenorphine detoxification, maintenance treatment appeared to be more efficacious in retaining patients in treatment (drop-out risk ratio (RR) 0.37; 95% confidence interval (CI) 0.26 to 0.54), but not in reducing the number of patients with a positive urine test at the end of the study (RR 0.97; 95% CI 0.78 to 1.22). Self reported opioid use at one-year follow-up was significantly lower in the maintenance group, even though both groups reported a high level of opioid use (RR 0.73; 95% CI 0.57 to 0.95). More patients in the maintenance group were enrolled in other addiction treatment programmes at 12-month follow-up (RR 1.33; 95% CI 0.94 to 1.88). The quality of the evidence was low. No serious side effects attributable to buprenorphine-naloxone were reported by study participants and no patients were removed from the study due to side effects. The most common side effect was headache, which was reported by 16% to 21% of patients in both groups

AUTHORS' CONCLUSIONS

It is difficult to draft conclusions on the basis of only two trials. One of the possible reasons for the lack of evidence could be the difficulty of conducting trials with young people for practical and ethical reasons.There is an urgent need for further randomised controlled trials comparing maintenance treatment with detoxification treatment or psychosocial treatment alone before carrying out studies that compare different pharmacological maintenance treatments. These studies should have long follow-up and measure relapse rates after the end of treatment and social functioning (integration at school or at work, family relationships).