A risk-benefit analysis of methadone maintenance treatment

Characteristics of non-fatal overdoses and associated risk factors in patients attending a specialist community-based substance misuse service

Introduction

There are concerns about rising drug-related deaths and the potential contribution of prescription analgesics. There is limited understanding regarding the role of prescription analgesics in non-fatal overdoses (NFODs), nor is there a good understanding of what factors are associated with more severe overdose.

Objectives

To explore risk factors and characteristics of NFODs among people attending a specialist community-based substance misuse service.

Methods

After Caldicott approval, data on NFODs, in people attending the Tayside Substance Misuse Service (TSMS), were extracted from the Scottish Ambulance Service database, along with opioid replacement therapy (ORT) prescribing data. Statistical analysis was performed using R studio and Microsoft Excel.

Results

557 people (78% [434/556] male, mean age ± standard deviation 38.4 ± 7.95) had an NFOD. Repeat NFODs were more likely in males compared to females ( p < .0065). Males were more likely to be administered naloxone (OR = 1.94, 95% CI = 1.10–3.40, p < .02). NFODs at home were more likely to be moderate to severe (categorized by Glasgow Comma Scale [ p < .02, OR = 4.95, 95% CI = 1.24–24.38]). Methadone (321/557, 57.63%), benzodiazepines (281/557, 50.45%) and heroin (244/557, 43.81%) were the commonest substances: prescribed methadone overdose was more likely than buprenorphine ( p < .00001). Opioids and benzodiazepines were often taken together (275/557, 49.40%), with almost all gabapentinoid NFODs also involving opioids (60/61, 98.40%).

Conclusions

Polysubstance use with opioids prescribed for ORT, such as methadone, is highly likely to be implicated in NFOD, with males being at the highest risk of severe and repeat NFOD. Future work should focus on strategies to further reduce NFODs.

"I'm Going to Stop Myself Before Someone Stops Me": Complicating Narratives of Volitional Substance Use Treatment

Background: Often people assume that entry into drug treatment is a voluntary action for persons who use drugs (PWUD). This narrative informs the organizational and regulatory structure of most treatment programs and consequently affects patients' ability to exert agency over their own treatment. Yet, this view ignores the complex interplay between individual and structural factors in peoples' decision-making processes, particularly among people who use drugs who are stigmatized and criminalized. Treatment programs that assume voluntary entry may lack appropriate services for the populations of treatment seekers that they serve. Methods: This paper uses semi-structured interviews with 42 participants in Opioid Substitution Treatment (OST) (including patients, clinic doctors and staff, and advocates) informed by one of the author's own lived experience in OST, to examine patients' treatment decisions, and in particular, if and how, the structural context of drugs' illegality/criminalization affected their willingness to pursue treatment. A Critical Discourse Analysis was used to identify key themes. Results: Interview data demonstrates that most people who use drugs enter treatment under constrained conditions related to drugs' illegality. Themes that emerged included: 1. A feeling of limited choices due to drugs' illegality; 2. Peer and family pressure; 3. Fear of losing children; and 4. Internalized stigma (i.e. feeling they are dirty or bad for using). Conclusion: Narratives that frame PWUD's treatment decisions as volitional provide political cover to policies that criminalize PWUD by obscuring their effect on PWUD's treatment decisions. Treatment models, particularly those that serve highly criminalized populations, should be re-conceptualized outside of normative narratives of individual choice, and be broadened to understand how larger structures constrain choices. By looking at macro-level factors, including the interplay of criminalization and drug treatment, programs can begin to understand the complexity of PWUD motivations to enter drug treatment. Recognizing the role of the War on Drugs as a force of oppression for people who use drugs, and that their treatment decisions are made within that setting, may enable people in treatment, and providers, to develop more productive ways of interacting with one another. Additionally, this may lead to better retention in treatment programs.

Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis

Opioid use disorder (OUD) is associated with a high risk of premature death. Medication-assisted treatment (MAT) is the primary treatment for opioid dependence. We comprehensively assessed the effects of different MAT-related characteristics on mortality among those with OUD by a systematic review and meta-analysis. The all-cause and overdose crude mortality rates (CMRs) and relative risks (RRs) by treatment status, different type, period, and dose of medication, and retention time were pooled using random effects, subgroup analysis, and meta-regression. Thirty cohort studies involving 370,611 participants (1,378,815 person-years) were eligible in the meta-analysis. From 21 studies, the pooled all-cause CMRs were 0.92 per 100 person-years (95% CI: 0.79-1.04) while receiving MAT, 1.69 (1.47-1.91) after cessation, and 4.89 (3.54-6.23) for untreated period. Based on 16 studies, the pooled overdose CMRs were 0.24 (0.20-0.28) while receiving MAT, 0.68 (0.55-0.80) after cessation of MAT, and 2.43 (1.72-3.15) for untreated period. Compared with patients receiving MAT, untreated participants had higher risk of all-cause mortality (RR 2.56 [95% CI: 1.72-3.80]) and overdose mortality (8.10 [4.48-14.66]), and discharged participants had higher risk of all-cause death (2.33 [2.02-2.67]) and overdose death (3.09 [2.37-4.01]). The all-cause CMRs during and after opioid substitution treatment with methadone or buprenorphine were 0.93 (0.76-1.10) and 1.79 (1.47-2.10), and corresponding estimate for antagonist naltrexone treatment were 0.26 (0-0.59) and 1.97 (0-5.18), respectively. Retention in MAT of over 1-year was associated with a lower mortality rate than that with retention ≤1 year (1.62, 1.31-1.93 vs. 5.31, -0.09-10.71). Improved coverage and adherence to MAT and post-treatment follow-up are crucial to reduce the mortality. Long-acting naltrexone showed positive advantage on prevention of premature death among persons with OUD.

A prospective observational study of heroin users in Johannesburg, South Africa: Assessing psychiatric comorbidities and treatment outcomes

BACKGROUND

Despite the rise in heroin use in sub Saharan-Africa opioid agonist maintenance treatment (OAMT) is still not state-funded in South Africa and many other African countries. In South Africa there has been little data published on the profile of heroin users and the outcomes of treatment for those who attend public treatment services.

METHODS

300 heroin users from two state-funded rehabilitation centres in Johannesburg were studied at entry into rehabilitation and 3-months after treatment. Treatment consisted of inpatient detoxification and inpatient psychosocial rehabilitation. Structured interviews measured changes in drug use, psychopathology and criminality post rehabilitation.

RESULTS

Most (65.7%) smoked heroin in combination with cannabis while 29.7% were injecting users. Almost half the sample (49.3%) had at least one mental illness. Of the 252 (84%) participants seen at 3-month follow-up, 6.3% were abstinent of all substances (excluding tobacco), 65.5% had continued heroin use (CHU) and the balance used other substances. At follow-up there were significant decreases in heroin use (p<0.0001) and criminality (p<0.0001). There were however significant increases in alcohol use (p<0.0001), crystalmetamphetamine use (p=0.032) and the prevalence of current episode of major depression (p<0.0001). Just 11.9% received formal psychosocial treatment after leaving rehabilitation. None were on OAMT and only three participants were on psychotropic medication. None were tested for Hepatitis C during the study period and the majority (53%) did not know their HIV status.

CONCLUSION

There are significant gaps in current treatment services for heroin users in South Africa. Retention in treatment and assessment and management of psychiatric and non-psychiatric comorbidities is low. Services need to be more integrated and should also include the provision of OAMT.

Construction and Analysis of Protein-Protein Interaction Network of Heroin Use Disorder

Heroin use disorder (HUD) is a complex disease resulting from interactions among genetic and other factors (e.g., environmental factors). The mechanism of HUD development remains unknown. Newly developed network medicine tools provide a platform for exploring complex diseases at the system level. This study proposes that protein–protein interactions (PPIs), particularly those among proteins encoded by casual or susceptibility genes, are extremely crucial for HUD development. The giant component of our constructed PPI network comprised 111 nodes with 553 edges, including 16 proteins with large degree (k) or high betweenness centrality (BC), which were further identified as the backbone of the network. JUN with the largest degree was suggested to be central to the PPI network associated with HUD. Moreover, PCK1 with the highest BC and MAPK14 with the secondary largest degree and 9^th highest BC might be involved in the development HUD and other substance diseases.

The value of harm reduction for injection drug use: A clinical and public health ethics analysis

The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.

Effects of Methadone Maintenance Therapy on Thyroid Function of Adult Men

One of the major challenges in methadone maintenance therapy (MMT) for drug dependence is the physiological side effects on endocrine hormones. Because of the key role of the thyroid gland in the normal functioning of the human body and brain, this study examined the effect of MMT on thyroid function. Thyroid hormones (T3, T4, and thyroid-stimulating hormone (TSH)) were evaluated in normal and user treated with MMT who were referred to the Province Clinical & Pathology Center of Urmia, Iran. The study was conducted for three months using the Case Series method. A total of 270 samples were collected, 215 were from individuals who were not treated, whereas 55 were from men treated with methadone. Average levels of T3 and T4 in non-treated sample of men are 1.34 ± 0.02 ng/mL and 90.96 ± 1.38 ng/mL while the corresponding values for patients treated with methadone are 1.39 ± 0.04 ng/mL for T3 and 94.57 ± 2.72 ng/mL for T4. Mean TSH levels of the non-treated group and the methadone consuming group were 1.75 ± 0.08 μIU/mL and 3.17 ± 0.45 μIU/mL, respectively. These results indicate that although men treated with methadone had higher levels of T3, T4, and TSH than normal individuals, only the difference in TSH level was significant. The importance of this difference among individuals on methadone maintenance programs should be investigated in larger samples over long periods of time. Additionally, the effects of methadone treatment on women should be examined.

The Impact of Social Support and Attachment Style on Quality of Life and Readiness to Change in a Sample of Individuals Receiving Medication-Assisted Treatment for Opioid Dependence

BACKGROUND

A basic principle within the addictions treatment field is that social support is a vital ingredient in the recovery process. This study examines the nature of social support in a sample of opioid-dependent men and women who are currently being treated in a medication-assisted treatment program (methadone). This research examines the types of social support behaviors that the opioid-dependent individuals consider helpful and explores whether attachment style (i.e., secure, ambivalent, or anxious attachment) was a determining factor in whether social support was perceived as helpful. The dependent variables included readiness to change addictive behaviors and abstinence from other mood-altering drugs.

METHODS

Participants (N = 159) completed a demographic questionnaire, the Significant Others Scale, the Experiences in Close Relationships Scale, the Multidimensional Scale of Perceived Social Support Assessment, the Readiness to Change Scale, and an Attachment Style Questionnaire. The demographic questionnaire included subjective ratings of self-improvement.

RESULTS

Social support predicted perceived improvement in all of the areas examined (e.g., health, family/social relationships) and abstinence; however, attachment style did not predict improvement or with readiness to change.

CONCLUSIONS

Social support is an important factor in one's recovery from substance use disorders. Yet attachment style (i.e., anxious, avoidant, or secure) did not predict abstinence or overall improvement in functioning.

Genetic signatures of heroin addiction

Heroin addiction is a complex psychiatric disorder with a chronic course and a high relapse rate, which results from the interaction between genetic and environmental factors. Heroin addiction has a substantial heritability in its etiology; hence, identification of individuals with a high genetic propensity to heroin addiction may help prevent the occurrence and relapse of heroin addiction and its complications. The study aimed to identify a small set of genetic signatures that may reliably predict the individuals with a high genetic propensity to heroin addiction. We first measured the transcript level of 13 genes (RASA1, PRKCB, PDK1, JUN, CEBPG, CD74, CEBPB, AUTS2, ENO2, IMPDH2, HAT1, MBD1, and RGS3) in lymphoblastoid cell lines in a sample of 124 male heroin addicts and 124 male control subjects using real-time quantitative PCR. Seven genes (PRKCB, PDK1, JUN, CEBPG, CEBPB, ENO2, and HAT1) showed significant differential expression between the 2 groups. Further analysis using 3 statistical methods including logistic regression analysis, support vector machine learning analysis, and a computer software BIASLESS revealed that a set of 4 genes (JUN, CEBPB, PRKCB, ENO2, or CEBPG) could predict the diagnosis of heroin addiction with the accuracy rate around 85% in our dataset. Our findings support the idea that it is possible to identify genetic signatures of heroin addiction using a small set of expressed genes. However, the study can only be considered as a proof-of-concept study. As the establishment of lymphoblastoid cell line is a laborious and lengthy process, it would be more practical in clinical settings to identify genetic signatures for heroin addiction directly from peripheral blood cells in the future study.

Use of pharmacotherapies in the treatment of alcohol use disorders and opioid dependence in primary care

Substance-related and addictive disorders are chronic relapsing conditions that substantially impact public health. Effective treatments for these disorders require addressing substance use/dependence comprehensively as well as other associated comorbidities. Comprehensive addressing of substance use in a medical setting involves screening for substance use, addressing substance use directly with the patient, and formulating an appropriate intervention. For alcohol dependence and opioid dependence, pharmacotherapies are available that are safe and effective when utilized in a comprehensive treatment paradigm, such as medication assisted treatment. In primary care, substance use disorders involving alcohol, illicit opioids, and prescription opioid abuse are common among patients who seek primary care services. Primary care providers report low levels of preparedness and confidence in identifying substance-related and addictive disorders and providing appropriate care and treatment. However, new models of service delivery in primary care for individuals with substance-related and addictive disorders are being developed to promote screening, care and treatment, and relapse prevention. The education and training of primary care providers utilizing approved medications for the treatment of alcohol use disorders and opioid dependence in a primary care setting would have important public health impact and reduce the burden of alcohol abuse and opioid dependence.

Pharmacological maintenance treatments of opiate addiction

For people seeking treatment, the course of heroin addiction tends to be chronic and relapsing, and longer duration of treatment is associated with better outcomes. Heroin addiction is strongly associated with deviant behaviour and crime, and the objectives in treating heroin addiction have been a blend of humane support, rehabilitation, public health intervention and crime control. Reduction in street heroin use is the foundation on which all these outcomes are based. The pharmacological basis of maintenance treatment of dependent individuals is to minimize withdrawal symptoms and attenuate the reinforcing effects of street heroin, leading to reduction or cessation of street heroin use. Opioid maintenance treatment can be moderately effective in suppressing heroin use, although deviations from evidence-based approaches, particularly the use of suboptimal doses, have meant that treatment as delivered in practice may have resulted in poorer outcomes than predicted by research. Methadone treatment has been 'programmatic', with a one-size-fits-all approach that in part reflects the perceived need to impose discipline on deviant individuals. However, differences in pharmacokinetics and in side-effects mean that many patients do not respond optimally to methadone. Injectable diamorphine (heroin) provides a more reinforcing medication for some 'nonresponders' and can be a valuable option in the rehabilitation of demoralized, socially excluded individuals. Buprenorphine, a partial agonist, is a less reinforcing medication with different side-effects and less risk of overdose. Not only is it a different medication, but also it can be used in a different paradigm of treatment, office-based opioid treatment, with less structure and offering greater patient autonomy.

Impact of cannabis use during stabilization on methadone maintenance treatment

BACKGROUND AND OBJECTIVES

Illicit drug use, particularly of cannabis, is common among opiate-dependent individuals and has the potential to impact treatment in a negative manner.

METHODS

To examine this, patterns of cannabis use prior to and during methadone maintenance treatment (MMT) were examined to assess possible cannabis-related effects on MMT, particularly during methadone stabilization. Retrospective chart analysis was used to examine outpatient records of patients undergoing MMT (n = 91), focusing specifically on past and present cannabis use and its association with opiate abstinence, methadone dose stabilization, and treatment compliance.

RESULTS

Objective rates of cannabis use were high during methadone induction, dropping significantly following dose stabilization. History of cannabis use correlated with cannabis use during MMT but did not negatively impact the methadone induction process. Pilot data also suggested that objective ratings of opiate withdrawal decrease in MMT patients using cannabis during stabilization.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The present findings may point to novel interventions to be employed during treatment for opiate dependence that specifically target cannabinoid-opioid system interactions.

Factors Associated with Symptoms of Depression among Injection Drug Users Receiving Antiretroviral Treatment in Indonesia

OBJECTIVE

Few studies have examined psychiatric comorbidity among HIV positive injection drug users (IDUs) in resource-limiting settings. We sought to identify key factors associated with symptoms of depression among IDUs receiving antiretroviral (ARV) treatment in Jakarta and Denpasar, Indonesia.

METHODS

The cross-sectional study was conducted at five ARV delivery sites in Indonesia. Former IDUs aged 18 years or older having received ARV treatment for at least three months (n=117) were recruited and interviewed face-to-face. A 9-item version of the Center for Epidemiologic Studies Depression Scale was used to measure symptoms of depression. A structured questionnaire measured participants' demographic characteristics, social support and services received, current substance use, and treatment for drug dependency and HIV. Multiple logistic regression was used to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CI).

RESULTS

Of the 117 participants, 33% (39) exhibited symptoms of depression, 24% (28) reported using an illicit substance in the past month, and 29% (34) were in methadone treatment. Depressive symptoms were significantly associated with recent substance use in the last 30 days (AOR, 95% CI: 5.3, 1.9 to 15.4) and being on methadone (3.5, 1.2 to 10). Older age (per year 0.9, 0.8 to 1), full-time employment (0.2, 0.1 to 0.7), and living with parents (0.2, 0.1 to 0.6) appeared to be protective.

CONCLUSION

The results suggest that depression is common among Indonesian IDUs, even among patients enrolled in methadone treatment. HIV clinics and drug treatment programs need to recognize the risk/protective factors and also provide services to address this common comorbidity.

Safe methadone induction and stabilization: report of an expert panel

OBJECTIVES

Methadone is a well-studied, safe, and effective medication when dispensed and consumed properly. However, a number of studies have identified elevated rates of overdose and death in patients being treated with methadone for either addiction or chronic pain. Among patients being treated with methadone in federally certified opioid treatment programs, deaths most often occur during the induction and stabilization phases of treatment. To address this issue, the federal Substance Abuse and Mental Health Services Administration invited the American Society of Addiction Medicine to convene an expert panel to develop a consensus statement on methadone induction and stabilization, with recommendations to reduce the risk of patient overdose or death related to methadone maintenance treatment of addiction.

METHODS

A comprehensive literature search of English-language publications (1979-2011) was conducted via MEDLINE and EMBASE. Methadone Action Group members evaluated the resulting information and collaborated in formulating the consensus statement presented here, which subsequently was reviewed by more than 100 experts in the field.

RESULTS

Published data indicate that deaths during methadone induction occur because the initial dose is too high, the dose is increased too rapidly, or the prescribed methadone interacts with another drug. Therefore, the Methadone Action Group has developed recommendations to help methadone providers avoid or minimize these risks.

CONCLUSIONS

Careful management of methadone induction and stabilization, coupled with patient education and increased clinical vigilance, can save lives in this vulnerable patient population.

Methadone-related deaths in Norway

INTRODUCTION

The use of methadone in opioid maintenance treatment (OMT) is potentially associated with a number of adverse effects and the risk of fatal toxicity. Increased methadone availability may lead to an increase in methadone-related deaths. We have investigated methadone-related deaths in Norway over the period 2000-2006.

MATERIALS AND METHODS

Methadone-positive samples over the period 2000-2006 were identified from forensic toxicological investigations, and demographic and toxicological data were retrieved. The cases were cross-linked with the Norwegian Cause of Death Registry and regional OMT registers.

RESULTS

A total of 312 individuals had died after taking methadone over the period 2000-2006, predominantly men with a mean age of 36. In 85% of cases (n=264), the deceased had died of a methadone-related intoxication, most often in combination with other drugs, including benzodiazepines, cannabis and other opioids. Only 22% of the deceased had been in OMT at the time of death. A larger proportion of OMT patients had died of causes other than intoxications compared to those not in OMT (30% vs. 8%, respectively), most commonly related to disease.

CONCLUSIONS

One methadone-related death occurred, on average, every week over the time period investigated. Only 22% of the deceased were registered in opioid maintenance treatment (OMT) programs. The findings underline the need to control diversion of medication from OMT programs.

The poor oral health status of former heroin users treated with methadone in a Chinese city

BACKGROUND

There have been few studies conducted on the oral health status of illegal drug users in China, affecting the development of preventive and therapeutic approaches. The aim of the present study was to investigate and analyze the oral health status of former heroin users treated with methadone in Chengdu, the capital of Sichuan Province in southwestern China.

MATERIAL/METHODS

The presence of caries (decayed tooth and root), missing teeth, residual roots, dental prosthetic restoration and periodontal health were investigated in 445 former heroin users treated with methadone (317 males and 128 females). Their ages ranged from 20 to 59 years old.

RESULTS

Among the study subjects, the prevalence of decayed/filled teeth was 64.72%, and the mean of decayed/filled teeth score was 2.92. The prevalence of decayed/filled roots was 21.80%, and the mean of decayed/filled roots score was 0.62. The prevalence of missing teeth was 31.46%, and the mean missing teeth score was 0.62. The prevalence of residual roots was 42.02%, with a mean score of 1.06. The rates of gingival bleeding, calculus, shallow pockets periodontal pocket, and deep periodontal pocket were 99.55%, 96.63%, 30.34%, and 2.70%, respectively.

CONCLUSIONS

The oral health status among the studied former heroin users in Chengdu was poorer than the general population. Better dental care for the former heroin users is needed to promote their oral health.

HIV and hepatitis C virus coinfection in Canada: challenges and opportunities for reducing preventable morbidity and mortality

OBJECTIVES

Hepatitis C virus (HCV) has emerged as an important health problem in the era of effective HIV treatment. However, very few data exist on the health status and disease burden of HIV/HCV-coinfected Canadians.

METHODS

HIV/HCV-coinfected patients were enrolled prospectively in a multicentre cohort from 16 centres across Canada between 2003 and 2010 and followed every 6 months. We determined rates of a first liver fibrosis or endstage liver disease (ESLD) event and all-cause mortality since cohort enrolment and calculated standardized mortality ratios compared with the general Canadian population.

RESULTS

A total of 955 participants were enrolled in the study and followed for a median of 1.4 (interquartile range 0.5-2.3) years. Most were male (73%) with a median age of 44.5 years; 13% self-identified as aboriginal. There were high levels of current injecting drug and alcohol use and poverty. Observed event rates [per 100 person-years; 95% confidence interval (CI)] were: significant fibrosis (10.21; 8.49, 12.19), ESLD (3.16; 2.32, 4.20) and death (3.72; 2.86, 4.77). The overall standardized mortality ratio was 17.08 (95% CI 12.83, 21.34); 12.80 (95% CI 9.10, 16.50) for male patients and 28.74 (95% CI 14.66, 42.83) for female patients. The primary causes of death were ESLD (29%) and overdose (24%).

CONCLUSIONS

We observed excessive morbidity and mortality in this HIV/HCV-coinfected population in care. Over 50% of observed deaths may have been preventable. Interventions aimed at improving social circumstances, reducing harm from drug and alcohol use and increasing the delivery of HCV treatment in particular will be necessary to reduce adverse health outcomes among HIV/HCV-coinfected persons.

Supervised daily consumption, contingent take-home incentive and non-contingent take-home in methadone maintenance

Methadone maintenance therapy (MMT) has been found effective in treating heroin addiction. Serious consideration should be given to the modality of methadone distribution, as it influences not only treatment outcome but the attitudes of policy makers and the community, too. On one hand, the choice of take-home methadone removes the need for daily attendance at a methadone clinic, which seems to improve patients' quality of life. On the other, this method, because of its lack of supervision and the absence of strict consumption monitoring, runs the risk of methadone misuse and diversion. In this study, we compared A) supervised daily consumption, B) contingent take-home incentives and C) non-contingent take-home in methadone maintenance in three groups of heroin-addicted patients attending three different MMT programmes. Retention rates at 12 months were significantly higher in contingent take-home patients (group B) than in those with supervised daily consumption (group A) and the non-contingent take-home (group C). Retention rates were higher in group A than in group C patients. Compared to patients in groups A and B, those in group C showed fewer negative urinalyses and higher rates of self-reported diversion and episodes of crime or violence. Results indicate a more positive outcomes following take-home methadone associated with behavioural incentives and other measures that aim to facilitate treatment compliance than those following daily supervised consumption. By contrast, non-contingent take-home methadone given to non-stabilized patients is associated with a high rate of diversion, along with more crime episodes and maladaptive behaviours.

Impact of supervision of methadone consumption on deaths related to methadone overdose (1993-2008): analyses using OD4 index in England and Scotland

OBJECTIVE

To evaluate the impact of introduction of supervision of methadone dosing on deaths related to overdose of methadone in Scotland and England between 1993 and 2008 while controlling for increased prescribing of methadone.

DESIGN

Analysis of annual trends in deaths related to overdose of methadone in relation to defined daily doses of methadone prescribed.

SETTING

Scotland and England. Population Deaths in which methadone was coded as the only drug involved or as one of the drugs implicated.

MAIN OUTCOME MEASURE

Annual OD4-methadone index (number of deaths with methadone implicated per million defined daily doses of methadone prescribed in that year).

RESULTS

OD4-methadone declined substantially over the four epochs of four years between 1993 and 2008. It decreased significantly (P<0.05) in 10 of 12 epoch changes: in Scotland from 19.3 (95% confidence interval 15 to 24) to 4.1 (2.8 to 5.4) and finally to 3.0 (2.4 to 3.5) for methadone only deaths (and from 58 to 29 to 14 for deaths with any mention of methadone); in England from 27.1 (25 to 29) to 24.8 (23 to 27) and finally to 5.8 (5.3 to 6.3) for methadone only deaths (and from 46 to 42 to 12 for deaths with any mention of methadone). The decreases in OD4-methadone were closely related to the introduction of supervised dosing of methadone in both countries, first in Scotland (1995-2000) and later in England (1999-2005). These declines occurred over periods of substantial increases in prescribing of methadone (18-fold increase in defined daily doses per million population annually in Scotland and sevenfold increase in England).

CONCLUSIONS

Introduction of supervised methadone dosing was followed by substantial declines in deaths related to overdose of methadone in both Scotland and England. OD4-methadone index analyses, controlled for substantial increases in methadone prescribing in both countries, identified at least a fourfold reduction in deaths due to methadone related overdose per defined daily dose (OD4-methadone) over this period.

Societal perception and support for methadone maintenance treatment in a Chinese province with high HIV prevalence

Methadone maintenance treatment (MMT) was first piloted in April 2004 in Yunnan, China, to reduce HIV transmission. This study aimed to examine public support for MMT and was based on cross-sectional data collected in March-April 2006 on a random sample of 411 police staff, medical/health professionals, community members, and drug users. Multivariate logistic regressions were used to analyze the data. The support was the strongest amongst the police and medical professionals but the lowest in drug users. A considerable proportion of the respondents viewed MMT as contradictory to China's drug control policies and this factor was negatively associated with support for MMT. Dissemination of more accurate knowledge and the resolution of these conflicts are urgently needed to increase the public support for MMT.

Tampering by office-based methadone maintenance patients with methadone take home privileges: a pilot study

Methadone Maintenance Treatment (MMT) is among the most widely studied treatments for opiate dependence with proven benefits for patients and society. When misused, however, methadone can also be lethal. The issue of methadone diversion is a major concern for all MMT programs. A potential source for such diversion is from those MMT patients who receive daily take home methadone doses. Using a reverse phase high performance liquid chromatography method, seven of the nine patients who were randomly selected to have all of their remaining methadone take home doses (within a 24 hour period) analyzed, returned lower than expected quantities of methadone. This finding suggests the possibility that such patients may have tampered with their daily take home doses. Larger prospective observational studies are clearly needed to test the supposition of this pilot study.

Pharmacotherapy of dual substance abuse and dependence

The US FDA has approved a limited number of treatments for alcohol, nicotine and opioid dependence; however, no treatments for other abused drugs such as marijuana, cocaine or methamphetamine are approved. This review focuses on research into drug pharmacotherapies, particularly single-drug therapies, for substance abuse and dependence contributing to the most important dual substance use disorders (SUDs). Given the implications of poly-substance abuse, it is essential that clinicians and researchers be aware of potential pharmacotherapies for the treatment of dual SUDs.A substantial number of patients abuse more than one drug concurrently, complicating the treatment of SUD and leaving clinicians with few FDA-approved drug options for their patients. In this era of evidence-based medicine, such patients are typically treated with therapeutically proven medications, but in ways that are outside the scope of a drug's original indication by the FDA. Such 'off-label' prescribing has become an important therapeutic strategy for practitioners seeking treatments for other diseases in subpopulations such as paediatrics and gerontology or for medical conditions such as oncology or mental illness. Similarly, the information that most clinicians use to make their decisions for treating patients abusing multiple drugs stems from trials treating a single SUD, anecdotal experiences from their own practice or that of their colleagues, or single-case studies reported in the literature. The existing evidence suggests there are few treatments for SUDs that confer significant reductions in substance use across a broad patient population. Moreover, even fewer clinical efficacy trials have been conducted that provide evidence of therapeutic benefit for these drugs. Recognising the difficulty in making the proper drug choice for facilitating maximum treatment success, this review highlights the single drugs or drug combinations that show some potential for treating dual SUDs. This review finds strongest support for the use of disulfiram for treatment of alcohol and cocaine dependence (with or without concomitant methadone maintenance), baclofen for alcohol and cocaine dependence (but not opioid-dependent cocaine users), tiagabine for cocaine dependence in methadone-maintained patients, and topiramate for alcohol, nicotine and cocaine dependence. While ondansetron and olanzapine show some efficacy in treating alcohol and cocaine dependence, more research is needed to better delineate the subpopulation in which these drugs may provide their maximum effect.

Does prescribing for opiate addiction change after national guidelines? Methadone and buprenorphine prescribing to opiate addicts by general practitioners and hospital doctors in England, 1995-2005

AIM

To assess changes in opiate prescribing (1995-2005) following a decade of national guidelines to address substandard opiate substitution prescribing for heroin addiction.

DESIGN

A repeat national survey (1995 and 2005) using random one-in-four samples of all community pharmacies in England, achieving response rates of 75% (1847/2475) in 1995 and 95% (2349/2473) in 2005. Data were obtained on 3732 (1995 data) and 9620 (2005 data) prescriptions dispensed in the preceding month from the 936 and 1463 pharmacies who were currently dispensing.

MEASUREMENTS

We have measured impact on practice for seven specific recommended changes.

FINDINGS

Between 1995 and 2005 the number of substitute opiate prescriptions doubled (x 2.03). By 2005, methadone still dominated (down from 97% to 83%), buprenorphine increased (from 1% to 16%) and other opiate medications virtually disappeared. Changes in the direction of national guidelines included: increased daily dose of methadone (from 47.3 mg to 56.3 mg), more frequent dispensing (from 38% to 60% as daily installments), more supervised consumption (from 0% to 36%) and fewer methadone tablets (from 10.9% to 1.8%). Nevertheless, despite the increased mean daily dose, only 41.0% of prescriptions for methadone were for daily doses in the recommended 60-120 mg dose range. Only one change was not in the direction of the national guidelines--the proportion of prescriptions from GPs fell from 41% to 30%, although this still represented an approximate 50% increase in the extent of GP prescribing.

CONCLUSION

Doubling in provision of opiate substitute treatment has occurred, alongside significant improvements in the nature of this treatment. These positive changes have occurred in the direction of six out of seven of the UK national guidelines.

Treatment retention in adolescent patients treated with methadone or buprenorphine for opioid dependence: a file review

The aim of this study was to compare retention and re-entry to treatment between adolescent subjects treated with methadone, those treated with buprenorphine, and those treated with symptomatic (non-opioid) medication only. We used a retrospective file review of all patients aged less than 18 at first presentation for treatment for opioid dependence. The study was conducted at the Langton Centre, Sydney, Australia, an agency specialising in the treatment of alcohol and other drug dependency. Sixty-one adolescents (age range 14 - 17 years at the time of commencing treatment); mean reported age of initiation of heroin use was 14 +/- 1.3 years (range 11 - 16). Sixty-one per cent were female. The first episode of treatment was methadone maintenance in 20 subjects, buprenorphine in 25, symptomatic medication in 15; one patient underwent assessment only. These 61 subjects had a total of 112 episodes of treatment. Subjects treated with methadone had significantly longer retention in first treatment episode than subjects treated with buprenorphine (mean days 354 vs. 58, p<0.01 by Cox regression) and missed fewer days in the first month (mean 3 vs. 8 days, p<0.05 by ttest). Subsequent re-entry for further treatment occurred in 25% of subjects treated with methadone, 60% buprenorphine and 60% symptomatic medications. Time to re-entry after first episode of buprenorphine treatment was significantly shorter than after methadone treatment (p<0.05 by Kaplan - Meier test). Methadone maintenance appears to have been more effective than buprenorphine at preventing premature drop-out from treatment of adolescent heroin users.

Methadone Induction Doses

PURPOSE

To review the literature on methadone deaths and propose evidence-based dosing guidelines.

METHODS

A literature search was conducted on overdose deaths during the induction phase. Data on methadone deaths from the Ontario coroner's office, as well as prescribing guidelines from different countries and jurisdictions, were reviewed. The information was collectively considered and, using the best available evidence, translated into safe dosing guidelines for methadone induction.

RESULTS

A literature review found high death rates during the methadone induction period. Data from the Ontario coroner's office revealed that of deaths that were felt to be attributable to methadone overdose, the majority occurred in those who had consumed diverted methadone: of those deaths within a registered program, the majority occurred during the initial dosing phase. Despite high death rates during induction onto methadone treatment, many jurisdictions do not have prescribing guidelines that take this evidence into account.

CONCLUSIONS

Safer prescribing guidelines are needed to reduce deaths during induction onto methadone treatment. Recommendations are made for safe methadone induction doses.

Opioid addicts at admission vs. slow-release oral morphine, methadone, and sublingual buprenorphine maintenance treatment participants

With use of a randomized study design, quality of life (QOL) and physical symptoms of opioid addicts at admission were compared with slow-release oral morphine, methadone, and sublingual buprenorphine maintenance program participants after 6 months of treatment. The study was conducted from February to July 2004 in the outpatient drug user treatment center at University Department of Psychiatry at Innsbruck, providing maintenance treatment programs and detoxification in Tyrol, Austria. One hundred twenty opioid users seeking treatment were compared with 120 opioid-dependent patients retained for 6 months on a slow-release oral morphine, methadone, or sublingual buprenorphine maintenance program. The German version ("Berlin Quality of Life Profile") of the Lancashire Quality of Life Profile was used, and illicit opioid use was determined by urinalysis. Physical symptoms were measured by using the Opioid Withdrawal Scale. Urinalyses revealed a significantly lower consumption of cocaine and opioids in all three substitution groups than in patients at admission (p < 0.001 and p < or = 0.004, respectively). Both the buprenorphine and the methadone maintenance group showed significantly more favorable values than opioid clients at admission for stomach cramps (p < or = 0.002), muscular tension (p < or = 0.027), general pain (p < or = 0.001), feelings of coldness (p < or = 0.000), heart pounding (p < or = 0.008), runny eyes (p < or = 0.047), and aggressions (p < or = 0.009). Patients who received slow-release oral morphine treatment generally showed the least favorable QOL scores compared with patients at admission or sublingual buprenorphine and methadone clients. Patients in the sublingual buprenorphine or methadone program showed nearly the same QOL scores. The buprenorphine and the methadone maintenance group showed significantly more favorable values than opioid clients at admission regarding leisure time (p < or = 0.019), finances (p < or = 0.014), mental health (p < or = 0.010), and overall satisfaction (p < or = 0.010). Slow-release oral morphine is a well-established treatment for pain, but more research is required to evaluate it as a treatment for heroin dependence. The present data indicate that slow-release oral morphine could have some disadvantages compared with sublingual buprenorphine and methadone in QOL, physical symptoms, and additional consumption. The results further suggest that buprenorphine treatment is as effective as methadone in effects on quality of life and physical symptoms.

Safety and efficacy of oral slow release morphine for maintenance treatment in heroin addicts: a 6-month open noncomparative study

This open-label, noncomparative, single-center trial evaluated the safety and efficacy of once-daily treatment with slow release oral morphine (SROM) capsules for the maintenance treatment of 20 outpatients with heroin dependency over 6 months at the National Institute for Addictions in Sofia, Bulgaria. Doses were individually titrated up to a mean daily maintenance dose of 760 mg (range 440-1,200 mg). SROM was effective in significantly reducing the signs and symptoms of opioid withdrawal and craving for heroin, with stabilization generally evident within two weeks. Nineteen patients completed 6 months of treatment and illicit opioid use was virtually eliminated. One patient withdrew voluntarily at 22 weeks. Validated questionnaires and tests indicated improvements in patients' well-being from baseline assessments. These included significant improvements with regard to suicidal depression (85%), anxiety and dysphoria (66%), general illness (58%), social dysfunction (54%), sense of hopelessness (34%), attention (25%), and self-reported typical depressive (27%) and disease-related (11%) symptoms. No deaths, serious adverse events, or withdrawals due to adverse events occurred. Five episodes of constipation and one episode of sweating (all nonserious and of mild or moderate severity) were reported. Vital signs were unaffected by SROM and no weight change was evident over the study period. The observations made in this study indicate a promising role for once-daily treatment with SROM in the clinical management of heroin dependency.

Fast gas chromatography/mass spectrometric assay for the validated quantitative determination of methadone and the primary metabolite EDDP in whole blood

A toxicological analysis was developed and validated for simultaneous screening and quantification of methadone (METH) and its primary metabolite 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP). The method employs microscale liquid-liquid extraction (microLLE) and direct injection of a separated aliquot of the organic layer into a gas chromatography/mass spectrometric (GC/MS) system without any other pre-treatment stages. A fast GC/MS runtime (total 5.8 min; METH, Rt = 3.55 min; EDDP, Rt = 3.40 min) combined with rapid sample preparation allowed cost-efficient and routinely applicable performance with a low amount of manual work. The validated parameters included: linearity (25-1000 ng mL(-1) both; R(METH)2 = 0.998 and R(EDDP)2 = 0.997), accuracy (Bias(METH): from -0.05 to 11.3%, Bias(EDDP): from 1.11 to 4.37%); intra and inter-assay precision (RSD(METH): from 2.4 to 3.9%, from 4.89 to 10.3%; RSD(EDDP): from 4.50 to 6.20%, from 4.57 to 15.2%), extraction efficiency (METH = 95.5%; EDDP = 90.6%), LOQ(Meth,EDDP) = 25 ng mL(-1). Samples were stable for at least 25 h and no selectivity problems or baseline interference were observed. The method should be applicable for identifying and quantitative confirmation of possible misuse and/or illegal use of METH in toxicological cases.

Mortality in heroin-assisted treatment in Switzerland 1994-2000

BACKGROUND

A major goal of heroin-assisted treatment in Switzerland has been to reduce the drug-related mortality of heroin users. Therefore, a continuous monitoring of deaths under treatment is essential.

AIMS

To assess mortality of participants in heroin-assisted treatment in Switzerland over a 7-year period from 1994 to 2000, and to compare this mortality to the general population and to other populations of opioid users, as reported in the literature.

METHOD

Estimation of person years under heroin-assisted treatment from the complete case registry of heroin-assisted treatment in Switzerland. Estimation of standardized mortality ratios comparing the population in treatment to the Swiss population (standardized to the year 2000).

RESULTS

Over the 7-year period, the crude death rate of patients in heroin-assisted treatment, and including one month after discharge from treatment, was 1% per year. The standardized mortality ratio for the entire observation period was 9.7 (95% C.I. 7.3-12.8), with females having higher standardized mortality ratios (SMR 17.2) than males (SMR 8.4). There was no clear time trend.

CONCLUSION

Mortality in heroin-assisted treatment was low compared to the mortality rate of Swiss opioid users 1990s (estimated to be between 2.5 and 3%). It was also low compared to mortality rates of opioid users in other maintenance treatments in other countries as reported in the literature. The SMR was also lower than that reported in the only meta-analysis in the literature: 13.2 (95% C.I. 12.3-14.1). The low mortality rate is all the more noteworthy as heroin-assisted treatment in Switzerland included only refractory opioid addicts with existing severe somatic and/or mental problems.

DECLARATION OF INTEREST

No conflicts of interest declared.

Gender differences in health-related quality of life on admission to a maintenance treatment program

We compared the gender differences in health-related quality of life (QOL) on admission to a maintenance program. 103 opioid users (65 men and 38 women) admitted to a maintenance treatment program during 2000-2002 were studied. During this period we assessed the QOL status using the German version ('Berlin Quality of Life Profile') of the Lancashire Quality of Life Profile. Physical symptoms were measured using the Opioid Withdrawal Scale. 312 urine screening tests were carried out to evaluate consumption. The female group showed significantly less additional consumption of other opiates (p = 0.043) compared with the male group. The male group showed significantly better QOL scores in self-esteem (p = 0.015), psychical health (p = 0.027), and law and security (p = 0.008). The outcome measures for withdrawal scores showed significantly less symptoms for males in twitching of muscles (p = 0.034), vomiting (p = 0.002), depressions (p = 0.004) and poor appetite (p = 0.008). In summary, both genders showed only a few significant differences on admission in terms of QOL and physical symptoms. The predominant effects of drug use appear to eclipse the gender-related role pattern. Further exploration of gender and QOL could have important theoretical and treatment implications.

Pharmacologic treatments for women with addictions

Physicians have a growing array of pharmacotherapies available for the treatment of substance use disorders. These medications are of central importance in the treatment of opioid and nicotine dependence and are of growing importance in the treatment of alcohol and stimulant dependence. Pharmacotherapy alone is rarely sufficient treatment for substance use disorder; appropriate psychosocial treatment or mutual help (eg, 12-step) participation is almost always indicated whether or not pharmacotherapy is used. Specialized facilities, licensing, and training are necessary for the use of some of the pharmacotherapies discussed in this article. The obstetrician gynecologist must determine the scope of his or her own practice in this area (ie, when to treat and when to refer) based on interest, training and experience, and available resources.

[Prevalence of infection by HIV and hepatitis C virus in a cohort of patients on methadone treatment]

BACKGROUND AND OBJECTIVES

Methadone maintenance treatment reduces drug-related-harm. The aims of the study were: a) to analyze the temporal tendencies of prevalence of infection by HIV and hepatitis C virus, and b) to evaluate if the adherence to methadone maintenance treatment protects against the infection by HIV and hepatitis C virus.

PATIENTS AND METHOD

Retrospective longitudinal study with All the 1,487 patients receiving treatment in the Province of Alicante between June 1990 and December 1997. The prevalence of infection by HIV and hepatitis C virus were computed. The variables associated to the infection by HIV and hepatitis C virus were recognized though a model of logistic regression.

RESULTS

The prevalence of infection by HIV decreased, and the prevalence of infection by hepatitis C virus increased along the studied period. The independent predictors with regard to the infection by HIV were the age of beginning in treatment (odds ratio [OR] = 0.95; 95% confident interval [95%CI], 0.93-0.97; p < 0.001), total time within treatment (OR = 0.99; 95%CI, 0.98-1.0; p = 0.01) and non-parenteral route of administration (OR = 0.25; 95%CI, 0.18-0.33; p < 0.001).

CONCLUSIONS

To be admitted to methadone maintenance treatment for the first time after opiate dependence has been developed and to remain in treatment for long periods of time, all that decreases the risk of infection by HIV.

Buprenorphine versus methadone maintenance treatment in an ambulant setting: a health-related quality of life assessment

BACKGROUND

To compare the effects on quality of life (QOL) of oral methadone with sublingual buprenorphine.

METHODS

We performed an open-label, non-randomized, two-site (methadone-buprenorphine) study. During 6 months we assessed the quality of life status of 53 opioid-dependent patients admitted to a methadone or buprenorphine maintenance programme using the German version (Berlin Quality of Life Profile) of the Lancashire Quality of Life Profile. Physical symptoms were measured using the Opioid Withdrawal Scale. Five hundred and thirty urine screening tests were carried out randomly to detect additional consumption.

RESULTS

Sixty-seven opioid-dependent subjects (38 on methadone and 29 on buprenorphine) were enrolled in the study, and 53 completed it (30 subjects treated with buprenorphine and 23 subjects with racemic methadone). The subjects were comparable on all baseline measures. At the first follow-up (week 8), the buprenorphine-maintained group showed significantly less additional consumption of opioids (P = 0.013) compared with the methadone group. Patients retained in the buprenorphine or methadone programme (week 24) showed no significant differences in all quality of life scores. At the end of the study period, the buprenorphine-maintained group showed significantly less additional consumption of opioids (P = 0.001) and cocaine (P = 0.018) compared with the methadone group. The outcome measures for withdrawal symptoms after 24 weeks of treatment with buprenorphine showed slight advantages in stomach cramps, fatigue or tiredness, feelings of coldness and heart pounding.

CONCLUSIONS

These results suggest that buprenorphine treatment is as effective as methadone regarding effects on quality of life and withdrawal symptoms. Buprenorphine has the potential to reduce the harm caused by drug abuse. Further research is needed to determine if buprenorphine is more effective than methadone in particular subgroups of patients.

Primary heroin users + drug-free treatment: an equation for success?

This study of persons referred to publicly funded drug-free substance abuse treatment in Washington State compares 122 primary heroin users (those specifying heroin as a drug of choice) with 532 persons who preferred other substances. Information on treatment entry and completion was obtained through review of client charts at the referral agency. Follow-up interviews with 587 participants provided self-reports of substance use during a 90-day period 3-6 months following removal from the treatment waitlist. Primary heroin users were significantly less likely than others to enter the treatment programs to which they were referred. Among treatment entrants, primary heroin users were somewhat less likely than other users to complete inpatient programs but no less likely to complete outpatient programs. The heroin preference group reported less abstinence and greater frequency of use during the follow-up period than did other users, patterns that almost entirely coincided with the lower treatment compliance in the heroin group. The authors note the importance of investigating methods for increasing treatment entry rates for opiate users who desire drug-free treatment.

Liver transplantation for patients on methadone maintenance

Most transplant programs require abstinence of at least 6 months from alcohol and illicit drugs before orthotopic liver transplantation (OLT). However, there are no published data regarding OLT outcomes in patients who are currently on methadone maintenance treatment (MMT) as part of the treatment of their heroin addiction at the time of OLT. The objective of this study is to evaluate our experience regarding the outcome of OLT in patients with end-stage liver disease (ESLD) who were on MMT at the time of OLT. Between March 1993 and May 1999, a total of 185 patients with ESLD underwent OLT at our center. Five transplant recipients (2.7%) had a history of heroin abuse and had undergone drug and alcohol rehabilitation, but could not be weaned off methadone. Pre-OLT status, drug history, perioperative course, compliance with medical therapy, post-OLT follow-up, and patient and allograft survival were analyzed in detail in these patients. All patients on MMT underwent uneventful OLTs. Their compliance with medications and follow-up was excellent. One patient was weaned completely off methadone after OLT. Post-OLT mean hospital stay in this group was 43 +/- 25 days. Although the number of patients was small, long-term outcome of liver transplant recipients on MMT appears similar to that of patients not on MMT who underwent OLT during this period. Our results suggest cirrhotic patients on MMT should be considered for OLT if they meet the same psychosocial requirements as patients with alcohol abuse. Furthermore, it is not necessary for patients to be weaned off methadone before OLT.