1
|
Grant I, Krupitsky E, Vetrova M, Umlauf A, Heaton RK, Hauger RL, Toussova O, Franklin DR, Letendre SL, Woody G, Blokhina E, Lioznov D, Zvartau E. Effects of Opioid Withdrawal on Psychobiology in People Living with HIV. Viruses 2024; 16:92. [PMID: 38257791 PMCID: PMC10818595 DOI: 10.3390/v16010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE Many persons with opioid use disorders (OUDs) have HIV disease and experience clinically significant stress after they enroll in abstinence-based treatment and undergo medically assisted withdrawal. We examined whether opioid withdrawal affects virologic control, inflammatory markers, cognition, and mood in persons with an OUD and HIV, and explored whether measures of withdrawal stress, such as activation of the HPA axis, contribute to alterations in immune function, cognition, and mood. METHOD AND PARTICIPANTS Study participants were 53 persons with HIV who were admitted for OUD treatment at the City Addiction Hospital in Saint Petersburg, Russian Federation. Participants were examined at admission, at the anticipated peak of withdrawal 3 to 7 days after the last day of a clonidine-based withdrawal process lasting 7 to 14 days, and 3 to 4 weeks after completing withdrawal. At these times, participants received medical exams and were evaluated for symptoms of withdrawal, as well as cognition and mood. Viral load, plasma cortisol, DHEA sulfate ester (DHEA-S), interleukin-6 (IL-6), and soluble CD14 (sCD14) were determined. Multivariable models examined the relationships between markers of HPA activation and the other parameters over time. RESULTS HPA activation as indexed by cortisol/DHEA-S ratio increased during withdrawal, as did markers of immune activation, IL-6 and sCD14. There were no significant associations between viral load and indicators of HPA activation. In longitudinal analyses, higher cortisol/DHEA sulfate was related to worse cognition overall, and more mood disturbance. Increase in IL-6 was associated with worse cognitive performance on a learning task. There were no significant associations with sCD14. CONCLUSIONS Worsening of cognition and measures of mood disturbance during withdrawal were associated with activation of the HPA axis and some measures of inflammation. Whether repeated episodes of opioid withdrawal have a cumulative impact on long-term HIV outcomes and neurocognition is a topic for further investigation.
Collapse
Affiliation(s)
- Igor Grant
- HIV Neurobehavioral Research Program, Department of Psychiatry, University of California San Diego, San Diego, CA 92103, USA; (A.U.); (R.K.H.); (R.L.H.); (D.R.F.); (S.L.L.)
| | - Evgeny Krupitsky
- Department of Pharmacology, Pavlov State Medical University, 197022 Saint Petersburg, Russia; (E.K.); (M.V.); (O.T.); (E.B.); (D.L.); (E.Z.)
- Department of Addictions, Bekhterev National Medical Research Center for Psychiatry and Neurology, 192019 Saint Petersburg, Russia
| | - Marina Vetrova
- Department of Pharmacology, Pavlov State Medical University, 197022 Saint Petersburg, Russia; (E.K.); (M.V.); (O.T.); (E.B.); (D.L.); (E.Z.)
| | - Anya Umlauf
- HIV Neurobehavioral Research Program, Department of Psychiatry, University of California San Diego, San Diego, CA 92103, USA; (A.U.); (R.K.H.); (R.L.H.); (D.R.F.); (S.L.L.)
| | - Robert K. Heaton
- HIV Neurobehavioral Research Program, Department of Psychiatry, University of California San Diego, San Diego, CA 92103, USA; (A.U.); (R.K.H.); (R.L.H.); (D.R.F.); (S.L.L.)
| | - Richard L. Hauger
- HIV Neurobehavioral Research Program, Department of Psychiatry, University of California San Diego, San Diego, CA 92103, USA; (A.U.); (R.K.H.); (R.L.H.); (D.R.F.); (S.L.L.)
- Center for Behavior Genetics of Aging, University of California San Diego, La Jolla, CA 92093, USA
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA 92093, USA
| | - Olga Toussova
- Department of Pharmacology, Pavlov State Medical University, 197022 Saint Petersburg, Russia; (E.K.); (M.V.); (O.T.); (E.B.); (D.L.); (E.Z.)
| | - Donald R. Franklin
- HIV Neurobehavioral Research Program, Department of Psychiatry, University of California San Diego, San Diego, CA 92103, USA; (A.U.); (R.K.H.); (R.L.H.); (D.R.F.); (S.L.L.)
| | - Scott L. Letendre
- HIV Neurobehavioral Research Program, Department of Psychiatry, University of California San Diego, San Diego, CA 92103, USA; (A.U.); (R.K.H.); (R.L.H.); (D.R.F.); (S.L.L.)
- Department of Medicine, University of California, San Diego, CA 92093, USA
| | - George Woody
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Elena Blokhina
- Department of Pharmacology, Pavlov State Medical University, 197022 Saint Petersburg, Russia; (E.K.); (M.V.); (O.T.); (E.B.); (D.L.); (E.Z.)
| | - Dmitry Lioznov
- Department of Pharmacology, Pavlov State Medical University, 197022 Saint Petersburg, Russia; (E.K.); (M.V.); (O.T.); (E.B.); (D.L.); (E.Z.)
| | - Edwin Zvartau
- Department of Pharmacology, Pavlov State Medical University, 197022 Saint Petersburg, Russia; (E.K.); (M.V.); (O.T.); (E.B.); (D.L.); (E.Z.)
| |
Collapse
|
2
|
Cadet T, Jalali A, Jeng PJ, Poole S, Woody G, Murphy SM. Determinants of health-related quality of life among individuals with opioid use disorder, recently released from incarceration. Addict Sci Clin Pract 2023; 18:34. [PMID: 37231479 DOI: 10.1186/s13722-023-00375-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 03/15/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND\OBJECTIVES: Concomitant with low rates of pharmacotherapy for incarcerated individuals with OUD, there is a high rate of opioid overdose following re-entry into the community. Our research objective was to develop a better understanding of the factors that influence health-related quality-of-life (HRQoL) among this population during the high-risk transition period from incarceration to community. Few studies have assessed health-related quality-of-life (HRQoL) among individuals with OUD who are involved with the criminal-legal system, let alone over the period directly surrounding release from incarceration. METHODS Secondary longitudinal analysis of data from a clinical trial where participants were randomized 1:1 to pre-release extended-release naltrexone (XR-NTX) + referral to community XR-NTX, vs. referral only. We conducted individual, multivariable regressions of EQ-5D domains (mobility, pain/discomfort, anxiety/depression; usual activities and self-care were excluded due to insufficient variation in scores), and the overall preference/utility score. HRQoL data were subset to timepoints immediately before release (baseline) and 12 weeks post-release; treatment groups were collapsed across condition. Multiple imputation by chained equations was conducted to handle missing 3-month data in the dependent variables and covariates, ad hoc. RESULTS Greater severity in the psychiatric composite score was associated with substantially lower HRQoL, across all measures, following release from incarceration. Greater severity in the medical composite score was associated with lower pain/discomfort-related HRQoL. CONCLUSIONS Our findings highlight the importance of ensuring individuals with OUD are linked not only to MOUD, but also treatment for their comorbid conditions upon release from incarceration.
Collapse
Affiliation(s)
- Techna Cadet
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, Suite 301, New York, NY, 10065, USA.
| | - Ali Jalali
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, Suite 301, New York, NY, 10065, USA
| | - Philip J Jeng
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, Suite 301, New York, NY, 10065, USA
| | - Sabrina Poole
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George Woody
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, Suite 301, New York, NY, 10065, USA
| |
Collapse
|
3
|
Miano TA, Wang L, Leonard CE, Brensinger CM, Acton EK, Dawwas GK, Bilker WB, Soprano SE, Nguyen TPP, Woody G, Yu E, Neuman M, Li L, Hennessy S. Identifying Clinically Relevant Drug-Drug Interactions With Methadone and Buprenorphine: A Translational Approach to Signal Detection. Clin Pharmacol Ther 2022; 112:1120-1129. [PMID: 35881659 PMCID: PMC10015595 DOI: 10.1002/cpt.2717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 07/18/2022] [Indexed: 11/11/2022]
Abstract
Methadone and buprenorphine have pharmacologic properties that are concerning for a high risk of drug-drug interactions (DDIs). We performed high-throughput screening for clinically relevant DDIs with methadone or buprenorphine by combining pharmacoepidemiologic and pharmacokinetic approaches. We conducted pharmacoepidemiologic screening via a series of self-controlled case series studies (SCCS) in Optum claims data from 2000 to 2019. We included persons 18 years or older who experienced an outcome of interest during target drug treatment. Exposures were all overlapping medications (i.e., the candidate precipitants) during target drug treatment. Outcomes were opioid overdose, non-overdose adverse effects, and cardiac arrest. We used conditional Poisson regression to calculate rate ratios, accounting for multiple comparisons with semi-Bayes shrinkage. We explored the impact of key study design choices in analyses that varied the exposure definitions of the target drugs and the candidate precipitant drugs. Pharmacokinetic screening was conducted by incorporating published data on CYP enzyme metabolism into an equation-based static model. In SCCS analysis, 1,432 events were included from 248,069 new users of methadone or buprenorphine. In the primary analysis, statistically significant DDIs included gabapentinoids with either methadone or buprenorphine; baclofen with methadone; and benzodiazepines with methadone. In sensitivity analysis, additional statistically significant DDIs included methocarbamol, quetiapine, or simvastatin with methadone. Pharmacokinetic screening identified two moderate-to-strong potential DDIs (clonidine and fluconazole with buprenorphine). The combination of clonidine and buprenorphine was also associated with a significantly increased risk of opioid overdose in pharmacoepidemiologic screening. These DDI signals may be the most important targets for future confirmation studies.
Collapse
Affiliation(s)
- Todd A. Miano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lei Wang
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Charles E. Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Colleen M. Brensinger
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily K. Acton
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ghadeer K. Dawwas
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Warren B. Bilker
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samantha E. Soprano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thanh Phuong Pham Nguyen
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Woody
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elmer Yu
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lang Li
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Chhatre S, Woody G, Metzger DS, Jayadevappa R. Burden of chronic conditions among persons with HIV/AIDS and psychiatric comorbidity. Curr HIV Res 2021; 19:504-513. [PMID: 34353265 DOI: 10.2174/1570162x19666210805092258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/23/2021] [Accepted: 06/28/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Improved survivorship among persons living with HIV translates into higher risk of medical comorbidities. OBJECTIVE We assessed the association between intersection of physical (HIV) and mental health (psychiatric) conditions and intermediate outcomes. METHODS Cross-sectional study of Medical Expenditure Panel Survey (MEPS)-Household Component between 1996 and 2016. We created four groups for persons aged ≥18: (1) HIV + psychiatric comorbidity, (2) HIV, (3) psychiatric comorbidity, and (4) no-HIV/no-psychiatric comorbidity. We compared the burden of medical comorbidities (metabolic disorders, cardiovascular disease, cancers, infectious diseases, pain, and substance use) across groups using chi square tests. We used logistic regression to determine the association between group status and medical comorbidity. RESULTS Of 218,133,630 (weighted) persons aged ≥18, 0.18% were HIV-positive. Forty-three percent of HIV group and 19% of no-HIV group had psychiatric comorbidities. Half of the HIV+ psychiatric disorder group had at least one medical comorbidity. Compared to the no-HIV/no-psychiatric comorbidity group, the HIV + psychiatric comorbidity group had highest odds of medical comorbidity (OR= 3.69, 95% CI = 2.99, 4.52). CONCLUSION Persons presenting with HIV + psychiatric comorbidity had higher odds of medical comorbidities of pain, cancer, cardiovascular disease, substance use, metabolic disorders and infectious diseases, beyond that experienced by persons with HIV infection or psychiatric disorders, independently. Future research will focus on the mediating effects of social determinants and biological factors on outcomes as quality of life, cost and mortality. This will facilitate a shift away from the single-disease framework and compress morbidity of the aging cohort of HIV-infected persons.
Collapse
Affiliation(s)
- Sumedha Chhatre
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. United States
| | - George Woody
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. United States
| | - David S Metzger
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. United States
| | | |
Collapse
|
5
|
Krupitsky EM, Zvartau EE, Blokhina EA, Verbitskaya EV, Wahlgren VY, Tsoy-Podosenin MV, Bushara NM, Burakov AM, Masalov DV, Romanova TN, Tiurina AA, Palatkin VY, Yaroslavtseva TS, Sulimov GY, Pecoraro A, Woody G. [Anhedonia, depression, anxiety, and craving in opioid dependent patients stabilized on oral naltrexone or naltrexone implant]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 118:26-33. [PMID: 29658501 DOI: 10.17116/jnevro20181181226-33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To assess the relationship between long-term naltrexone treatment and anxiety, depression and craving in opioid dependent individuals. MATERIAL AND METHODS Opioid dependent patients (n=306) were enrolled in a three cell (102ss/cell) randomized, double blind, double dummy, placebo-controlled 6-month trial comparing extended release implantable naltrexone with oral naltrexone and placebo (oral and implant). Monthly assessments of affective responses used a Visual Analog Scale for opioid craving, the Beck Depression Inventory, Spielberger Anxiety Inventory, and the Ferguson and Chapman Anhedonia Scales. Between-group outcomes were analyzed using mixed model analysis of variance (Mixed ANOVA) and repeated measures and the post hoc Tukey test. RESULTS AND CONCLUSION Anhedonia, depression, anxiety, and craving for opiates were elevated at baseline but gradually reduced to normal within the first 1-2 months for patients who remained in treatment and did not relapse. There were no significant between-group differences prior to treatment dropout as well as between those who relapsed and who continued on naltrexone. CONCLUSION These data do not support concerns that naltrexone treatment of opioid dependence precipitates anhedonia, depression, anxiety or craving for opiates.
Collapse
Affiliation(s)
- E M Krupitsky
- Valdman Institute of Pharmacology of Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia; St. Petersburg Bekhterev Research Psychoneurological Institute, St. Petersburg, Russia; Leningrad Regional Narcology Dispensary, St. Petersburg, Russia; Department of Psychiatry, University of Pennsylvania, Phyladelphia, USA
| | - E E Zvartau
- Valdman Institute of Pharmacology of Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - E A Blokhina
- Valdman Institute of Pharmacology of Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - E V Verbitskaya
- Valdman Institute of Pharmacology of Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - V Yu Wahlgren
- Valdman Institute of Pharmacology of Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - M V Tsoy-Podosenin
- Valdman Institute of Pharmacology of Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - N M Bushara
- Valdman Institute of Pharmacology of Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - A M Burakov
- Leningrad Regional Narcology Dispensary, St. Petersburg, Russia
| | - D V Masalov
- Leningrad Regional Narcology Dispensary, St. Petersburg, Russia
| | - T N Romanova
- Leningrad Regional Narcology Dispensary, St. Petersburg, Russia
| | - A A Tiurina
- Valdman Institute of Pharmacology of Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - V Ya Palatkin
- Valdman Institute of Pharmacology of Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - T S Yaroslavtseva
- Valdman Institute of Pharmacology of Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - G Yu Sulimov
- Valdman Institute of Pharmacology of Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - A Pecoraro
- Department of Psychiatry, University of Pennsylvania, Phyladelphia, USA
| | - G Woody
- Department of Psychiatry, University of Pennsylvania, Phyladelphia, USA
| |
Collapse
|
6
|
Krupitsky E, Blokhina E, Zvartau E, Verbitskaya E, Lioznov D, Yaroslavtseva T, Palatkin V, Vetrova M, Bushara N, Burakov A, Masalov D, Mamontova O, Langleben D, Poole S, Gross R, Woody G. Slow-release naltrexone implant versus oral naltrexone for improving treatment outcomes in people with HIV who are addicted to opioids: a double-blind, placebo-controlled, randomised trial. Lancet HIV 2019; 6:e221-e229. [PMID: 30880163 DOI: 10.1016/s2352-3018(18)30362-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/02/2018] [Accepted: 12/04/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Untreated opioid addiction in people with HIV is associated with poor HIV treatment outcomes. Slow-release, long-acting, implantable naltrexone might improve these outcomes. Here, we present results of a study aimed to test this hypothesis. METHODS We did a 48 week double-blind, double-dummy, placebo-controlled, phase 3, randomised trial with men and women addicted to opioids who were starting antiretroviral therapy (ART) for HIV and whose viral loads were higher than 1000 copies per mL. Participants were seeking treatment at two HIV and two narcology programme centres in Saint Petersburg, Russia, and the surrounding Leningrad region. The Pavlov statistical department created a table with stratification on gender distribution, viral load, and CD4 cell count. We stratified participants according to gender, viral load, and CD4 cells per μL, and randomly assigned (1:1) them to addiction treatment with a naltrexone implant and oral naltrexone placebo (implant group) or oral naltrexone and placebo implant (oral group). The primary outcome was plasma viral load of less than 400 copies per mL at 24 weeks and 48 weeks. We included all randomly assigned participants in outcome analyses (intention to treat). Treatment staff and patients were masked to group assignment. The study is complete and registered at ClinicalTrials.gov, NCT01101815. FINDINGS Between July 14, 2011, and April 14, 2014, 238 potential participants were recruited and screened, 35 were excluded for not meeting inclusion criteria, three declined to participate, and 200 were randomly assigned to treatment (100 to each group). At week 24, 38 (38) participants in the implant group and 35 (35%) in the oral group had viral loads less than 400 copies per mL (risk ratio 1·1, 95% CI 0·76-1·56; p=0·77). At week 48, 66 participants in the implant group and 50 in the oral group had viral loads less than 400 copies per mL (risk ratio 1·32, 95% CI 1·04-1·68; p=0·045). There were seven serious adverse events: three deaths in the implant group (one due to heart disease, one trauma, and one AIDS), and four in the oral group (two overdoses, one pancreatic cancer, and one AIDS). The overdose deaths occurred 9-10 months after the last naltrexone dose. INTERPRETATION The longer the blockade of opioid effects, the more protection an individual gets from missed ART doses and impulsive behaviours that lead to relapse and poor, even fatal, outcomes. Commercial development of implants could result in a meaningful addition to addiction treatment options. FUNDING National Institutes of Health, National Institute on Drug Abuse, Penn Centre for AIDS Research, and Penn Mental Health AIDS Research Centre.
Collapse
Affiliation(s)
- Evgeny Krupitsky
- First Pavlov State Medical University of Saint Petersburg, Saint Petersburg, Russia; VM Bekhterev National Medical Research Centre for Psychiatry and Neurology, Saint Petersburg, Russia
| | - Elena Blokhina
- First Pavlov State Medical University of Saint Petersburg, Saint Petersburg, Russia
| | - Edwin Zvartau
- First Pavlov State Medical University of Saint Petersburg, Saint Petersburg, Russia
| | - Elena Verbitskaya
- First Pavlov State Medical University of Saint Petersburg, Saint Petersburg, Russia
| | - Dmitri Lioznov
- First Pavlov State Medical University of Saint Petersburg, Saint Petersburg, Russia
| | | | - Vladimir Palatkin
- First Pavlov State Medical University of Saint Petersburg, Saint Petersburg, Russia
| | - Marina Vetrova
- First Pavlov State Medical University of Saint Petersburg, Saint Petersburg, Russia
| | - Natalia Bushara
- First Pavlov State Medical University of Saint Petersburg, Saint Petersburg, Russia
| | - Andrei Burakov
- First Pavlov State Medical University of Saint Petersburg, Saint Petersburg, Russia
| | - Dmitri Masalov
- First Pavlov State Medical University of Saint Petersburg, Saint Petersburg, Russia
| | - Olga Mamontova
- First Pavlov State Medical University of Saint Petersburg, Saint Petersburg, Russia
| | - Daniel Langleben
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sabrina Poole
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Gross
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George Woody
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
7
|
Chang KC, Wang JD, Saxon A, Matthews AG, Woody G, Hser YI. Causes of death and expected years of life lost among treated opioid-dependent individuals in the United States and Taiwan. Int J Drug Policy 2017; 43:1-6. [PMID: 28160734 DOI: 10.1016/j.drugpo.2016.12.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 11/01/2016] [Accepted: 12/13/2016] [Indexed: 11/30/2022]
Abstract
AIMS This study compared the cause-specific standardized mortality ratios (SMRs) and expected years of life lost (EYLL) among opioid-dependent individuals in the United States and Taiwan. METHODS Survival data came from two cohorts followed until 2014: The U.S. data were based on a randomized trial of 1267 opioid-dependent participants enrolled between 2006 and 2009; the Taiwan data were from a study of 983 individuals that began in 2006, when opioid agonist treatment (OAT) was implemented in Taiwan. SMRs were calculated for each national cohort and compared. Kaplan-Meier estimation was performed on the survival data, then lifespans were extrapolated to 70 years (840 months) to estimate life expectancy using a semi-parametric method. EYLLs for both cohorts were estimated by subtracting their life expectancies from the age- and gender-matched referents within the general population of their respective country. RESULTS Compared with age- and gender-matched referents, the SMRs were 3.2 for the U.S. sample and 7.8 for the Taiwan sample; the EYLLs were 7.7 and 16.4 years, respectively. Half of decedents died of unnatural causes in both cohorts; overdose deaths predominated in the U.S. and suicide in Taiwan. CONCLUSIONS Our study identified differences by country in EYLL and causes of deaths. These findings suggest that intervention strategies to reduce mortality risk by overdose (particularly in the U.S.) and suicide (particularly in Taiwan) are urgently needed in these countries.
Collapse
Affiliation(s)
- Kun-Chia Chang
- Jianan Psychiatric Center, Taiwan; National Cheng Kung University, Taiwan
| | - Jung-Der Wang
- National Cheng Kung University, Taiwan; National Cheng Kung University Hospital, Taiwan
| | - Andrew Saxon
- Veterans Affairs Puget Sound Health Care System, USA
| | | | | | - Yih-Ing Hser
- UCLA Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., Suite 200, Los Angeles, CA 90025, USA.
| |
Collapse
|
8
|
Krupitsky E, Zvartau E, Blokhina E, Verbitskaya E, Wahlgren V, Tsoy-Podosenin M, Bushara N, Burakov A, Masalov D, Romanova T, Tyurina A, Palatkin V, Yaroslavtseva T, Pecoraro A, Woody G. Anhedonia, depression, anxiety, and craving in opiate dependent patients stabilized on oral naltrexone or an extended release naltrexone implant. Am J Drug Alcohol Abuse 2016; 42:614-620. [PMID: 27436632 DOI: 10.1080/00952990.2016.1197231] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Naltrexone is a μ-opioid receptor antagonist that blocks opioid effects. Craving, depression, anxiety, and anhedonia are common among opioid dependent individuals and concerns have been raised that naltrexone increases them due to blocking endogenous opioids. Here, we present data that address these concerns. OBJECTIVE Assess the relationship between affective responses and naltrexone treatment. METHODS Opioid dependent patients (N = 306) were enrolled in a three cell (102ss/cell) randomized, double blind, double dummy, placebo-controlled 6-month trial comparing extended release implantable naltrexone with oral naltrexone and placebo (oral and implant). Monthly assessments of affective responses used a Visual Analog Scale for opioid craving, the Beck Depression Inventory, Spielberger Anxiety Test, and the Ferguson and Chapman Anhedonia Scales. Between-group outcomes were analyzed using mixed model analysis of variance (Mixed ANOVA) and repeated measures and the Tukey test for those who remained and treatment and did not relapse, and between the last measure before dropout with the same measure for those remaining in treatment. RESULTS Depression, anxiety, and anhedonia were elevated at baseline but reduced to normal within the first 1-2 months for patients who remained in treatment and did not relapse. Other than a slight increase in two anxiety measures at week two, there were no significant between-group differences prior to treatment dropout. CONCLUSION These data do not support concerns that naltrexone treatment of opioid dependence increases craving, depression, anxiety or anhedonia.
Collapse
Affiliation(s)
- Evgeny Krupitsky
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia.,b Department of Addictions, Bekhterev Research Psychoneurological Institute , St. Petersburg , Russia
| | - Edwin Zvartau
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia
| | - Elena Blokhina
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia
| | - Elena Verbitskaya
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia
| | - Valentina Wahlgren
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia
| | - Marina Tsoy-Podosenin
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia
| | - Natalia Bushara
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia
| | - Andrey Burakov
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia
| | - Dmitry Masalov
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia
| | - Tatyana Romanova
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia
| | - Arina Tyurina
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia
| | - Vladimir Palatkin
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia
| | - Tatyana Yaroslavtseva
- a Department of Pharmacology , St. Petersburg Pavlov State Medical University , St. Petersburg , Russia
| | - Anna Pecoraro
- c Department of Psychiatry, Treatment Research Institute , University of Pennsylvania , Philadelphia , PA , USA
| | - George Woody
- c Department of Psychiatry, Treatment Research Institute , University of Pennsylvania , Philadelphia , PA , USA
| |
Collapse
|
9
|
Woody G. Clonidine: new use of an old medication to reduce stress-related substance use. Evid Based Ment Health 2016; 19:e9. [PMID: 27056636 PMCID: PMC10699420 DOI: 10.1136/eb-2015-102137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 03/10/2016] [Accepted: 03/21/2016] [Indexed: 11/04/2022]
|
10
|
Hser YI, Evans E, Huang D, Weiss R, Saxon A, Carroll KM, Woody G, Liu D, Wakim P, Matthews AG, Hatch-Maillette M, Jelstrom E, Wiest K, McLaughlin P, Ling W. Long-term outcomes after randomization to buprenorphine/naloxone versus methadone in a multi-site trial. Addiction 2016; 111:695-705. [PMID: 26599131 PMCID: PMC4801718 DOI: 10.1111/add.13238] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 08/19/2015] [Accepted: 11/13/2015] [Indexed: 12/12/2022]
Abstract
AIMS To compare long-term outcomes among participants randomized to buprenorphine or methadone. DESIGN, SETTING AND PARTICIPANTS Follow-up was conducted in 2011-14 of 1080 opioid-dependent participants entering seven opioid treatment programs in the United States between 2006 and 2009 and randomized (within each program) to receive open-label buprenorphine/naloxone or methadone for up to 24 weeks; 795 participants completed in-person interviews (~74% follow-up interview rate) covering on average 4.5 years. MEASUREMENTS Outcomes were indicated by mortality and opioid use. Covariates included demographics, site, cocaine use and treatment experiences. FINDINGS Mortality was not different between the two randomized conditions, with 23 (3.6%) of 630 participants randomized to buprenorphine having died versus 26 (5.8%) of 450 participants randomized to methadone. Opioid use at follow-up was higher among participants randomized to buprenorphine relative to methadone [42.8 versus 31.7% positive opioid urine specimens, P < 0.01, effect size (h) = 0.23 (0.09, 0.38); 5.8 days versus 4.4 days of past 30-day heroin use, P < 0.05, effect size (d) = 0.14 (0.00, 0.28)]. Opioid use during the follow-up period by randomization condition was also significant (F(7,39,600) = 3.16; P < 0.001) due mainly to less treatment participation among participants randomized to buprenorphine than methadone. Less opioid use was associated with both buprenorphine and methadone treatment (relative to no treatment); no difference was found between the two treatments. Individuals who are white or used cocaine at baseline responded better to methadone than to buprenorphine. CONCLUSIONS There are few differences in long-term outcomes between buprenorphine and methadone treatment for opioid dependence, and treatment with each medication is associated with a strong reduction in opioid use.
Collapse
|
11
|
Abstract
Over the past decade, the amount and variety of addiction research around the world has increased substantially. Researchers in Australia, Canada, United Kingdom, United States, and western Europe have significantly contributed to knowledge about addiction and its treatment. However, the nature and context of substance use disorders and the populations using drugs are far more diverse than is reflected in studies done in Western cultures. To stimulate new research from a diverse set of cultural perspectives, the National Institute on Drug Abuse (NIDA) has promoted the development of addiction research capacity and skills around the world for over 25 years. This review will describe the programs NIDA has developed to sponsor international research and research fellows and will provide some examples of the work NIDA has supported. NIDA fellowships have allowed 496 individuals from 96 countries to be trained in addiction research. The United Arab Emirates and Saudi Arabia have recently developed funding to support addiction research to study, with advice from NIDA, the substance use disorder problems that affect their societies. Examples from Malaysia, Tanzania, Brazil, Russian Federation, Ukraine, Republic of Georgia, Iceland, China, and Vietnam are used to illustrate research being conducted with NIDA support. Health services research, collaboratively funded by the U.S. National Institutes of Health and Department of State, addresses a range of addiction service development questions in low- and middle-income countries. Findings have expanded the understanding of addiction and its treatment, and are enhancing the ability of practitioners and policy makers to address substance use disorders.
Collapse
Affiliation(s)
- Richard A. Rawson
- Professor and Co-Director, UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California at Los Angeles
| | - George Woody
- Professor, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania Principal Investigator, Delaware Valley Node of Clinical Trials Network, Treatment Research Institute
| | - Thomas F. Kresina
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, Maryland
| | - Steve Gust
- Director, International Program, National Institute on Drug Abuse, United States National Institutes of Health
| |
Collapse
|
12
|
Chhatre S, Metzger DS, Malkowicz SB, Woody G, Jayadevappa R. Substance use disorder and its effects on outcomes in men with advanced-stage prostate cancer. Cancer 2014; 120:3338-45. [PMID: 25042396 DOI: 10.1002/cncr.28861] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 04/20/2014] [Accepted: 05/21/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Substance use disorder in patients with cancer has implications for outcomes. The objective of this study was to analyze the effects of the type and timing of substance use on outcomes in elderly Medicare recipients with advanced prostate cancer. METHODS This was an observational cohort study using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from 2000 to 2009. Among men who were diagnosed with advanced prostate cancer between 2001 and 2004, we identified those who had a claim for substance use disorder in the year before cancer diagnosis, 1 year after cancer diagnosis, and an additional 4 years after diagnosis. The outcomes investigated were use of health services, costs, and mortality. RESULTS The prevalence of substance use disorder was 10.6%. The category drug psychoses and related had greater odds of inpatient hospitalizations (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.9-2.8), outpatient hospital visits (OR, 2.6; 95% CI, 1.9-3.6), and emergency room visits (OR, 1.7; 95% CI, 1.2-2.4). Substance use disorder in the follow-up phase was associated with greater odds of inpatient hospitalizations (OR, 2.0; 95% CI, 1.8-2.2), outpatient hospital visits (OR, 2.0; 95% CI, 1.7-2.4), and emergency room visits (OR, 1.7; 95% CI, 1.5-2.1). Compared with men who did not have substance use disorder, those in the category drug psychoses and related had 70% higher costs, and those who had substance use disorder during the follow-up phase had 60% higher costs. The hazard of all-cause mortality was highest for patients in the drug psychoses and related category (hazard ratio, 1.3; 95% CI, 1.1-1.7) and the substance use disorder in treatment phase category (hazard ratio, 1.5; 95% CI, 1.3-1.7). CONCLUSIONS The intersection of advanced prostate cancer and substance use disorder may adversely affect outcomes. Incorporating substance use screening and treatments into prostate cancer care guidelines and coordination of care is desirable.
Collapse
Affiliation(s)
- Sumedha Chhatre
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | |
Collapse
|
13
|
Dvoriak S, Karachevsky A, Chhatre S, Booth R, Metzger D, Schumacher J, Chychula N, Pecoraro A, Woody G. Methadone maintenance for HIV positive and HIV negative patients in Kyiv: acceptability and treatment response. Drug Alcohol Depend 2014; 137:62-7. [PMID: 24548802 PMCID: PMC3985084 DOI: 10.1016/j.drugalcdep.2014.01.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 01/10/2014] [Accepted: 01/10/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND With up to 40% of opioid injectors infected with HIV, Ukraine has one of the most concentrated HIV epidemics in the world, mainly due to unsterile injection practices and a historical absence of effective prevention services. Harm reduction programs, including syringe exchange and a small buprenorphine treatment program, were introduced in 2004 and methadone maintenance was allowed in 2007. Despite an initial expansion, by 2009, only 3221 injectors were receiving methadone treatment. A growing body of research on methadone maintenance has found high retention rates with reduction in opioid use and HIV risk behaviors. We report on the acceptability and initial outcome of methadone treatment as a function of HIV status, an issue that has not yet been reported for injectors in Ukraine. METHODS Longitudinal observational study of a 12-week course of methadone treatment in 25 HIV+ and 25 HIV- opioid addicted individuals recruited from a harm reduction program and the city AIDS Center. Drug use and HIV risk were assessed at baseline and weeks 4, 8, 12 and 20; all patients were offered continued methadone maintenance in the Kyiv city program at the end of 12 weeks. RESULTS Fifty-four individuals were asked if they were interested in the study and 50, demographically similar to other samples of opioid addicted Ukrainians, agreed to participate. Two died of non-study related causes; the other 48 completed assessments at weeks 4, 8 and 12, and 47 completed followups at week 20. Significant reductions were seen in use of heroin (p<0.0001), other opiates/analgesics (p<0.0001), and HIV risk behaviors (drug, sex, total; all p<0.0001). All 48 patients chose to continue methadone after the 12-weeks of study medication ended. Unlike most opioid treatment studies, sexual risk was somewhat higher than injecting risk at study intake. CONCLUSIONS Methadone maintenance was well accepted by HIV+ and HIV- opioid dependent individuals and has the potential for significant public health impact if made more widely available with sustained access and support.
Collapse
Affiliation(s)
- Sergii Dvoriak
- Director, Ukrainian Institute of Public Health Policy, 4 Malopidvalna Str. Of. 6 Kyiv 01001 Kyiv, Ukraine
| | - Andrey Karachevsky
- Department of Psychiatry and Drug Abuse, O.O. Bogomolets National Medical University 34, Peremogy Avenue, Kyiv, Ukraine, 01601
| | - Sumedha Chhatre
- Treatment Research Institute, Suite 600, 150 South Independence Mall (W), Philadelphia, PA 19106
| | - Robert Booth
- Department of Psychiatry, University of Colorado, 1741 Vine Street, Denver, CO 80206
| | - David Metzger
- Perelman School of Medicine at the University of Pennsylvania and Treatment Research Institute, Suite 600, 150 South Independence Mall (W), Philadelphia, PA 19106
| | - Joseph Schumacher
- School of Medicine, University of Alabama, 1530 3rd Avenue South, Birmingham, AL
| | - Nina Chychula
- Department of Veterans Affairs Medical Center, 39th & Woodland Avenues, Philadelphia, PA 19104
| | - Anna Pecoraro
- Perelman School of Medicine at the University of Pennsylvania and Treatment Research Institute, Suite 600, 150 South Independence Mall (W), Philadelphia, PA 19106
| | - George Woody
- Perelman School of Medicine at the University of Pennsylvania and Treatment Research Institute, Suite 600, 150 South Independence Mall (W), Philadelphia, PA 19106, United States.
| |
Collapse
|
14
|
Pecoraro A, Mimiaga MJ, O'Cleirigh C, Safren SA, Blokhina E, Verbitskaya E, Krupitsky E, Dvoriak S, Woody G. Lost-to-care and engaged-in-care HIV patients in Leningrad Oblast, Russian Federation: barriers and facilitators to medical visit retention. AIDS Care 2014; 26:1249-57. [PMID: 24666174 DOI: 10.1080/09540121.2014.897910] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Sixty-nine percent of the 1.5 million Eastern Europeans and Central Asians with HIV live in the Russian Federation. Antiretroviral therapy (ART) is effective but cannot help those who leave treatment. Focus groups with patients who dropped out of ART for ≥12 months (lost-to-care, LTCs, n = 21) or continued for ≥12 months (engaged-in-care; EICs; n = 24) were conducted in St. Petersburg. Structural barriers included stigma/discrimination and problems with providers and accessing treatment. Individual barriers included employment and caring for dependents, inaccurate beliefs about ART (LTC only), side-effects, substance use (LTCs, present; EICs, past), and depression. Desire to live, social support, and spirituality were facilitators for both; EICs also identified positive thinking and experiences with ART and healthcare/professionals. Interventions to facilitate retention and adherence are discussed.
Collapse
Affiliation(s)
- Anna Pecoraro
- a Department of Psychiatry, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Crits-Christoph P, Gallop R, Sadicario JS, Markell HM, Calsyn DA, Tang W, He H, Tu X, Woody G. Predictors and moderators of outcomes of HIV/STD sex risk reduction interventions in substance abuse treatment programs: a pooled analysis of two randomized controlled trials. Subst Abuse Treat Prev Policy 2014; 9:3. [PMID: 24433412 PMCID: PMC3929547 DOI: 10.1186/1747-597x-9-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 01/08/2014] [Indexed: 11/17/2022]
Abstract
Background The objective of the current study was to examine predictors and moderators of response to two HIV sexual risk interventions of different content and duration for individuals in substance abuse treatment programs. Methods Participants were recruited from community drug treatment programs participating in the National Institute on Drug Abuse Clinical Trials Network (CTN). Data were pooled from two parallel randomized controlled CTN studies (one with men and one with women) each examining the impact of a multi-session motivational and skills training program, in comparison to a single-session HIV education intervention, on the degree of reduction in unprotected sex from baseline to 3- and 6- month follow-ups. The findings were analyzed using a zero-inflated negative binomial (ZINB) model. Results Severity of drug use (p < .01), gender (p < .001), and age (p < .001) were significant main effect predictors of number of unprotected sexual occasions (USOs) at follow-up in the non-zero portion of the ZINB model (men, younger participants, and those with greater severity of drug/alcohol abuse have more USOs). Monogamous relationship status (p < .001) and race/ethnicity (p < .001) were significant predictors of having at least one USO vs. none (monogamous individuals and African Americans were more likely to have at least one USO). Significant moderators of intervention effectiveness included recent sex under the influence of drugs/alcohol (p < .01 in non-zero portion of model), duration of abuse of primary drug (p < .05 in non-zero portion of model), and Hispanic ethnicity (p < .01 in the zero portion, p < .05 in the non-zero portion of model). Conclusion These predictor and moderator findings point to ways in which patients may be selected for the different HIV sexual risk reduction interventions and suggest potential avenues for further development of the interventions for increasing their effectiveness within certain subgroups.
Collapse
|
16
|
Pecoraro A, Ewen E, Horton T, Mooney R, Kolm P, McGraw P, Woody G. Using the AUDIT-PC to predict alcohol withdrawal in hospitalized patients. J Gen Intern Med 2014; 29:34-40. [PMID: 23959745 PMCID: PMC3889973 DOI: 10.1007/s11606-013-2551-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 12/11/2012] [Accepted: 06/27/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alcohol withdrawal syndrome (AWS) occurs when alcohol-dependent individuals abruptly reduce or stop drinking. Hospitalized alcohol-dependent patients are at risk. Hospitals need a validated screening tool to assess withdrawal risk, but no validated tools are currently available. OBJECTIVE To examine the admission Alcohol Use Disorders Identification Test-(Piccinelli) Consumption (AUDIT-PC) ability to predict the subsequent development of AWS among hospitalized medical-surgical patients admitted to a non-intensive care setting. DESIGN Retrospective case–control study of patients discharged from the hospital with a diagnosis of AWS. All patients with AWS were classified as presenting with AWS or developing AWS later during admission. Patients admitted to an intensive care setting and those missing AUDIT-PC scores were excluded from analysis. A hierarchical (by hospital unit) logistic regression was performed and receiver-operating characteristics were examined on those developing AWS after admission and randomly selected controls. Because those diagnosing AWS were not blinded to the AUDIT-PC scores, a sensitivity analysis was performed. PARTICIPANTS The study cohort included all patients age ≥18 years admitted to any medical or surgical units in a single health care system from 6 October 2009 to 7 October 2010. KEY RESULTS After exclusions, 414 patients were identified with AWS. The 223 (53.9 %) who developed AWS after admission were compared to 466 randomly selected controls without AWS. An AUDIT-PC score ≥4 at admission provides 91.0 % sensitivity and 89.7 % specificity (AUC=0.95; 95 % CI, 0.94–0.97) for AWS, and maximizes the correct classification while resulting in 17 false positives for every true positive identified. Performance remained excellent on sensitivity analysis (AUC=0.92; 95 % CI, 0.90–0.93). Increasing AUDIT-PC scores were associated with an increased risk of AWS (OR=1.68, 95 % CI 1.55–1.82, p<0.001). CONCLUSIONS The admission AUDIT-PC score is an excellent discriminator of AWS and could be an important component of future clinical prediction rules. Calibration and further validation on a large prospectivecohort is indicated.
Collapse
Affiliation(s)
- Anna Pecoraro
- />Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
- />NIDA Clinical Trials Network, Delaware Valley Node, Philadelphia, PA USA
| | - Edward Ewen
- />Department of Medicine,, Christiana Care Health System, Newark, DE USA
| | - Terry Horton
- />NIDA Clinical Trials Network, Delaware Valley Node, Philadelphia, PA USA
- />Department of Medicine,, Christiana Care Health System, Newark, DE USA
| | - Ruth Mooney
- />Department of Nursing,, Christiana Care Health System, Newark, DE USA
| | - Paul Kolm
- />Center for Outcomes Research,, Christiana Care Health System, Newark, DE USA
| | - Patty McGraw
- />Department of Medicine,, Christiana Care Health System, Newark, DE USA
| | - George Woody
- />Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
- />NIDA Clinical Trials Network, Delaware Valley Node, Philadelphia, PA USA
| |
Collapse
|
17
|
Wilcox CE, Bogenschutz MP, Nakazawa M, Woody G. Concordance between self-report and urine drug screen data in adolescent opioid dependent clinical trial participants. Addict Behav 2013; 38:2568-74. [PMID: 23811060 DOI: 10.1016/j.addbeh.2013.05.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 04/15/2013] [Accepted: 05/25/2013] [Indexed: 10/26/2022]
Abstract
Objective measures of drug use are very important in treatment outcome studies of persons with substance use disorders, but obtaining and interpreting them can be challenging and not always practical. Thus, it is important to determine if, and when, drug-use self-reports are valid. To this end we explored the relationships between urine drug screen results and self-reported substance use among adolescents and young adults with opioid dependence participating in a clinical trial of buprenorphine-naloxone. In this study, 152 individuals seeking treatment for opioid dependence were randomized to a 2-week detoxification with buprenorphine-naloxone (DETOX) or 12weeks of buprenorphine-naloxone (BUP), each with weekly individual and group drug counseling. Urine drug screens and self-reported frequency of drug use were obtained weekly, and patients were paid $5 for completing weekly assessments. At weeks 4, 8, and 12, more extensive assessments were done, and participants were reimbursed $75. Self-report data were dichotomized (positive vs. negative), and for each major drug class we computed the kappa statistic and the sensitivity, specificity, positive predictive value, and negative predictive value of self-report using urine drug screens as the "gold standard". Generalized linear mixed models were used to explore the effect of treatment group assignment, compensation amounts, and participant characteristics on self-report. In general, findings supported the validity of self-reported drug use. However, those in the BUP group were more likely to under-report cocaine and opioid use. Therefore, if used alone, self-report would have magnified the treatment effect of the BUP condition.
Collapse
|
18
|
Abstract
BACKGROUND Little in known about the extent to which outcome measures used in studies of the treatment of cocaine dependence are associated with longer-term use and with broader measures of clinical improvement. The current study examined reductions in use, and abstinence-oriented measures, in relation to functioning and longer-term clinical benefits in the treatment of cocaine dependence. METHODS Overall drug use, cocaine use, and functioning in a number of addiction-related domains for 487 patients diagnosed with DSM-IV cocaine dependence and treated with one of four psychosocial interventions in the NIDA Cocaine Collaborative Treatment Study were assessed monthly during 6 months of treatment and at 9, 12, 15, and 18 month follow-up. RESULTS Measures of during-treatment reduction in use were moderately correlated with drug and cocaine use measures 12 months, but showed non-significant or small correlations with measures of functioning at 12 months. Highest correlations were evident for abstinence measures (maximum consecutive days abstinence and completely abstinent) during treatment in relation to sustained (3 month) abstinence at 12 months. Latent class analysis of patterns of change over time revealed that most patients initially (months 1 to 4 of treatment) either became abstinent immediately or continued to use every month. Over the couse of follow-up, patients either maintained abstinence or used regularly - intermittent use was less common. CONCLUSIONS There were generally small associations between various measures of cocaine use and longer-term clinical benefits, other than abstinence was associated with continued abstinence. No one method of measuring outcome of treatment of cocaine dependence appears superior to others.
Collapse
Affiliation(s)
- Paul Crits-Christoph
- Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
| | - Robert Gallop
- Applied Statistics Program, Department of Mathematics, West Chester University, 25 University Avenue, West Chester, PA 19383, USA
| | | | - Jaclyn S. Sadicario
- Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
| | - George Woody
- Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
| |
Collapse
|
19
|
Saxon AJ, Ling W, Hillhouse M, Thomas C, Hasson A, Ang A, Doraimani G, Tasissa G, Lokhnygina Y, Leimberger J, Bruce RD, McCarthy J, Wiest K, McLaughlin P, Bilangi R, Cohen A, Woody G, Jacobs P. Buprenorphine/Naloxone and methadone effects on laboratory indices of liver health: a randomized trial. Drug Alcohol Depend 2013; 128:71-6. [PMID: 22921476 PMCID: PMC3543467 DOI: 10.1016/j.drugalcdep.2012.08.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 08/02/2012] [Accepted: 08/03/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Buprenorphine/naloxone (BUP) and methadone (MET) are efficacious treatments for opioid dependence, although concerns about a link between BUP and drug-induced hepatitis have been raised. This study compares the effects of BUP and MET on liver health in opioid-dependent participants. METHODS This was a randomized controlled trial of 1269 opioid-dependent participants seeking treatment at 8 federally licensed opioid treatment programs and followed for up to 32 weeks between May 2006 and August 2010; 731 participants met "evaluable" criteria defined as completing 24 weeks of medication and providing at least 4 blood samples for transaminase testing. Participants were randomly assigned to receive BUP or MET for 24 weeks. Shift table analysis determined how many evaluable participants moved between categories of low and elevated transaminase levels. Predictors of moving from low to high transaminase levels were identified. RESULTS Changes in transaminase levels did not differ by medication condition. Baseline infection with hepatitis C or B was the only significant predictor of moving from low to elevated transaminase levels; 9 BUP and 15 MET participants showed extreme liver test elevations and were more likely than those without extreme elevations to have seroconverted to both hepatitis B and C during the study, or to use illicit drugs during the first 8 weeks of treatment. MET participants were retained longer in treatment than BUP participants. CONCLUSIONS This study demonstrated no evidence of liver damage during the initial 6 months of treatment in either condition. Physicians can prescribe either medication without major concern for liver injury.
Collapse
Affiliation(s)
- Andrew J. Saxon
- Veteran’s Affairs Puget Sound Health Care System, 1660 South Columbian Way, Room 116 ATC, Seattle, WA 98108
| | - Walter Ling
- University of California, Los Angeles, Integrated Substance Abuse Programs, 1640 S. Sepulveda Blvd., Suite 120, Los Angeles, CA 90025
| | - Maureen Hillhouse
- University of California, Los Angeles, Integrated Substance Abuse Programs, 1640 S. Sepulveda Blvd., Suite 120, Los Angeles, CA 90025
| | - Christie Thomas
- University of California, Los Angeles, Integrated Substance Abuse Programs, 1640 S. Sepulveda Blvd., Suite 120, Los Angeles, CA 90025
| | - Albert Hasson
- University of California, Los Angeles, Integrated Substance Abuse Programs, 1640 S. Sepulveda Blvd., Suite 120, Los Angeles, CA 90025
| | - Alfonso Ang
- University of California, Los Angeles, Integrated Substance Abuse Programs, 1640 S. Sepulveda Blvd., Suite 120, Los Angeles, CA 90025
| | - Geetha Doraimani
- University of California, Los Angeles, Integrated Substance Abuse Programs, 1640 S. Sepulveda Blvd., Suite 120, Los Angeles, CA 90025
| | - Gudaye Tasissa
- Duke Clinical Research Institute, Room 0311 Terrace Level, 2400 Pratt St., Durham, NC 27705
| | - Yuliya Lokhnygina
- Duke Clinical Research Institute, Room 0311 Terrace Level, 2400 Pratt St., Durham, NC 27705
| | - Jeff Leimberger
- Duke Clinical Research Institute, Room 0311 Terrace Level, 2400 Pratt St., Durham, NC 27705
| | - R. Douglas Bruce
- Yale University School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510
| | - John McCarthy
- Bi-Valley Medicine Clinic, Inc., 310 Harris Avenue, Suite A, Carmichael, CA 95838
| | | | | | - Richard Bilangi
- Connecticut Counseling Center, 60 Beaver Brook Road, Danbury CT 06810
| | - Allan Cohen
- Bay Area Addiction Research & Treatment, 15325 Del Gado Drive, Sherman Oaks, CA 91403
| | - George Woody
- Univeristy of Pennsylvania School of Medicine, 150 South Independence Mall West, Suite 600, Philadelphia, PA 19106-3475
| | - Petra Jacobs
- National Institute on Drug Abuse, Clinical Trials Network, 6001 Executive Boulevard, Room 3105, Bethesda, MD 20892-9557
| |
Collapse
|
20
|
Woody G. George Woody on Dr. Anonymous: "Treatment failure one step removed: the loss of researchers in the addictions". Subst Use Misuse 2012. [PMID: 23186482 DOI: 10.3109/10826084.2012.738902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- George Woody
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
| |
Collapse
|
21
|
Winhusen T, Brady KT, Stitzer M, Woody G, Lindblad R, Kropp F, Brigham G, Liu D, Sparenborg S, Sharma G, Vanveldhuisen P, Adinoff B, Somoza E. Evaluation of buspirone for relapse-prevention in adults with cocaine dependence: an efficacy trial conducted in the real world. Contemp Clin Trials 2012; 33:993-1002. [PMID: 22613054 PMCID: PMC3408816 DOI: 10.1016/j.cct.2012.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 05/03/2012] [Accepted: 05/13/2012] [Indexed: 11/29/2022]
Abstract
Cocaine dependence is a significant public health problem for which there are currently no FDA-approved medications. Hence, identifying candidate compounds and employing an efficient evaluation process is crucial. This paper describes key design decisions made for a National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) study that uses a novel two-stage process to evaluate buspirone (60 mg/day) for cocaine-relapse prevention. The study includes pilot (N=60) and full-scale (estimated N=264) trials. Both trials will be randomized, double-blind, and placebo-controlled and both will enroll treatment-seeking cocaine-dependent participants engaged in inpatient/residential treatment and scheduled for outpatient treatment post-discharge. All participants will receive contingency management in which incentives are given for medication adherence as evaluated by the Medication Events Monitoring System (MEMS). The primary outcome measure is maximum days of continuous cocaine abstinence, as assessed by twice-weekly urine drug screens (UDS) and self-report, during the 15-week outpatient treatment phase. Drug-abuse outcomes include cocaine use as assessed by UDS and self-report of cocaine use, other substance use as assessed by UDS and self-report of substance use (i.e., alcohol and/or illicit drugs), cocaine bingeing, HIV risk behavior, quality of life, functioning, and substance abuse treatment attendance. Unique aspects of the study include conducting an efficacy trial in community treatment programs, a two-stage process to efficiently evaluate buspirone, and an evaluation of mediators by which buspirone might exert a beneficial effect on relapse prevention.
Collapse
Affiliation(s)
- Theresa Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Sigmon SC, Bisaga A, Nunes EV, O'Connor PG, Kosten T, Woody G. Opioid detoxification and naltrexone induction strategies: recommendations for clinical practice. Am J Drug Alcohol Abuse 2012; 38:187-99. [PMID: 22404717 PMCID: PMC4331107 DOI: 10.3109/00952990.2011.653426] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Opioid dependence is a significant public health problem associated with high risk for relapse if treatment is not ongoing. While maintenance on opioid agonists (i.e., methadone, buprenorphine) often produces favorable outcomes, detoxification followed by treatment with the μ-opioid receptor antagonist naltrexone may offer a potentially useful alternative to agonist maintenance for some patients. METHOD Treatment approaches for making this transition are described here based on a literature review and solicitation of opinions from several expert clinicians and scientists regarding patient selection, level of care, and detoxification strategies. CONCLUSION Among the current detoxification regimens, the available clinical and scientific data suggest that the best approach may be using an initial 2-4 mg dose of buprenorphine combined with clonidine, other ancillary medications, and progressively increasing doses of oral naltrexone over 3-5 days up to the target dose of naltrexone. However, more research is needed to empirically validate the best approach for making this transition.
Collapse
Affiliation(s)
- Stacey C Sigmon
- Department of Psychiatry, University of Vermont College of Medicine, Burlington, 05401, USA.
| | | | | | | | | | | |
Collapse
|
23
|
Winhusen T, Stitzer M, Woody G, Brigham G, Kropp F, Ghitza U, Lindblad R, Adinoff B, Green C, Sharma G, Somoza E. Design considerations for a study to evaluate the impact of smoking cessation treatment on stimulant use outcomes in stimulant-dependent individuals. Contemp Clin Trials 2011; 33:197-205. [PMID: 22005174 DOI: 10.1016/j.cct.2011.09.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 09/24/2011] [Accepted: 09/27/2011] [Indexed: 11/30/2022]
Abstract
Cigarette smoking is prevalent in cocaine/methamphetamine-dependent patients and associated with significant morbidity and mortality, yet, the provision of smoking cessation treatment in conjunction with substance use disorder (SUD) treatment is not standard practice. This is due, in part, to clinician concern that combining smoking cessation treatment with SUD treatment could lead to poorer SUD outcomes. The NIDA Clinical Trials Network is conducting a 10-week, two-group, randomized trial to evaluate the impact of providing smoking cessation treatment (SCT) with SUD treatment as usual (TAU), compared to TAU alone, in smokers who are in outpatient treatment for cocaine or methamphetamine dependence. Approximately 528 participants, recruited from 12 community treatment programs, will be randomized into the trial. The present paper describes key design decisions made during protocol development. The trial is designed to evaluate the relationship between cigarette smoking and stimulant use, which prior research suggests is linked, and should contribute to our understanding of how best to address the co-occurring problems of nicotine dependence and cocaine/methamphetamine-dependence. Unique aspects of the trial include the primary question of interest, which concerns the impact of providing SCT on SUD outcomes rather than on smoking outcomes, and the intensity of the SCT chosen, which includes bupropion, nicotine replacement, and two psychosocial interventions.
Collapse
Affiliation(s)
- Theresa Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3210 Jefferson Avenue, Cincinnati, OH 45220, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Mimiaga MJ, Safren SA, Dvoryak S, Reisner SL, Needle R, Woody G. "We fear the police, and the police fear us": structural and individual barriers and facilitators to HIV medication adherence among injection drug users in Kiev, Ukraine. AIDS Care 2011; 22:1305-13. [PMID: 20640954 DOI: 10.1080/09540121003758515] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Ukraine has one of the most severe HIV/AIDS epidemics in Europe, with an estimated 1.63% of the population living with HIV/AIDS in 2007. Injection drug use (IDU) remains the predominant mode of transmission in Kiev - the capital and largest city. Prior reports suggest that the HIV infection rate among IDUs in Kiev reaches 33%, and many have poor and inequitable access to highly active antiretroviral therapy (HAART). Among those with access to HAART, little is understood about barriers and facilitators to HAART medication adherence. In May 2009, two semi-structured focus groups were conducted with HIV-infected IDUs seeking treatment at the City AIDS Center, Kiev. The goal was to use this information to adapt and tailor, to Ukrainian culture, an evidence-based intervention for improving adherence to HAART. All 16 participants attributed HIV infection to IDU. Their average age was 31.6 (SD=7.0), average time with HIV 5.7 years (SD=4.0), average time on HAART 2.5 years (SD=1.7), average time as IDU 14.6 years (SD=6.8), and 88% were on opioid substitution therapy. The most salient themes related to adherence barriers included: (1) harassment and discrimination by police; (2) opioid dependence; (3) complexity of drug regimen; (4) side effects; (5) forgetting; (6) co-occurring mental health problems; and (7) HIV stigma. Facilitators of adherence included: (1) cues for pill taking; (2) support and reminders from family, significant other, and friends; (3) opioid substitution therapy; and (4) wanting improved health. Additional factors explored included: (1) knowledge about HAART; (2) storage of medications; and (3) IDU and sexual risk behaviors. Findings highlighted structural and individual barriers to adherence. At the structural level, police discrimination and harassment was reported to be a major barrier to adherence to opioid substitution therapy and HAART. Privacy and stigma were barriers at the individual level. Recommendations for adherence interventions included education, training, and identification cards to show police that medication was for treatment of HIV, not for abuse; and involving family members and other systems of support for HIV treatment.
Collapse
Affiliation(s)
- Matthew J Mimiaga
- Harvard Medical School/Massachusetts General Hospital, Boston, MA, USA.
| | | | | | | | | | | |
Collapse
|
25
|
Krupitskiĭ EM, Zvartau EE, Blokhina EA, Woody G. [The use of different forms of naltrexone in the treatment of opioid dependence]. Zh Nevrol Psikhiatr Im S S Korsakova 2011; 111:66-72. [PMID: 22611701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The authors compared the results of own studies and foreign publications on the use of different formulations of naltrexone (peroral, implantable, injectable) for the remission stabilization and relapse prevention in patients with opioid dependence. Opioid antagonists, in particular naltrexone, are the unique medication for the specific pharmacotherapy of opioid dependence currently approved in the Russian Federation. The main problem that considerably reduces the efficacy and restricts the use of naltrexone in the treatment of opioid dependence is the problem of compliance. Nevertheless, in the double blind randomized placebo-controlled trials, we have demonstrated the higher efficacy of peroral naltrexone for the remission stabilization compared to analogous foreign publications. It might be explained by the cultural specifics of the family in the Russia Federation, in particular, by the possibility to control the treatment by relatives of the patient. However the possibilities of this control are significantly reduced as the patient gets older. Long-acting depot formulations of naltrexone (implantable and injectable) are more effective than peroral ones that allows to solve the problem of compliance and opens new perspectives in the treatment of opiate dependence.
Collapse
|
26
|
Crits-Christoph P, Baranackie K, Kurcias J, Beck A, Carroll K, Perry K, Luborsky L, McLellan A, Woody G, Thompson L, Gallagher D, Zitrin C. Meta‐Analysis of Therapist Effects in Psychotherapy Outcome Studies. Psychother Res 2010. [DOI: 10.1080/10503309112331335511] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
27
|
Abstract
Opioid dependence is one of the most severe drug dependencies. Naltrexone is a medication that completely blocks the subjective and other effects of opioids and, when administered to detoxified opioid addicts and taken as directed, prevents relapse and helps maintain abstinence. The major problem with naltrexone is poor compliance, particularly in countries in which there is a treatment alternative based on substitution of illicit opioids such as heroin with orally administered opioid agonists (methadone) or partial agonist/antagonists (buprenorphine). In Russia, substitution therapy is forbidden by law, and naltrexone is the only available pharmacotherapy for heroin dependence. Due to the lack of alternatives to naltrexone and stronger family control of compliance (adherence), naltrexone is more effective for relapse prevention and abstinence stabilization in Russia than in Western countries. Long-acting, sustained-release formulations (injectable and implantable) seem particularly effective compared with oral formulations. This article summarizes the results of studies conducted in Russia during the past 10 years that demonstrate these points.
Collapse
Affiliation(s)
- Evgeny Krupitsky
- Department of Addictions, St. Petersburg Bekhterev Psychoneurological Research Institute, Bekhtereva Street 3, St.-Petersburg 192019, Russia
| | - Edwin Zvartau
- Department of Pharmacology, St. Petersburg State Pavlov Medical University, Lev Tolstoy Street 6/8, St. Petersburg 197022, Russia
| | - George Woody
- Treatment Research Institute, 600 Public Ledger Building, 150 South Independence Mall West, Philadelphia, PA 19129, USA
| |
Collapse
|
28
|
Calsyn DA, Cousins SJ, Hatch-Maillette MA, Forcehimes A, Mandler R, Doyle SR, Woody G. Sex under the influence of drugs or alcohol: common for men in substance abuse treatment and associated with high-risk sexual behavior. Am J Addict 2010; 19:119-27. [PMID: 20163383 DOI: 10.1111/j.1521-0391.2009.00022.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Sex under the influence of drugs or alcohol is associated with high-risk sexual behavior. Heterosexual men (n = 505) in substance abuse treatment completed a computer-administered interview assessing sexual risk behaviors. Most men (73.3%) endorsed sex under the influence in the prior 90 days, and 39.1% endorsed sex under the influence during their most recent sexual event. Sex under the influence at the most recent event was more likely to involve anal intercourse, sex with a casual partner, and less condom use. Patients might benefit from interventions targeting sexual behavior and substance use as mutual triggers. (Am J Addict 2010;00:1-9).
Collapse
Affiliation(s)
- Donald A Calsyn
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA.
| | | | | | | | | | | | | |
Collapse
|
29
|
Nunes EV, Ball S, Booth R, Brigham G, Calsyn DA, Carroll K, Feaster DJ, Hien D, Hubbard RL, Ling W, Petry NM, Rotrosen J, Selzer J, Stitzer M, Tross S, Wakim P, Winhusen T, Woody G. Multisite effectiveness trials of treatments for substance abuse and co-occurring problems: have we chosen the best designs? J Subst Abuse Treat 2010; 38 Suppl 1:S97-112. [PMID: 20307801 PMCID: PMC2909698 DOI: 10.1016/j.jsat.2010.01.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 01/15/2010] [Accepted: 01/23/2010] [Indexed: 11/20/2022]
Abstract
Multisite effectiveness trials such as those carried out in the National Drug Abuse Treatment Clinical Trials Network (CTN) are a critical step in the development and dissemination of evidence-based treatments because they address how such treatments perform in real-world clinical settings. As Brigham et al. summarized in a recent article (G. S. Brigham, D. J. Feaster, P. G. Wakim, & C. L. Dempsey C. L., 2009), several possible experimental designs may be chosen for such effectiveness trials. These include (a) a new treatment intervention (Tx) is compared to an existing mode of community based treatment as usual (TAU): Tx versus TAU; (b) a new intervention is added to TAU and compared to TAU alone: Tx + TAU versus TAU; or (c) a new intervention is added to TAU and compared to a control condition added to TAU: Tx + TAU versus control + TAU. Each of these designs addresses a different question and has different potential strengths and weaknesses. As of December 2009, the primary outcome paper had been published for 16 of the multisite randomized clinical trials conducted in the CTN, testing various treatments for drug abuse, HIV risk behavior, or related problems. This paper systematically examines, for each of the completed trials, the experimental design type chosen and its original rationale, the main findings of the trial, and the strengths and weaknesses of the design in hindsight. Based on this review, recommendations are generated to inform the design of future effectiveness trials on treatments for substance abuse, HIV risk, and other behavioral health problems.
Collapse
Affiliation(s)
- Edward V Nunes
- Columbia University Department of Psychiatry, New York State Psychiatric Institute, National Drug Abuse Clinical Trials Network, Long Island Node, New York, NY, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Crits-Christoph P, Gallop R, Temes CM, Woody G, Ball SA, Martino S, Carroll KM. The alliance in motivational enhancement therapy and counseling as usual for substance use problems. J Consult Clin Psychol 2010; 77:1125-35. [PMID: 19968388 DOI: 10.1037/a0017045] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Data from a community-based multicenter study of motivational enhancement therapy (MET) and counseling as usual (CAU) for outpatient substance users were used to examine questions about the role of the alliance in MET and CAU. Most (94%) of the sample met diagnostic criteria for abuse or dependence (primarily alcohol and/or cocaine). Sixteen therapists for CAU and 14 for MET participated. No reliable differences in patient ratings (n = 319) on the Helping Alliance Questionnaire-II (HAq-II) were evident for MET compared to CAU, but significant differences between therapists were found within each condition in mean patient-rated HAq-II scores. Overall, average levels of alliance were high. The between-therapists component of the alliance, but not the within-therapist component, was significantly associated with self-reported days of primary substance use during the follow-up period from Week 4 to Week 16 (Cohen's d = 0 .39; n = 257). Therapists with either low or very high alliances had relatively poorer average outcomes (quadratic effect, d = 0.44). For therapists in both MET and CAU, increased use of MET fundamental techniques and MET advanced techniques during treatment sessions was associated with higher levels of alliance. Implications of the findings for conceptualization of the alliance and for training of therapists are discussed.
Collapse
Affiliation(s)
- Paul Crits-Christoph
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | | | | | | | | | | | | |
Collapse
|
31
|
Smith MY, Dart R, Hughes A, Geller A, Senay E, Woody G, Colucci S. Clinician Validation of Poison Control Center (PCC) Intentional Exposure Cases Involving Prescription Opioids. The American Journal of Drug and Alcohol Abuse 2009; 32:465-78. [PMID: 16864474 DOI: 10.1080/00952990600753982] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Poison Control Center (PCC) cases involving intentional ingestion, injection or inhalation of prescription opioids are a potentially valuable source of information on the abuse and misuse of these products. This study sought to validate PCC classifications of prescription opioid intentional exposure cases against clinical diagnostic criteria. 4,321 cases were reviewed. PCC-clinician concordance was good to excellent for Withdrawal, Abuse, and Suicide (kappa statistics: 0.73, 0.53, 0.48, respectively), but poor for Misuse and Intentional Unknown (Specific motive not known). Interrater reliability among clinicians was good (weighted kappa range: 0.56-0.68). Results demonstrate the degree of compatibility between PCC and standard nosologic classifications.
Collapse
|
32
|
Andersen M, Coleman SB, Ford W, Gorsuch RL, Kaplan H, Kleber H, Lief N, McAuliffe W, Phd FS, Weil A, Zinberg N, Brown B, Leon GD, Glaser F, Huba G, Khantzian EJ, Laskowitz D, Martin W, Reed B, Spotts J, Woody G. From Theory to Practice: The Planned Treatment of Drug Users. ACTA ACUST UNITED AC 2009. [DOI: 10.3109/10826088909047331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
33
|
Andersen M, Brown B, Coleman SB, Leon GD, Ford W, Glaser F, Gorsuch RL, Huba G, Kaplan H, Khantzian EJ, Kleber H, Laskowitz D, Lief N, Martin W, McAuliffe W, Reed B, Shontz F, Spotts J, Weil A, Woody G, Zinberg N. From Theory to Practice: The Planned Treatment of Drug Users. ACTA ACUST UNITED AC 2009. [DOI: 10.3109/10826088909047313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
34
|
Kessler F, Woody G, De Boni R, Von Diemen L, Benzano D, Faller S, Pechansky F. Evaluation of psychiatric symptoms in cocaine users in the Brazilian public health system: need for data and structure. Public Health 2009; 122:1349-55. [PMID: 19014831 DOI: 10.1016/j.puhe.2008.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Revised: 01/30/2008] [Accepted: 05/27/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Few studies of comorbidity among cocaine users have been undertaken in Brazil, despite the fact that cocaine is one of the most commonly used illegal drugs in the country. The aim of this paper is to review existing data on psychiatric evaluations of cocaine users, and present data from two studies that have addressed this issue as it pertains to the Brazilian public health system. STUDY DESIGN Review and results from two studies (cross-sectional and matched control). METHODS The Brazilian literature on PubMed, Lilacs, Psychinfo and DATASUS was searched using the key words: 'psychiatric symptoms', 'diagnosis', 'evaluation', 'assessment', 'cocaine disorders' and others related to this issue. Intake data from two studies of male and female cocaine users were also analysed with regard to psychiatric symptoms as measured by the Symptom Check List - 90 Revised (SCL-90). RESULTS The literature review found no specific studies regarding psychiatric evaluation of cocaine users in Brazil. Analyses from the two studies presented showed high levels of psychiatric symptoms in this population. In the first study, psychiatric symptoms were measured at treatment entry and their prevalence was high, ranging from 27.4% to 53.4%. In the second study, SCL-90R scores at programme admission were higher in cocaine users than normal controls, with effect sizes ranging from moderate to high. CONCLUSIONS To the authors' knowledge, this is the first article to discuss psychiatric evaluations of comorbidity among cocaine users in Brazil. The results indicate a need to: pay more attention to the evaluation of psychiatric symptoms in cocaine users; emphasize the importance of standardized data collection in this area; and evaluate the course of these symptoms, their impact on outcome, and how they are best addressed in treatment.
Collapse
Affiliation(s)
- F Kessler
- Center for Drug and Alcohol Research, Federal University of Rio Grande do Sul, Brazil.
| | | | | | | | | | | | | |
Collapse
|
35
|
Subramaniam GA, Stitzer ML, Woody G, Fishman MJ, Kolodner K. Clinical characteristics of treatment-seeking adolescents with opioid versus cannabis/alcohol use disorders. Drug Alcohol Depend 2009; 99:141-9. [PMID: 18818027 PMCID: PMC2758688 DOI: 10.1016/j.drugalcdep.2008.07.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Revised: 06/06/2008] [Accepted: 07/20/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the clinical characteristics of adolescents with DSM-IV opioid use disorder (OUD) and compare them to adolescents with cannabis/alcohol use disorders. METHOD 94 adolescents (ages 14-18 years) with a current OUD and 74 adolescents with a current non-OUD cannabis/alcohol use disorders were recruited from admissions, predominantly residential, to a substance abuse treatment program in Baltimore, ML. Participants were assessed cross-sectionally using standardized interviews and self-reports. Chi-square, t-tests and ANCOVA (adjusting for age, gender and treatment setting, race and residence) were performed to determine group differences on demographic, substance use, psychiatric and HIV-risk behaviors; logistic regression analyses, both unadjusted and adjusted for the above five factors were conducted to assess the strength of associations. RESULTS The OUD group was more likely to be Caucasian, to have dropped out of school and to live in the suburbs (trend). They also had greater substance use severity with higher proportion of current sedative and multiple substance use disorders (SUD). There were generally no differences in rates of criminal behaviors. Both groups had high rates of current psychiatric disorders (83% vs. 78%, n.s.) but the OUD adolescents reported higher depressive symptoms, mostly in the moderate range. Injection drug use (IDU) and needle sharing was almost exclusive to the OUD group, while both groups reported similar high rates of risky sexual behaviors. CONCLUSIONS While there were similarities between the two groups, OUD adolescents evidenced greater impairment in academic, substance use, depressive symptom and IDU-related HIV-risk areas. Findings suggest poorer long-term prognosis and highlight the need for specialized interventions for treatment-seeking OUD adolescents.
Collapse
Affiliation(s)
- Geetha A Subramaniam
- Department of Psychiatry, Johns Hopkins University, C/O Mountain Manor Treatment Center, 3800 Frederick Avenue, Baltimore, MD 21229, United States.
| | | | | | | | | |
Collapse
|
36
|
Abstract
This article reviews the history of substance abuse treatment and its evaluation. The authors comment on key aspects of this history and its implications for the future. Research has been a key factor in the support of substance abuse treatment and the expansion and improvement of treatment options. Despite the progress in the field, organizational structure and functioning, ambivalence on the moral/medical basis of addiction, and narrow perspectives on evidence-based practice have presented barriers for advancement. Future improvement of treatment is seen as dependent on the partnership of researchers and real world providers, studies of evidence- based practice in a wide variety of community based settings and the consideration of complex and changing real-world environments, particularly for rural, uninsured and under-served populations.
Collapse
|
37
|
Kessler FHP, Woody G, Portela LVC, Tort ABL, De Boni R, Peuker ACWB, Genro V, von Diemen L, de Souza DOG, Pechansky F. Brain injury markers (S100B and NSE) in chronic cocaine dependents. Rev Bras Psiquiatr 2007; 29:134-9. [PMID: 17650535 DOI: 10.1590/s1516-44462006005000029] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: Studies have shown signs of brain damage caused by different mechanisms in cocaine users. The serum neuron specific enolase and S100B protein are considered specific biochemical markers of neuronal and glial cell injury. This study aimed at comparing blood levels of S100B and NSE in chronic cocaine users and in volunteers who did not use cocaine or other illicit drugs. METHOD: Twenty subjects dependent on cocaine but not on alcohol or marijuana, and 20 non-substance using controls were recruited. Subjects were selected by consecutive and non-probabilistic sampling. Neuron specific enolase and S100B levels were determined by luminescence assay. RESULTS: Cocaine users had significantly higher scores than controls in all psychiatric dimensions of the SCL-90 and had cognitive deficits in the subtest cubes of WAIS and the word span. Mean serum S100B level was 0.09 ± 0.04 µg/l among cocaine users and 0.08 ± 0.04 µg/l among controls. Mean serum neuron specific enolase level was 9.7 ± 3.5 ng/l among cocaine users and 8.3 ± 2.6 ng/l among controls. CONCLUSIONS: In this first study using these specific brain damage markers in cocaine users, serum levels of S100B and neuron specific enolase were not statistically different between cocaine dependent subjects and controls.
Collapse
Affiliation(s)
- Felix Henrique Paim Kessler
- Center for Drug and Alcohol Research, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre (RS), Brazil.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Cook JM, Walser RD, Kane V, Ruzek JI, Woody G. Dissemination and feasibility of a cognitive-behavioral treatment for substance use disorders and posttraumatic stress disorder in the Veterans Administration. J Psychoactive Drugs 2006; 38:89-92. [PMID: 16681179 DOI: 10.1080/02791072.2006.10399831] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This article describes a small dissemination effort and provides initial efficacy data for use of Seeking Safety, a cognitive-behavioral treatment for comorbid substance use disorders (SUD) and posttraumatic stress disorder (PTSD), in a VA setting. After providing a daylong interactive training in Seeking Safety to front-line clinicians, a cotherapist group practice model was implemented. Following 14 months of clinician training and an uncontrolled pilot study of four groups with 18 veterans, initial efficacy data indicate significant symptom reduction for patients and acceptability to clinicians. Findings are encouraging in that Seeking Safety treatment appears to have the potential to be beneficial for veterans with SUD-PTSD and also appeal to clinicians. Dissemination of Seeking Safety is feasible in the VA, yet there are likely barriers to sustaining it as a routine treatment. Recommendations for future dissemination are proposed, including ways VA administration can facilitate this process.
Collapse
Affiliation(s)
- Joan M Cook
- Columbia University Medical Center, New York, NY, USA.
| | | | | | | | | |
Collapse
|
39
|
Abstract
Persons with opiate use disorders, especially veterans, have a number of both chronic and acute indicators of risk for suicide, but are not typically screened for suicidal ideation on a routine basis, beyond initial evaluations. One hundred one veterans receiving treatment for opiate dependence at an urban VA medical center were screened for suicidal ideation. Over 24% reported some suicidal ideation. Current ideation was associated with severe chronic pain, ongoing problems with street drugs, firearm ownership, and with having recently enrolled in treatment. It was also associated with a variety of recent negative life events and mental health issues, especially depression, recurring troubling thoughts, hallucinations, loss of jobs, and conflicts with family members. Two veterans endorsing suicidal ideation required immediate hospitalization. The implications of these findings are discussed, and frequent screening for suicidal ideation among patients receiving treatment for opiate dependence is recommended.
Collapse
Affiliation(s)
- Richard Thompson
- Juvenile Protective Association, Department of Psychiatry, University of Illinois at Chicago, Chicago, IL 60622, USA
| | | | | | | | | | | |
Collapse
|
40
|
Pechansky F, Woody G, Inciardi J, Surratt H, Kessler F, Von Diemen L, Bumaguin DB. HIV seroprevalence among drug users: an analysis of selected variables based on 10 years of data collection in Porto Alegre, Brazil. Drug Alcohol Depend 2006; 82 Suppl 1:S109-13. [PMID: 16769439 DOI: 10.1016/s0376-8716(06)80017-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Data from five studies were pooled to describe associations between drug use and HIV. The Risk Assessment. Battery in Porto Alegre, Brazil, was used to collect data from 1449 subjects in 5 separate studies conducted between 1995 and 2004. The subjects were divided into categories based on their pattern of drug use: (1) injection drug users (IDUs), (2) crack smokers, (3) frequent drug users, and (4) infrequent cocaine/alcohol/marijuana users. The sample consisted primarily of young males with low education and income levels. Half of the subjects reported frequent condom use, and exchanges involving drugs, sex, and money were infrequent (although more common in groups 1 and 2). The overall seroprevalence was 20.6%, and the prevalence was different across the four groups, showing a linear decrease from group 1 (57.1%) to group 4 (11.7%). The IDU and crack-smoking groups showed similarities in their risk levels when compared with the other two groups, and individuals in group 1, 2, and 3 were more likely to report having had four or more sex partners. After controlling for all other risk factors, IDU, males having sex with males, and crack use were highly associated with HIV (OR 7.30, 95% CI: 5.10.10.40; OR 3.04, 95%CI: 1.89,4.80; OR 2.03, 95%CI: 1.40, 2.92, respectively). The findings confirm that poverty, low education, and IDU remain risk factors for HIV in Porto Alegre, Brazil, and the study identities crack smoking as a new risk factor.
Collapse
Affiliation(s)
- Flavio Pechansky
- Center for Drug and Alcohol Research, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
| | | | | | | | | | | | | |
Collapse
|
41
|
Smith MY, Woody G. Nonmedical use and abuse of scheduled medications prescribed for pain, pain-related symptoms, and psychiatric disorders: patterns, user characteristics, and management options. Curr Psychiatry Rep 2005; 7:337-43. [PMID: 16216151 DOI: 10.1007/s11920-005-0033-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The nonmedical use of scheduled medications commonly prescribed for pain, pain-related symptoms, and psychiatric disorders began rising in the mid-1990s. Physicians are confronted with the dilemma of how to minimize the abuse and diversion potential of these products without compromising access for patients with a legitimate medical need. Using data from the National Survey on Drug Use and Health, we describe the scope of nonmedical use of opioids, stimulants, and tranquilizers; characteristics of nonmedical users; and options available to reduce abuse liability. In 2003, lifetime prevalence estimates of nonmedical use were 31.2 million for opioids, 20.7 million for stimulants, and 20.2 million for tranquilizers. Nonmedical users of psychotherapeutics were more likely to be Caucasian; use alcohol, cocaine, or heroin; and to use needles to inject drugs than those who reported using illicit drugs only. Sources of diversion are enumerated, and options for minimizing the abuse liability associated with these medications are described.
Collapse
Affiliation(s)
- Meredith Y Smith
- Purdue Pharma, L.P., One Stamford Forum, Stamford, CT 06901, USA.
| | | |
Collapse
|
42
|
Li Y, Wang X, Douglas SD, Metzger DS, Woody G, Zhang T, Song L, Ho WZ. CD8+ T cell depletion amplifies hepatitis C virus replication in peripheral blood mononuclear cells. J Infect Dis 2005; 192:1093-101. [PMID: 16107965 DOI: 10.1086/432957] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2005] [Accepted: 04/28/2005] [Indexed: 11/03/2022] Open
Abstract
We investigated the ability of CD8+ T cells to inhibit hepatitis C virus (HCV) replication in peripheral blood mononuclear cells (PBMCs). PBMCs isolated from 11 of 20 HCV-infected subjects had no detectable HCV RNA. Removal of CD8+ T cells from these PBMCs resulted in detection of HCV RNA, and depletion of CD8+ T cells from PBMCs that had detectable HCV RNA amplified HCV replication. Reconstitution of CD8- PBMCs with autologous CD8+ T cells led to inhibition of HCV replication. Interferon-gamma produced by CD8+ T cells was partially responsible for CD8+ T cell-mediated noncytotoxic anti-HCV activity in PBMCs. This noncytotoxic anti-HCV activity was confirmed in HCV replicon cells. Supernatants from CD8+ T cell cultures inhibited HCV RNA expression in the replicon cells. These findings may have important implications for the immunopathogenesis of HCV in both immune and hepatic cells and are relevant to the development of host innate immunity-based anti-HCV interventions.
Collapse
Affiliation(s)
- Yuan Li
- Division of Allergy and Immunology, Department of Pediatrics, Joseph Stokes Jr. Research Institute, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Ling W, Amass L, Shoptaw S, Annon JJ, Hillhouse M, Babcock D, Brigham G, Harrer J, Reid M, Muir J, Buchan B, Orr D, Woody G, Krejci J, Ziedonis D. A multi-center randomized trial of buprenorphine-naloxone versus clonidine for opioid detoxification: findings from the National Institute on Drug Abuse Clinical Trials Network. Addiction 2005; 100:1090-100. [PMID: 16042639 PMCID: PMC1480367 DOI: 10.1111/j.1360-0443.2005.01154.x] [Citation(s) in RCA: 176] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS The clinical effectiveness of buprenorphine-naloxone (bup-nx) and clonidine for opioid detoxification in in-patient and out-patient community treatment programs was investigated in the first studies of the National Institute of Drug Abuse Clinical Trials Network. DESIGN Diagnostic and Statistical Manual version IV (DSM IV)-diagnosed opioid-dependent individuals seeking short-term treatment were randomly assigned, in a 2 : 1 ratio favoring bup-nx, to a 13-day detoxification using bup-nx or clonidine. METHODS A total of 113 in-patients (77 bup-nx, 36 clonidine) and 231 out-patients (157 bup-nx, 74 clonidine) participated. Supportive interventions included appropriate ancillary medications and standard counseling procedures guided by a self-help handbook. The criterion for treatment success was defined as the proportion of participants in each condition who were both retained in the study for the entire duration and provided an opioid-free urine sample on the last day of clinic attendance. Secondary outcome measures included use of ancillary medications, number of side effects reported and withdrawal and craving ratings. FINDINGS A total of 59 of the 77 (77%) in-patients assigned to the bup-nx condition achieved the treatment success criterion compared to eight of the 36 (22%) assigned to clonidine, whereas 46 of the 157 (29%) out-patients assigned to the bup-nx condition achieved the treatment success criterion, compared to four of the 74 (5%) assigned to clonidine. CONCLUSION The benefits of bup-nx for opioid detoxification are supported and illustrate important ways in which clinical research can be conducted in community treatment programs.
Collapse
Affiliation(s)
- Walter Ling
- David Geffen School of Medicine, NPI/Integrated Substance Abuse Programs, University of California, Los Angeles, CA 90025, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Rosenheck R, Leslie D, Woody G. Fiscal Strain and Access to Opiate Substitution Therapy at Department of Veterans Affairs Medical Centers. Am J Addict 2003. [DOI: 10.1111/j.1521-0391.2003.tb00650.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
45
|
Rosenheck R, Leslie D, Woody G. Fiscal strain and access to opiate substitution therapy at Department of Veterans Affairs Medical Centers. Am J Addict 2003; 12:220-8. [PMID: 12851018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
This study examines the relationship between institutional fiscal strain and the availability of opiate substitution therapy (eg, methadone maintenance), an effective but relatively expensive treatment for heroin addiction. An observational design was used to examine the association of changes in funding and changes in provision for treating opiate addiction at 29 VA Medical Centers (VAMCs). We hypothesized that VAMCs experiencing greater fiscal strain would show reduced availability of opiate substitution treatment. Administrative records from each of 29 VAMCs that provided opiate substitution therapy in both Fiscal Year (FY) 1995 and FY 1999 were used to measure changes in the availability of this service, ie, the percent change in total patients treated, annual visits per patient, and total services delivered. Institutional fiscal strain was measured by the percent decline in per capita funding at four levels at each VAMC: the entire medical center, all mental health programs, all substance abuse programs (inpatient and outpatient), and outpatient substance abuse programs alone. The total number of patients receiving opiate substitution increased from 5,549 in FY 1995 to 6,884 in FY 1999 (24%), annual visits per patient decreased by 16%, and the total number of units of services increased by 4%. There were no significant relationships between changes in the delivery of opiate substitution services and changes in per capita funding at any of the four institutional levels. No new programs were started during these years. Although no new programs were started, the availability of opiate substitution therapy at VA facilities with existing programs was maintained over a five-year period regardless of local funding changes, although at somewhat reduced intensity.
Collapse
Affiliation(s)
- Robert Rosenheck
- Veterans Integrated Service Network, Mental Illness Research, Education, and Clinical Center, West Haven, Conn., USA.
| | | | | |
Collapse
|
46
|
Rosenheck R, Leslie D, Woody G. Fiscal Strain and Access to Opiate Substitution Therapy at Department of Veterans Affairs Medical Centers. Am J Addict 2003. [DOI: 10.1080/10550490390202659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
|
47
|
Abstract
Staff from 10 community-based addiction treatment organizations in the National Drug Abuse Clinical Trials Network participated in an educational session about addiction research practices and human subject protections. This 1.5-hour presentation addressed "informed consent," "confidentiality of research information," "inclusion and exclusion criteria," "random assignment," "patient protections," and "patient payments." Pre- and postsession surveys were administered to 115 staff members measuring their beliefs about clinical trials. At baseline, 52% of staff believed patients could transfer out of a study even if they were doing poorly, and 55% believed staff had this right; 44% agreed that patients could participate in a clinical trial without understanding what would take place in the study. After the educational session, staff beliefs about patient protections were significantly increased in five of the seven items. A fourth of staff continued to believe patient payments were harmful, and 37% did not believe participation in a clinical trial would increase a patient's chances at recovery.
Collapse
Affiliation(s)
- Robert F Forman
- Treatment Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | | | | | | | | | | | | |
Collapse
|
48
|
Abstract
This case describes a heroin addict who was participating in a placebo-controlled randomized trial of naltrexone as an aid to relapse prevention. The patient tried to commit suicide by taking a heroin overdose after learning that he was HIV-positive. He was on naltrexone at the time and, as a result, survived what would probably have been a fatal overdose. This case demonstrates that naltrexone can have immediate as well as long-term positive effects in persons who are attempting to recover from heroin addiction.
Collapse
Affiliation(s)
- E M Krupitsky
- St. Petersburg Regional Center for Research in Addiction and Psychopharmacology, affiliated with Pavlov State Medical University, Novo-Deviatkino 19/1, St. Petersburg, Leningrad Region 188661, Russia.
| | | | | | | | | | | | | |
Collapse
|
49
|
Abstract
In 1999, the National Institute on Drug Abuse established a researcher/provider partnership designed to test the effectiveness of research-based innovations in community-based treatment settings and facilitate the transfer of those innovations throughout the national treatment system. As a preliminary step in developing their local Clinical Trials Network, researchers and treatment providers within the Delaware Valley Node surveyed 317 staff members concerning their beliefs about addiction treatment. More than 80% of respondents supported increased use of research-based innovations, 12-step/traditional approaches, and spirituality in addiction treatment, while only 39% and 34%, respectively, endorsed the increased use of naltrexone and methadone maintenance. Also, 35% of respondents indicated that confrontation should be used more, and 46% agreed with discharging noncompliant patients. Individuals with more formal training tended to be less supportive of confrontation and more supportive of the increased use of medications. Implications for the clinical trials and technology transfer are discussed.
Collapse
Affiliation(s)
- R F Forman
- Treatment Research Center, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.
| | | | | |
Collapse
|
50
|
Belshe RB, Stevens C, Gorse GJ, Buchbinder S, Weinhold K, Sheppard H, Stablein D, Self S, McNamara J, Frey S, Flores J, Excler JL, Klein M, Habib RE, Duliege AM, Harro C, Corey L, Keefer M, Mulligan M, Wright P, Celum C, Judson F, Mayer K, McKirnan D, Marmor M, Woody G. Safety and immunogenicity of a canarypox-vectored human immunodeficiency virus Type 1 vaccine with or without gp120: a phase 2 study in higher- and lower-risk volunteers. J Infect Dis 2001; 183:1343-52. [PMID: 11294665 DOI: 10.1086/319863] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2000] [Revised: 02/06/2001] [Indexed: 11/04/2022] Open
Abstract
Live attenuated viral vectors that express human immunodeficiency virus (HIV) antigens are being developed as potential vaccines to prevent HIV infection. The first phase 2 trial with a canarypox vector (vCP205, which expresses gp120, p55, and protease) was conducted in 435 volunteers with and without gp120 boosting, to expand the safety database and to compare the immunogenicity of the vector in volunteers who were at higher risk with that in volunteers at lower risk for HIV infection. Neutralizing antibodies to the MN strain were stimulated in 94% of volunteers given vCP205 plus gp120 and in 56% of volunteers given vCP205 alone. CD8(+) cytotoxic T lymphocyte cells developed at some time point in 33% of volunteers given vCP205, with or without gp120. Phase 3 field trials with these or similar vaccines are needed, to determine whether efficacy in preventing HIV infection or in slowing disease progression among vaccinees who become infected is associated with the level and types of immune responses that were induced by the vaccines in this study.
Collapse
Affiliation(s)
- R B Belshe
- Department of Internal Medicine, Saint Louis University School of Medicine and St. Louis Veterans Affairs Medical Center, 3635 Vista Ave. (FDT-8N) St. Louis, MO 63110, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|