Discontinuation of medication treatment for opioid use disorder after a successful course: The discontinuation phase of the CTN-0100 (RDD) trial

INTRODUCTION AND BACKGROUND

Buprenorphine, and extended-release naltrexone, are effective in decreasing opioid use, morbidity and mortality. The available evidence suggests that these medications should be used for long term treatment; however, patients often ask how long they need to be on medication, and whether it would be safe to discontinue. There are sparse data to guide us. The CTN-0100 trial will address this gap in our knowledge by studying participants who have decided to discontinue buprenorphine and extended-release naltrexone for OUD.

RESEARCH DESIGN AND METHODS

The trial is a multicenter, randomized, non-blinded study. Participants are stable adult volunteers, on sublingual buprenorphine, extended-release buprenorphine, or extended-release naltrexone, expressing an interest in discontinuing medication. Participants on buprenorphine must be stable for at least 1 year and participants on extended-release naltrexone must be stable for at least 6 months. Participants are engaged in the study for up to 96 weeks, including a flexible taper period, and are then transitioned to follow-up within the trial. All participants are randomly assigned to the study Medical Management (MM) or to MM plus Connections (CHESS health) digital smartphone application aimed at recovery and abstinence (MMD). Sublingual Buprenorphine participants are also randomized (2 × 2 design) to a taper using either sublingual or extended-release buprenorphine.

DISCUSSION/CONCLUSION

It is hoped that this trial will provide a rich source of data on management of patients discontinuing medication for opioid use disorder (MOUD) to inform future research and practice. The trial will shed light on which strategies are most likely to lead to long-term success (absence of relapse), and what participant characteristics distinguish those who can safely discontinue MOUD from those who remain at risk of relapse should they discontinue.

CLINICALTRIALS

gov Identifier: NCT04464980.

Methylomic changes during conversion to psychosis

The onset of psychosis is the consequence of complex interactions between genetic vulnerability to psychosis and response to environmental and/or maturational changes. Epigenetics is hypothesized to mediate the interplay between genes and environment leading to the onset of psychosis. We believe we performed the first longitudinal prospective study of genomic DNA methylation during psychotic transition in help-seeking young individuals referred to a specialized outpatient unit for early detection of psychosis and enrolled in a 1-year follow-up. We used Infinium HumanMethylation450 BeadChip array after bisulfite conversion and analyzed longitudinal variations in methylation at 411 947 cytosine-phosphate-guanine (CpG) sites. Conversion to psychosis was associated with specific methylation changes. Changes in DNA methylation were significantly different between converters and non-converters in two regions: one located in 1q21.1 and a cluster of six CpG located in GSTM5 gene promoter. Methylation data were confirmed by pyrosequencing in the same population. The 100 top CpGs associated with conversion to psychosis were subjected to exploratory analyses regarding the related gene networks and their capacity to distinguish between converters and non-converters. Cluster analysis showed that the top CpG sites correctly distinguished between converters and non-converters. In this first study of methylation during conversion to psychosis, we found that alterations preferentially occurred in gene promoters and pathways relevant for psychosis, including oxidative stress regulation, axon guidance and inflammatory pathways. Although independent replications are warranted to reach definitive conclusions, these results already support that longitudinal variations in DNA methylation may reflect the biological mechanisms that precipitate some prodromal individuals into full-blown psychosis, under the influence of environmental factors and maturational processes at adolescence.

Randomized multi-site trial of the Job Seekers' Workshop in patients with substance use disorders

BACKGROUND

Unemployment is associated with negative outcomes both during and after drug abuse treatment. Interventions designed to increase rates of employment may also improve drug abuse treatment outcomes. The purpose of this multi-site clinical trial was to evaluate the Job Seekers' Workshop (JSW), a three session, manualized program designed to train patients in the skills needed to find and secure a job.

METHOD

Study participants were recruited through the NIDA Clinical Trials Network (CTN) from six psychosocial counseling (n=327) and five methadone maintenance (n=301) drug treatment programs. Participants were randomly assigned to either standard care (program-specific services plus brochure with local employment resources) (SC) or standard care plus JSW. Three 4-h small group JSW sessions were offered weekly by trained JSW facilitators with ongoing fidelity monitoring.

RESULTS

JSW and SC participants had similar 12- and 24-week results for the primary outcome measure (i.e., obtaining a new taxed job or enrollment in a training program). Specifically, one-fifth of participants at 12weeks (20.1-24.3%) and nearly one-third at 24 weeks (31.4-31.9%) had positive outcomes, with "obtaining a new taxed job" accounting for the majority of cases.

CONCLUSION

JSW group participants did not have higher rates of employment/training than SC controls. Rates of job acquisition were modest for both groups, suggesting more intensive interventions may be needed. Alternate targets (e.g., enhancing patient motivation, training in job-specific skills) warrant further study as well.

The influence of primary health care organizational models on patients’ experience of care in different chronic disease situations

Objectives

To examine the extent to which experience of care varies across chronic diseases, and to analyze the relationship of primary health care (PHC) organizational models with the experience of care reported by patients in different chronic disease situations.

Methods

We linked a population survey and a PHC organizational survey conducted in two regions of Quebec. We identified five groups of chronic diseases and contrasted these with a no–chronic-disease group.

Results

Accessibility of care is low for all chronic conditions and shows little variation across diseases. The contact and the coordination-integrated models are the most accessible, whereas the single-provider model is the least. Process and outcome indices of care experience are much higher than accessibility for all conditions and vary across diseases, with the highest being for cardiovascular-risk-factors and the lowest for respiratory diseases (for people aged 44 and under). However, as we move from risk factors to more severe chronic conditions, the coordination-integrated and community models are more likely to generate better process of care, highlighting the greater potential of these two models to meet the needs of more severely chronically ill individuals within the Canadian health care system.

The influence of primary health care organizational models on patients' experience of care in different chronic disease situations

OBJECTIVES

To examine the extent to which experience of care varies across chronic diseases, and to analyze the relationship of primary health care (PHC) organizational models with the experience of care reported by patients in different chronic disease situations.

METHODS

We linked a population survey and a PHC organizational survey conducted in two regions of Quebec. We identified five groups of chronic diseases and contrasted these with a no-chronic-disease group.

RESULTS

Accessibility of care is low for all chronic conditions and shows little variation across diseases. The contact and the coordination-integrated models are the most accessible, whereas the single-provider model is the least. Process and outcome indices of care experience are much higher than accessibility for all conditions and vary across diseases, with the highest being for cardiovascular-risk-factors and the lowest for respiratory diseases (for people aged 44 and under). However, as we move from risk factors to more severe chronic conditions, the coordination-integrated and community models are more likely to generate better process of care, highlighting the greater potential of these two models to meet the needs of more severely chronically ill individuals within the Canadian health care system.

Conducting clinical research with prescription opioid dependence: defining the population

Most treatment studies of opioid-dependent populations have focused predominantly on heroin users, despite a recent increase in those dependent upon prescription opioids. A key methodological challenge involved in studying the latter group involves defining the population. Specifically, researchers must decide whether to include (1) concurrent heroin users and (2) individuals with pain. The multi-site Prescription Opioid Addiction Treatment Study is examining treatments for this population. This paper describes various inclusion criteria considered by the study team related to heroin use and pain. The goal was to recruit a distinct but generalizable population of individuals dependent upon prescription opioids. (Am J Addict 2010;00:1-6).

Telomere length is severely and similarly reduced in JAK2V617F-positive and -negative myeloproliferative neoplasms

Myeloproliferative neoplasms (MPNs) are clonal stem cell disorders characterized by chronic proliferation of hematopoietic progenitors. We studied the telomere length (TL) of 335 MPN patients and 93 gender- and age-matched controls using a quantitative PCR method (relative TL calculated as the ratio of the amount of telomere DNA vs single-copy DNA: T/S ratio). TL was markedly reduced in MPN patients compared with controls (T/S 0.561 vs 0.990, P<0.001). In JAK2V617F MPN patients, TL correlated inversely with allelic burden (P<0.001). Patients homozygous for the mutation (allelic burden 90-100%) had the shortest TL, even when compared with patients with lower allele burdens consistent with a dominant heterozygous population (allelic burden 55-65%) (T/S 0.367 vs 0.497, P=0.037). This suggests that the high degree of proliferation of the MPN clone reduces TL and suggests the possibility that TL shortening may be indicative of progressive genomic instability during MPN progression. The TL of JAK2V617F-negative MPN patients was similar to JAK2V617F-positive counterparts (T/S 0.527 vs 0.507, P=0.603), suggesting that the yet-to-be-discovered causative mutation(s) impact the mutated stem cell similarly to JAK2V617F, and that TL measurement may prove useful in the diagnostic workup of JAK2V617F-negative MPN.

A novel autosomal dominant restless legs syndrome locus maps to chromosome 20p13

The authors investigated genetic factors contributing to restless legs syndrome (RLS) by performing a 10-cM genome-wide scan in a large French-Canadian pedigree. They detected an autosomal-dominant locus mapping to chromosome 20p13, with a maximum multipoint lod score of 3.86 at marker D20S849. This is the third reported autosomal-dominant locus for RLS and the first autosomal-dominant RLS locus in the French-Canadian population.

Achieving consensus across diverse stakeholders on quality measures for mental healthcare

OBJECTIVE

Quality-improvement efforts are hindered by a lack of consensus on meaningful and feasible measures of care. The objective of this study was to develop a core set of quality measures for mental health and substance-related care that are meaningful to stakeholders, feasible to implement, and broadly representative of diverse dimensions of the mental health system.

METHOD

A 12-member panel of stakeholders from national organizations evaluated 116 process measures in a 2-stage modified Delphi consensus development process. Drawing on a conceptual framework and literature review, panelists rated each measure on 7 domains using a 9-point scale (1 = best). Measures were then mapped to a framework of system dimensions to identify a core set with the highest ratings for system characteristics within each dimension.

RESULTS

Twenty-eight measures were identified assessing treatment (12), access (2), assessment (2), continuity (4), coordination (2), prevention (1), and safety (5). Overall, mean ratings for meaningfulness were: clinical importance 2.29; perceived gap between actual and optimal care 2.59; association between improved performance and outcome 2.61. For feasibility, mean ratings were clarity of specifications 3.39; acceptability of data collection burden 4.77; and adequacy of case mix adjustment 4.20. The measures address a range of treatment modalities, clinical settings, diagnostic categories, vulnerable populations, and other dimensions of mental healthcare.

CONCLUSIONS

A structured consensus process identified a core set of quality measures that are meaningful and feasible to multiple stakeholders, as well as broadly representative of the mental healthcare system. By yielding quantitative assessments of meaningfulness, feasibility and degree of consensus among stakeholders, these results can inform ongoing national efforts to adopt common quality measures for mental healthcare.

Process measures for the assessment and improvement of quality of care for schizophrenia

The development of process measures for the assessment and improvement of care for schizophrenia is at an early stage. As part of a national inventory of mental health quality measures, we identified 42 process measures developed to assess the quality of schizophrenia care. A greater proportion of measures assessed pharmacotherapy than assessed psychosocial interventions or other clinical processes, such as assessment, continuity, or coordination. Twenty-five measures (60%) were based on research evidence linking measure conformance with improved patient outcomes, while 17 (40%) were based on clinical consensus or opinion. Only 12 measures (29%) were fully operationalized. Few were tested for validity or reliability. A number of demonstration projects currently under way should expand the pool of well-developed and tested measures. Further research and consensus development will be needed to identify common measurement priorities, reduce the data collection burden, enhance the interpretability of results, and allow for comparisons of clinical practice across facilities and health care systems.

Predictors of pretravel consultation in tourists from Quebec (Canada)

BACKGROUND

Although many tourists from Quebec (Canada) each year visit destinations at risk for infectious diseases, only a few of them seek travel health advice. To identify the determinants of travel health consultation, we conducted a study among Quebec's tourists visiting two popular sun destinations.

METHODS

A conceptual model based on psychosocial determinants of human behavior was constructed. A cross-sectional survey was carried out, from January to April 1999, on two samples of travelers planning to visit Mexico and the Dominican Republic. One sample was composed of people who did not consult a travel clinic (cluster sampling in seven flights), and the other sample was one of clients of travel clinics (purposive selection of 13 specialized clinics located in Quebec). A 34-item self-administered bilingual questionnaire was distributed to travelers. Statistical analysis included a multivariate approach (logistic regression).

RESULTS

A total of 2,242 travelers were surveyed (response rate in flight 75% and in clinics 99%). We present only results reported by French-speaking tourists: 1,152 who did not consult a travel clinic and were reached in flight, and 449 who were reached in clinics. Multivariate analyses indicated that travel agent recommendation was the most important predictor of consultation among travelers (OR 8.0, 95% CI 5.1-13), especially among those under 45 years of age and those who never sought pretravel consultation before (OR 21, 95% CI 11-41). Other important predictors were: traveling for the first time, traveling with children, previous consultation, perception about efficacy of immunization, risk perception, and information from travel agent, family doctor, and pharmacist.

CONCLUSIONS

Despite its limitations, this study provides data that should help improve public health interventions aimed at encouraging travelers to get a pretravel consultation.

Quality measures for mental health care: results from a national inventory

The National Inventory of Mental Health Quality Measures was funded by the Agency for Healthcare Research and Quality to (1) inventory process measures for assessing the quality of mental health care; (2) identify clinical, administrative, and quality domains where measures have been developed; and (3) identify areas where further research and development is needed. Among the 86 measures identified, most evaluated treatment of major mental disorders, for example, schizophrenia (24 percent) and major depression (21 percent). A small proportion focused on children (8 percent) or the elderly (9 percent). Domains of quality included treatment appropriateness (65 percent), continuity (26 percent), access (26 percent), coordination (13 percent), detection (12 percent), and prevention (6 percent). Few measures were evaluated for reliability (12 percent) or validity (3 percent). Measures imposing a lower burden were more likely to be in use (chi 2 = 4.41, p = .036). Further measures are needed to assess care for several priority clinical and demographic groups. Research should focus on measure validity, reliability, and implementation costs. In order to foster quality improvement activities and use of common measures and specifications for mental health care, the inventory of quality measures will be made available at www.challiance.org/cqaimh.

Spontaneous mutation in lacI transgenic mice: a comparison of tissues

The nature of spontaneous mutations in the lacI transgene of Big Blue mice was determined in selected tissues. The mutant frequencies ranged from 2.5 x 10(-5) to 7.1 x 10(-5) for liver, spleen, bladder, stomach, kidney, bone marrow, lung and skin. We also determined the DNA sequence alterations in the mutants recovered from these tissues. In all tissues the predominant class of mutations was G:C-->A:T transitions, most of which occurred at 5'-CpG-3' dinucleotide sequences. Bladder, kidney and skin display the highest contribution of G:C-->A:T transitions. The second most common class of mutations was G:C-->T:A transversions. All other base substitution classes contributed < 10% each. Of the non-substitution events, the loss of a single base pair was the most frequently occurring event (< 10%). The similarity of mutational spectra (in terms of kinds of mutations detected by the lacI transgenic system) in all tissues examined supports the idea that similar mutational pathways function in these tissues in the absence of chemical or physical stimulus.

Analysis of allele distribution for six short tandem repeat loci in the French Canadian population of Québec

Short tandem repeat (STR) loci represent a rich source of highly polymorphic markers in the human genome which are useful for the purposes of forensic identification and determination of biological relatedness of individuals. Here, as a part of an ongoing extensive study, we report the analysis of a multilocus genotype survey of 642 to 870 chromosomes in the French Canadian Caucasian population of Québec at six STR loci. The loci HUMCSF1PO, HUMTPOX, HUMTH01, HUMF13A01, HUMFESFPS, and HUMvWA were typed using two multiplex polymerase chain reactions (PCR). Amplified DNA samples were subsequently analyzed by polyacrylamide gel electrophoresis followed by silver staining. The heterozygote frequencies of the loci range from 0.614 to 0.820 (0.661 to 0.818 expected) and the number of alleles from 7 to 12 per locus. Although statistically significant deviation from Hardy-Weinberg expectations of genotype frequencies was noted at some loci by one or more tests, in general, the genotype frequencies are well estimated from the product of allele frequencies at all loci. The most frequent six-locus genotype is expected to occur in the French Canadian population with a frequency of 3.50 by 10(-5) and together, these six loci have an average probability of discrimination of 0.9999985. The study presented here indicates that these six STR loci are informative genetic markers for identity testing purposes in the French Canadian Caucasian population of Québec.

Job sharing at the managerial level

Job sharing restructures a full-time position-two individuals share the responsibilities and the benefits of the position. If nurses are committed to making it work, this arrangement can succeed at the managerial level.

Spontaneous mutants recovered from liver and germ cell tissue of low copy number lacI transgenic rats

The finding of a large discordance between animal species in their response to a carcinogenic challenge, has led to the realization that the useful extrapolation of animal test data to humans requires a better understanding of animal interspecies differences. With the development of transgenic shuttle vector based animal systems we are now able to study mutation of the same genetic target in both mice and rats. We have begun to analyze mutants recovered from rat lines carrying low copy numbers of the same lambda/lacI constructs carried by the Big Blue mouse. A large database on mutations in lacI transgenic mice is already available for comparison. The data indicate that the differences between the mutations recovered from rat liver and germ cell tissues are similar to those recovered from transgenic mice, but when compared with a large database of mutations available for mice, some site-to-site differences may exist. This study represents the first interspecies look into the molecular nature of mutations in the lacI transgenic rodents.

pGATA: a positive selection vector based on the toxicity of the transcription factor GATA-1 to bacteria

The transcription factor GATA-1 is a zinc finger DNA-binding protein essential for the development of red blood cells. When we expressed different regions of the zinc finger domain in bacteria using an isopropyl-beta-D-thiogalactoside (IPTG) inducible system, growth of bacteria harboring the active DNA-binding domain of GATA-1 was rapidly inhibited upon IPTG induction. The growth inhibition pattern suggested it may be occurring at the level of the initiation of replication, and GATA-1 was found to bind to three of the four DNA A protein-binding sites in the origin of replication. This toxicity was used to develop a positive selection vector system in which cloned DNA fragments interfered with the production of the GATA-1 DNA-binding domain. Thus, vector molecules containing the insert of interest are selected for when bacteria are grown in the presence of IPTG. With this system, the vector does not need to be dephosphorylated, purified or completely digested with a restriction enzyme for the efficient cloning of DNA fragments even when the vector-to-insert DNA molar ratio in ligation reactions is 10 to 1. Moreover, no special strain of Escherichia coli is required, and the selection might also be applicable to other species of bacteria if the toxicity of GATA-1 relates to inhibition of the DNA A protein.

Delay of early B-lymphocyte development by gamma 2b immunoglobulin transgene: effect on differentiation-specific molecules

Mice transgenic for gamma 2b Ig heavy chain were examined for alterations in B-cell differentiation and endogenous Ig gene rearrangement and expression. Fresh bone marrow from these mice was markedly reduced in BP-1+ cells and there were small reductions in B220+ and sIg+ cells. A-MuLV (Abelson murine leukemia virus) transformants from these bone marrow cells showed little alteration in Ig gene rearrangement and expression when compared to controls, however. Isolation of the B-lymphoid compartment from these mice in vitro using LBMC (lymphoid bone marrow cultures) enabled more detailed characterization of the effects of the transgene. LBMC derived from gamma 2b transgenic mice had similar growth kinetics, but a 4-5-week delay in the expression of endogenous mu Ig in comparison to control cultures. Nucleic acids derived from these early cultures prior to endogenous mu Ig expression showed reduced Ig JH rearrangements, some sterile mu transcription, low levels of BP-1 expression, and virtually undetectable TdT (terminal deoxynucleotidyl transferase) expression. Thus, this gamma 2b transgene appears able to affect early B-lymphocyte development.