Predictors of retention in heroin-assisted treatment in Denmark 2010-2018 - A record-linkage study

INTRODUCTION

While randomized-controlled trials have shown that heroin-assisted treatment (HAT) is superior to methadone maintenance alone in treatment of refractory clients, little is known about client factors associated with retention in HAT in routine care.

METHODS

This retrospective cohort study assessed predictors of retention in first treatment episode among a consecutive cohort of clients admitted to HAT in Denmark from 2010 to 2018, who could be matched to the Danish population register and for whom a Short Form Health Survey (SF-36) was available at admission (N = 432). The study derived predictors from client self-reports at intake and administrative data available in national registers. Cox proportional hazards regression modelled retention in treatment.

RESULTS

The one-year retention rate was 69.63 % (95 % CI 65.06 %-73.74 %), and the median time in treatment was 2.45 years (95 % CI, 1.83-3.12). Bivariate analyses showed that retention was lower for clients who had recent cocaine or benzodiazepine use and among those who had experienced an overdose in the year prior to enrollment in HAT. Age below 40, recent illegal activity, poorer emotional wellbeing, previous residential treatment experience, and previous intensive outpatient treatment were also predictors of dropout from HAT.

CONCLUSIONS

This observational study found that retention in HAT in routine care was similar to rates observed in randomized-controlled trials conducted in other countries. The results suggest that addressing polysubstance use as part of the HAT program may promote long-term retention, as may directing resources to certain subgroups identified at intake, including clients under 40 years and those who report recent criminal activity, emotional problems, or overdoses. The findings that previous residential treatment and intensive outpatient treatment were associated with dropout were unexpected.

The prevalence of substance use disorders among people in Norwegian, Danish and Swedish prisons: A multi-national cohort study, 2010-19

AIMS

We estimated the prevalence of substance use disorders (SUDs) in the Norwegian, Danish and Swedish prison populations and compared the prevalence of SUDs in the national prison populations with country-specific general population prevalence rates.

DESIGN

A multi-national cohort study using data from the National Prison Registries linked to the National Patient Registries in Norway, Denmark and Sweden.

SETTING AND PARTICIPANTS

We used data from the PriSUD-Nordic study, including national prison populations aged 19 years and older in Norway (2010-19), Denmark (2010-18) and Sweden (2010-13). A total of 119 507 Individuals (108 971 men and 10 536 women) contributing to 191 549 incarcerations were included in the study (Norway: 45432 men; 5429 women, Denmark: 42 162 men; 3370 women, Sweden: 21 377 men; 1737 women).

MEASUREMENT

We calculated a study prevalence and prevalence at entry to prison for all types of SUDs before imprisonment each consecutive year of observation in each prison population. We also extracted country-specific 1-year prevalence rates from the Global Burden of Diseases database to calculate comparative national prevalence ratios.

FINDINGS

The study prevalence of any SUD was approximately 40% [Norway: 44.0%, 95% confidence interval (CI) = 43.6-44.5%; Denmark: 39.9%, CI = 39.5-40.4%; Sweden: 39.1%, CI = 38.4-39.7%] in all three countries. Women had a significantly higher study prevalence of any SUD compared with men (Norway: 55.8 versus 42.6%, P < 0.001; Denmark 43.1 versus 39.7%, P = 0.004; Sweden: 51.7 versus 38.0%, P < 0.001). Prevalence estimates were higher for SUDs among people in prison than in the general population. We observed an increasing proportion of people with SUDs entering prison in Norway (P = 0.003), while the proportion was more stable in Denmark and Sweden.

CONCLUSIONS

Substance use disorders (SUDs) appear to be highly prevalent among the Scandinavian prison populations compared with the general population, especially among women. In Norway, there was a relative increase in SUDs from 2010 to 2019.

Met and unmet prison-based treatment needs for people who are incarcerated with a history of substance use disorder: A nationwide cohort study

BACKGROUND

Substance use disorders (SUD) are highly prevalent among incarcerated people. However, in some prisons, only a small percentage of those who need treatment receive it. The aims of this study were to examine coverage of treatment for SUD in Danish prisons and assess whether treatment differed by substance class. Further, we examined factors associated with receiving treatment for SUD, and types of services received.

DATA AND METHODS

We linked multiple Danish register data using unique personal identification numbers. This study retrospectively analysed data for 49,330 individuals (aged 18-90) incarcerated in Danish prisons between 2008 and 2018. We used a multivariable logistic regression model to predict enrolment in treatment for SUD in prison.

RESULTS

Of incarcerated people with a history of SUD, 34.6 % received treatment care during incarceration. We observed only minor variations in terms of substance classes concerning the type of treatment. Those who were women, immigrants, had higher education, or were married were less likely to receive treatment.

CONCLUSIONS

Improving access and increasing treatment coverage in the Danish Prison and Probation Services is crucial to reduce the burden of SUD in incarcerated populations.

Evaluation of heroin-assisted treatment in Norway: protocol for a mixed methods study

BACKGROUND

Opioid agonist treatment (OAT) for patients with opioid use disorder (OUD) has a convincing evidence base, although variable retention rates suggest that it may not be beneficial for all. One of the options to include more patients is the introduction of heroin-assisted treatment (HAT), which involves the prescribing of pharmaceutical heroin in a clinical supervised setting. Clinical trials suggest that HAT positively affects illicit drug use, criminal behavior, quality of life, and health. The results are less clear for longer-term outcomes such as mortality, level of function and social integration. This protocol describes a longitudinal evaluation of the introduction of HAT into the OAT services in Norway over a 5-year period. The main aim of the project is to study the individual, organizational and societal effects of implementing HAT in the specialized healthcare services for OUD.

METHODS

The project adopts a multidisciplinary approach, where the primary cohort for analysis will consist of approximately 250 patients in Norway, observed during the period of 2022-2026. Cohorts for comparative analysis will include all HAT-patients in Denmark from 2010 to 2022 (N = 500) and all Norwegian patients in conventional OAT (N = 8300). Data comes from individual in-depth and semi-structured interviews, self-report questionnaires, clinical records, and national registries, collected at several time points throughout patients' courses of treatment. Qualitative analyses will use a flexible inductive thematic approach. Quantitative analyses will employ a wide array of methods including bi-variate parametric and non-parametric tests, and various forms of multivariate modeling.

DISCUSSION

The project's primary strength lies in its comprehensive and longitudinal approach. It has the potential to reveal new insights on whether pharmaceutical heroin should be an integral part of integrated conventional OAT services to individually tailor treatments for patients with OUD. This could affect considerations about drug treatment even beyond HAT-specific topics, where an expanded understanding of why some do not succeed with conventional OAT will strengthen the knowledge base for drug treatment in general. Results will be disseminated to the scientific community, clinicians, and policy makers.

TRIAL REGISTRATION

The study was approved by the Norwegian Regional Committee for Medical and Health Research Ethics (REK), ref.nr.:195733.

The prevalence and comorbidity of mental health and substance use disorders in Scandinavian prisons 2010-2019: a multi-national register study

BACKGROUND

Mental health disorders are common among people in prison, but their prevalence in the Scandinavian prison population remain unclear. In this multinational register study, we examined the prevalence of mental health disorders and the comorbidity of substance use disorders (SUDs) with other mental health disorders in this population. Further, we investigated how the prevalence of mental disorders at prison entry had changed in Norway, Denmark, and Sweden over the study period.

METHODS

The three study cohorts included all individuals, aged 19 or older, whom had been imprisoned in Norway (2010-2019), Denmark (2011-2018), and Sweden (2010-2013). Mental disorders were defined as ICD-10 diagnoses (F-codes) registered in the national patient registers. The study prevalence was estimated based on recorded diagnoses during the entire study follow-up period in each respective country. The one-year prevalence of mental disorders was estimated for each calendar year for individuals entering prison during that year.

RESULTS

The Scandinavian prison cohorts included 119 507 individuals released 191 549 times during the study period. Across all three countries a high proportion of both women (61.3%-74.4%) and men (49.6%-57.9%) had at least one mental health disorder during the observation period. The most prevalent disorders were SUDs (39.1%-44.0%), depressive disorder (8.1%-17.5%), and stress related disorder (8.8%-17.1%). Women (31.8%-41.1%) had higher levels of mental health and substance use comorbidities compared to men (20.8%-27.6%). The one-year prevalence of any mental health disorder increased over time with a 33% relative increase in Norway, 8% in Denmark, and 10% in Sweden. The proportion of individuals entering prison with a comorbid SUD and other mental disorder had also increased.

CONCLUSIONS

While the incarceration rate has been decreasing during the past decade in the Scandinavian countries, an increasing proportion of people entering prison have a diagnosed mental health disorder. Our results suggest that prisons should provide adequate treatment and scale up services to accommodate the increasing proportion of people with complex health needs among incarcerated people.

Who receives heroin-assisted treatment? A comparison of patients receiving opioid maintenance treatment in Denmark

BACKGROUND

Since 2010, heroin-assisted treatment (HAT) has been one of the treatment options available to people with opioid use disorder (OUD) in Denmark. This study aimed to characterize HAT patients at treatment start and compare their individual characteristics to those of patients entering traditional opioid maintenance treatment (OMT) with methadone or buprenorphine during the same period.

METHODS

Patients who initiated HAT or OMT with methadone or buprenorphine in Denmark from 2010 to 2018 were included (n=6798). Multiple national registers were linked to compare treatment groups in terms of socio-demographic variables, previous OUD treatment episodes, hospital-based care, and criminal conviction history.

RESULTS

Nearly all HAT patients had a history of methadone treatment (91%) and half had residential treatment experience (48%). In the year previous to admission, HAT patients recorded the highest percentages of non-fatal overdoses (12%) and chronic hepatitis C diagnoses (16%), and the lowest percentages of psychiatric disorders (11%) compared to traditional OMT patients. Criminal convictions were also common: 39% of the HAT group had committed a property crime and 18% a drug-related crime the year before HAT entry. During the study period, an overall reduction in OMT enrollments for each year was recorded. The HAT proportion to the total remained fairly stable (4%-10%), while the buprenorphine proportion increased.

CONCLUSIONS

In Denmark, OMT patients exhibited numerous vulnerabilities at treatment start, and among the patient groups, HAT patients were the most burdened. HAT seems to reach the target group and adhere to formulated eligibility criteria.

Problematic parental substance use, childhood family structures and adverse outcomes in young adulthood

Aim: The aim of the present study was to investigate the association between childhood family structures, including the presence or absence of problematic parental substance use (PPSU), and adverse outcomes during adolescence/young adulthood. Methods: The study population included 9,770 young people (aged 15-25 years) from samples drawn for two national surveys in Denmark during 2014-2015. By combining surveys with national register data, five types of childhood family structures were constructed based on whether the child experienced PPSU and/or family separation and the number of years the child lived with a parent with substance use problems. Using binary logistic regression models, the relationships between family structure and adverse outcomes in young adulthood (i.e., hospital admissions, mental disorders and criminality) were investigated. Results: Young people who experienced PPSU and did not live with both parents had higher odds of the different long-term adverse outcomes compared with young people who did not experience PPSU, and similar odds of the outcomes compared to youth who had not experienced PPSU and did not live with both parents. The highest odds of adverse outcomes were found among young people who experienced PPSU and lived with the parent with substance use problems for less than five years. Conclusions: Living with both parents protected against adverse outcomes in young adulthood, and if PPSU was present, the odds of adverse outcomes increased. The hypothesis that there would be a positive association between years living with a parent with substance use problems and adverse outcomes in young adulthood was not supported. Awareness should be raised in health service, educational and legal institutions about the risk for young people from families with PPSU who do not live with both parents.

Large variations in all-cause and overdose mortality among >13,000 patients in and out of opioid maintenance treatment in different settings: a comparative registry linkage study

Background

Opioid maintenance treatment (OMT) has the potential to reduce mortality rates substantially. We aimed to compare all-cause and overdose mortality among OMT patients while in or out of OMT in two different countries with different approaches to OMT.

Methods

Two nation-wide, registry-based cohorts were linked by using similar analytical strategies. These included 3,637 male and 1,580 female patients enrolled in OMT in Czechia (years 2000-2019), and 6,387 male and 2,078 female patients enrolled in OMT in Denmark (years 2007-2018). The direct standardization method using the European (EU-27 plus EFTA 2011-2030) Standard was employed to calculate age-standardized rate to weight for age. All-cause and overdose crude mortality rates (CMR) as number of deaths per 1,000 person years (PY) in and out of OMT were calculated for all patients. CMRs were stratified by sex and OMT medication modality (methadone, buprenorphine, and buprenorphine with naloxone).

Results

Age-standardized rate for OMT patients in Czechia and Denmark was 9.7/1,000 PY and 29.8/1,000 PY, respectively. In Czechia, the all-cause CMR was 4.3/1,000 PY in treatment and 10.8/1,000 PY out of treatment. The overdose CMR was 0.5/1,000 PY in treatment and 1.2/1,000 PY out of treatment. In Denmark, the all-cause CMR was 26.6/1,000 PY in treatment and 28.2/1,000 PY out of treatment and the overdose CMR was 7.3/1,000 PY in treatment and 7.0/1,000 PY out of treatment.

Conclusion

Country-specific differences in mortality while in and out of OMT in Czechia and Denmark may be partly explained by different patient characteristics and treatment systems in the two countries. The findings contribute to the public health debate about OMT management and may be of interest to practitioners, policy and decision makers when balancing the safety and accessibility of OMT.

Full aperture backscatter diagnostics for characterization of laser plasma instabilities at the extreme light infrastructure (ELI) beamlines

We report on the commissioning of a full aperture backscatter diagnostics station for the kilojoule, nanosecond high repetition rate L4n laser operating at a wavelength of 527 nm at the Extreme Light Infrastructure (ELI) - Beamlines, Dolni Brezany, Czech Republic. Light scattered back from laser-plasma interaction into the cone of the final focusing lens is captured and split into different channels to measure the signatures of laser plasma instabilities from stimulated Brillouin scattering, stimulated Raman scattering, and two plasmon decay with respect to back scattered energy, its spectrum, and its temporal profile. The performance was confirmed in a commissioning experiment with more than 800 shots at laser intensities ranging from 0.5 × 1013 to 1.1 × 1015 W cm-2. These diagnostics are permanently installed at ELI Beamlines, and can be used to understand the details of laser-plasma interactions in experiments with kJ and 527 nm light. The large number of shots that can be collected in an experimental campaign will allow us to study the details of the laser-plasma interaction with a high level of confidence.

Cause-Specific Mortality among Patients in Treatment for Opioid Use Disorder in Multiple Settings: A Prospective Comparative Cohort Study

INTRODUCTION

Among people receiving current or previous opioid maintenance treatment (OMT), the leading cause of premature death is an opioid overdose. However, other causes of mortality remain high in this group. An understanding of causes of deaths across multiple settings can be useful in informing more comprehensive prevention responses. The aim of this study was to describe all non-overdose causes of death in three national cohorts (Czechia, Denmark, and Norway) among OMT patients and to explore associations of non-overdose mortality with age and gender.

METHODS

This prospective comparative cohort study used national mortality registry databases for OMT patients from Czechia (2000-2019), Denmark (2000-2018), and Norway (2010-2019). Crude mortality rates and age-standardized mortality rates (ASMRs) were calculated as deaths per 1,000 person years for cause-specific mortality.

RESULTS

In total, 29,486 patients were included, with 5,322 deaths recorded (18%). We found variations in causes of death among the cohorts and within gender and age groups. The leading non-overdose causes of death were accidents in Czechia and Denmark, and neoplasms in Norway. Cardiovascular deaths were highest in Czechia, particularly for women in OMT (ASMR 3.59 vs. 1.24 in Norway and 1.87 in Denmark).

CONCLUSION

This study found high rates of preventable death among both genders and all age groups. Different demographic structures, variations in risk exposure, as well as variations in coding practices can explain the differences. The findings support increased efforts towards screening and preventative health initiatives among OMT patients specific to the demographic characteristics in different settings.

Screening of coexisting depression or anxiety disorders among Danish patients with alcohol use disorder in outpatient treatment

BACKGROUND

Depression and anxiety are highly prevalent among patients seeking outpatient treatment for alcohol use disorders (AUD) and if depression and anxiety are addressed the prognosis is improved. Screening instruments for depression and anxiety have been validated in populations suffering from drug use disorders, but not in populations suffering from AUD. The aim of this study was to validate four self-administrated screening instruments (PHQ-9, GAD-7, Kessler-6, and SRQ) and calculate the optimal cut-off value for identifying depression and anxiety.

METHODS

The study included 73 patients with self-reported depression or anxiety during AUD treatment. Each patient filled out the above-mentioned instruments and was subsequently interviewed by trained clinicians blinded to the results of the instruments with the Present State Examination to establish a diagnosis of depression or anxiety according to ICD-10. ROC curves were constructed for each instrument and the area under the curve (AUC) was calculated using patients with no depression or anxiety as reference. Youden's index was calculated to assess the optimal cut-off for each instrument.

RESULTS

A total of 33 (45.2%) were diagnosed with depression or anxiety. The AUC for PHQ-9, GAD-7, Kessler-6, and SRQ were 0.767, 0.630, 0.793, and 0.698 respectively. Kessler-6, the instruments performing best based on the AUC, identified 27 (82%) of the 33 patients using a cut-off of 10 points.

CONCLUSION

Kessler-6 seems to be valid and reliable in identifying patients requiring treatment for depression or anxiety among patients seeking treatment for AUD who are reporting depression or anxiety.

The predictive value of brief measures of externalizing behavior and internalizing problems in young people receiving substance use treatment: A secondary analysis

BACKGROUND

Identifying people at risk of poor outcomes following treatment for substance use disorders is important for developing tailored services. The aim of this study was to test whether a brief measure of internalizing and externalizing behavior could identify young adults at high risk of psychiatric care episodes and criminal offending up to four years after enrolment in treatment for substance use disorder.

METHODS

Clients aged 15-25 years from a randomized multicenter study were included (N = 457). At baseline, all completed the YouthMap12 screener, a measure of internalizing symptoms (IP6) and externalizing problems (EP6). We used accelerated failure time regression to assess time to psychiatric care and criminal offending, adjusting for baseline occurrence, gender, age, treatment group, and uptake area. Youden's J was used to assess optimal cut-points for risk of events.

RESULTS

The IP6 was associated with shorter time to psychiatric care following treatment enrolment (beta = -0.71, 95% confidence interval [CI] = -0.94 to -0.48; adjusted beta = -0.45, 95% CI = -0.66 to -0.25). The EP6 was associated with shorter time to criminal offending, coefficient = -0.32, 95% CI = -0.44 to -0.19; adjusted coefficient = -0.18, 95% CI = -0.30 to -0.06). Optimal cut-points were two or more for the IP6 and three or more for the EP6.

CONCLUSIONS

The IP6 and the EP6, two simple and easily administered instruments, can identify young adults who are at an increased risk of future criminal offending or in need of psychiatric care. The findings lend support to using the 12-item YouthMap, as it identifies relevant risks, is compatible with local service delivery needs, and is theoretically and empirically supported.

Using the alcohol use disorders identification test to predict hospital admission for alcohol-related conditions in the Danish general population: a record-linkage study

BACKGROUND AND AIMS

Most studies validating the alcohol use disorders identification test (AUDIT) have either assessed its factor structure and/or test-retest reliability or used diagnostic interviews as validators of current alcohol use disorders. The aim of the present study was to determine whether AUDIT and AUDIT-Consumption (AUDIT-C) scores are associated with subsequent risk of hospital admission for alcohol-related disorders and diseases (ARDDs).

DESIGN

We used a historical cohort study. Using national registers, survey respondents were tracked from 1 September 2011 to hospitalization for an ARDD, emigration, death, or 31 December 2018, whichever occurred first.

SETTING

Denmark.

PARTICIPANTS

Respondents (n = 4522) from a Danish national survey conducted in autumn 2011.

MEASUREMENTS

Outcome was incident ARDD admission recorded in the National Patient Register. Predictors were AUDIT and AUDIT-C scores, and covariates were age, gender, highest level of education and previous psychiatric disorder.

FINDINGS

During the study period, 56 respondents had a first-time ARDD admission. Respondents who scored above the 8-point AUDIT cut-off and respondents who scored above the 5-point AUDIT-C cut-off had a significantly increased risk of being admitted for an ARDD compared with respondents who scored below the cut-offs, (AUDIT: hazard ratio (HR), 4.72; 95% CI, 2.59-8.60; AUDIT-C: HR, 7.97; 95% CI, 3.66-17.31).

CONCLUSIONS

Scores above alcohol use disorders identification test (AUDIT) and AUDIT-Consumption (AUDIT-C) cut-offs are associated with an increased risk of long-term alcohol-related hospital admissions. At widely used cut-offs, the AUDIT-C is a better predictor of alcohol-related hospitalizations among members of the general population than the full AUDIT.

Negative experiences, social exclusion and unwanted attention on social media: exploring the association with adolescent alcohol use

BACKGROUND

Adolescents' presence on Social Media (SoMe) facilitates peer connections making them susceptible to peer-influences and approval. Negative experiences on SoMe can affect adolescent stress and wellbeing, impelling their use of alcohol. This paper provides a novel understanding of the relationship between negative experiences on SoMe and key indicators of alcohol use in adolescents.

METHODS

Data was collected from upper secondary school students (n = 3528, ages 16-19, 45% boys) in Bergen (Norway) using a web-based questionnaire during school-hours in 2020 and 2021. Dependent variables were alcohol consumption, binge drinking and scoring ≥ 2 points on the CRAFFT instrument screening for substance use problems in adolescents. Independent variables were two scales indicating "negative acts and exclusion" and "unwanted attention from others". Covariates included age, gender, country of birth and subjective socioeconomic status. Results are presented as relative risk ratios (RRR), odds ratios (OR) and incidence rate ratios (IRR) with 95% confidence intervals.

RESULTS

Using multinomial logistic regression models, "negative acts and exclusion" and "unwanted attention" were positively associated with trying alcohol (OR: 1.50 (95% CI 1.28-1.76) and 1.86 (95% CI 1.66-2.09) respectively, both p ≤ 0.001), with frequency and amount of alcohol consumed. Findings from logistic regression models indicated that "negative acts and exclusion" and "unwanted attention" were positively associated with i. CRAFFT-caseness (OR: 2.13 and 1.86) and ii. frequent binge drinking (OR: 1.55 and 1.89).

CONCLUSION

Both exclusion and unwanted attention on SoMe were associated with indicators of problematic drinking, including frequency, quantity, and consequences related to alcohol.

Substance Use and Violent Victimization: Evidence from a Cohort of >82,000 Patients Treated for Alcohol and Drug Use Disorder in Denmark

Although the association between substance use and violence has been well established, knowledge on predictors for violent victimization of individuals treated for alcohol use disorder (AUD) or drug use disorder (DUD) is lacking. Using Goldstein's tripartite conceptual framework, this study examines the relationship between substance use and violent victimization. Data were derived from national registers on persons aged between 15 and 75 years, living in Denmark, and admitted for AUD or DUD treatment during 2006-2016 (n = 82,767). Rates of new incidence of violent victimization were estimated per 10,000 person years for the patient cohort, and for an age- and gender-matched control group of 492,397 people with no history of treatment for drug and alcohol problems. The incidence of victimization for the AUD/DUD sample was 145.6 per 10,000 person years and 5.4 per 10,000 person years for the comparison cohort. Results of multivariate Cox regression on specific types of substance use supported Goldstein's psychopharmacological and economic compulsive models of victimization, but not the systemic model. Gender-stratified results showed that the use of cannabis and methadone was associated with victimization in women treated for AUD and DUD. Patients with a non-Western background were more likely to experience victimization than Danish patients. The study highlights the strong association between substance use disorder and victimization, and the important role that service providers play in addressing the high levels of victimization experienced by patients with AUD or DUD.

Magnetic Field Annihilation in a Magnetotail Electron Diffusion Region With Electron-Scale Magnetic Island

We present observations in Earth's magnetotail by the Magnetospheric Multiscale spacecraft that are consistent with magnetic field annihilation, rather than magnetic topology change, causing fast magnetic-to-electron energy conversion in an electron-scale current sheet. Multi-spacecraft analysis for the magnetic field reconstruction shows that an electron-scale magnetic island was embedded in the observed electron diffusion region (EDR), suggesting an elongated shape of the EDR. Evidence for the annihilation was revealed in the form of the island growing at a rate much lower than expected for the standard X-type geometry of the EDR, which indicates that magnetic flux injected into the EDR was not ejected from the X-point or accumulated in the island, but was dissipated in the EDR. This energy conversion process is in contrast to that in the standard EDR of a reconnecting current sheet where the energy of antiparallel magnetic fields is mostly converted to electron bulk-flow energy. Fully kinetic simulation also demonstrates that an elongated EDR is subject to the formation of electron-scale magnetic islands in which fast but transient annihilation can occur. Consistent with the observations and simulation, theoretical analysis shows that fast magnetic diffusion can occur in an elongated EDR in the presence of nongyrotropic electron effects. We suggest that the annihilation in elongated EDRs may contribute to the dissipation of magnetic energy in a turbulent collisionless plasma.

Impulsive Lifestyle Counselling versus treatment as usual to reduce offending in people with co-occurring antisocial personality disorder and substance use disorder: a post hoc analysis

OBJECTIVES

To assess the impact of a short psychoeducation intervention for antisocial personality disorder on offending after randomization to treatment.

DESIGN

Multicentre, superiority, non-blinded randomized controlled trial. Random assignment was conducted in blocks of varying sizes at a central randomization centre. Participants were followed using national register data until 365 days after randomization, migration, or death, whichever occurred first.

SETTING

Thirteen outpatient uptake areas in Denmark.

PARTICIPANTS

Patients with antisocial personality disorder in treatment for substance use disorders were randomized to treatment as usual (TAU, n = 80) or Impulsive Lifestyle Counselling (ILC, n = 96). A total of 165 patients could be linked to criminal records (TAU, n = 74; ILC, n = 91).

INTERVENTION

ILC is a brief psychoeducational program targeting antisocial behavior. The trial was conducted between January 2012 and June 2014.

OUTCOMES

Number of criminal offences leading to convictions based on national registers.

RESULTS

The mean number of offences was 2.76 in the TAU group (95% Poisson confidence interval [CI] = 2.39, 3.16) and 1.87 in the ILC group (95% CI = 0.97, 1.43). Negative binomial regression was used to assess total number of convictions, as well as convictions for violent, property, driving under the influence, and drug-related crimes. In both adjusted and unadjusted analyses, random assignment to ILC was associated with a lower number of total offences (incidence rate risk ratio [IRR] = 0.43, p = .013; adjusted IRR = 0.45, p < .001) and convictions related to violence (IRR = 0.19, p = .001 adjusted IRR = 0.19, p = .007) and property offences (unadjusted IRR = 0.30, p = 0.003, adjusted IRR = 0.42, p = 0.010). Differences between conditions were not significant for driving under the influence (unadjusted IRR = 0.49, p = .370; adjusted IRR = 0.53, p = .417) or drug offences (unadjusted IRR = 1.06, p = .907; adjusted IRR = 0.55, p = .223).

CONCLUSIONS

The ILC program shows promise in reducing offending behavior in people with comorbid substance use and antisocial personality disorder.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN67266318 , 15/10/2012.

Parker Solar Probe Observations of Solar Wind Energetic Proton Beams Produced by Magnetic Reconnection in the Near-Sun Heliospheric Current Sheet

We report observations of reconnection exhausts in the Heliospheric Current Sheet (HCS) during Parker Solar Probe Encounters 08 and 07, at 16 R _s and 20 R _s , respectively. Heliospheric current sheet (HCS) reconnection accelerated protons to almost twice the solar wind speed and increased the proton core energy by a factor of ∼3, due to the Alfvén speed being comparable to the solar wind flow speed at these near-Sun distances. Furthermore, protons were energized to super-thermal energies. During E08, energized protons were found to have leaked out of the exhaust along separatrix field lines, appearing as field-aligned energetic proton beams in a broad region outside the HCS. Concurrent dropouts of strahl electrons, indicating disconnection from the Sun, provide further evidence for the HCS being the source of the beams. Around the HCS in E07, there were also proton beams but without electron strahl dropouts, indicating that their origin was not the local HCS reconnection exhaust.

Prescription opioids among older adults: ten years of data across five countries

BACKGROUND

Opioid use has increased globally in the recent decade. Although pain remains a significant problem among older adults, susceptibility to opioid-related harms highlights the importance of careful opioid therapy monitoring on individual and societal levels. We aimed to describe the trends of prescription opioid utilisation among residents aged ≥65 in all Nordic countries during 2009-2018.

METHODS

We conducted cross-sectional measurements of opioid utilisation in 2009-2018 from nationwide registers of dispensed drugs in Denmark, Finland, Iceland, Norway, and Sweden. The measures included annual opioid prevalence, defined daily doses (DDDs) per 1000 inhabitants per day (DIDs), and morphine milligram equivalents (MMEs) per user per day.

RESULTS

From 2009 to 2018, an average of 808,584 of adults aged ≥65 used opioids yearly in all five countries; an average annual prevalence of 17.0%. During this time period, the prevalence decreased in Denmark, Norway, and Sweden due to declining codeine and/or tramadol use. Iceland had the highest opioid prevalence in 2009 (30.2%), increasing to 31.7% in 2018. In the same period, DIDs decreased in all five countries, and ranged from 28.3 in Finland to 58.5 in Denmark in 2009, and from 23.0 in Finland to 54.6 in Iceland in 2018. MMEs/user/day ranged from 4.4 in Iceland to 19.6 in Denmark in 2009, and from 4.6 in Iceland to 18.8 in Denmark in 2018. In Finland, Norway, and Sweden, MMEs/user/day increased from 2009 to 2018, mainly due to increasing oxycodone utilisation.

CONCLUSIONS

The stable or decreasing opioid utilisation prevalence among a majority of older adults across the Nordic countries coincides with an increase in treatment intensity in 2009-2018. We found large cross-national differences despite similarities across the countries' cultures and healthcare systems. For the aged population, national efforts should be placed on improving pain management and monitoring future trends of especially oxycodone utilisation.

Primary Outcome from a cluster-randomized trial of three formats for delivering Community Reinforcement and Family Training (CRAFT) to the significant others of problem drinkers

BACKGROUND

Community Reinforcement and Family Training (CRAFT) is an intervention designed to help the concerned significant others (CSOs) of people with alcohol problems who are reluctant to seek treatment. It aims to improve the well-being of CSOs and teach them how to change their behavior in order to positively influence the "identified patient" (IP) to seek treatment.

METHODS

The aim of the present pragmatic cluster-randomized trial was to compare the effectiveness of three formats for delivering CRAFT in real life settings: group sessions, individual sessions, and written material only (control group). Eighteen public treatment centers for alcohol use disorders were randomly assigned to deliver CRAFT in one of the three formats as part of their daily clinical routine. CSOs were recruited via pamphlets, general practitioners, and advertisements on social media. Trained clinicians delivered CRAFT in individual and group format, and self-administered CRAFT was limited to handing out a self-help book. The primary outcome was treatment engagement of the IP after three months.

RESULTS

A total of 249 CSOs were found to be eligible and randomly assigned to receive CRAFT delivered in group, individual, or self-administered format. The three-month follow-up rate was 60%. At three months follow-up, 29% (n = 32) of the CSOs who received group/individual CRAFT reported that their IP had engaged in treatment. The corresponding rate for the CSOs who received self-administered CRAFT was lower (15%; n = 5) but did not differ significantly from the other group of CSOs (Odds ratio (OR) = 2.27 (95% CI: 0.80, 6.41)).

CONCLUSION

We hypothesized that CSOs receiving CRAFT in a group format would improve the most, but although our findings pointed in this direction, the differences were not statistically significant.

TRIAL REGISTRATION

Clinical trials.gov ID: NCT03281057 . Registration date:13/09/2017.

Hazardous drinking and violence-related hospitalizations in the Danish general population: A historical cohort study

BACKGROUND

It is well documented by case-control and case-crossover studies that hazardous drinking and the risk of experiencing violence-related injuries are related. The present study investigated this relationship in a cohort of general population survey respondents in Denmark using subsequent hospital admissions for violence.

METHODS

The cohort consisted of participants in the 2011 Danish national survey on alcohol and drugs (N = 5126). Survey responses were used to identify those with hazardous alcohol use. Register data on the cohort's hospital admissions for violence from 2010 through 2018 served as the outcome. The relationship between respondents' hazardous drinking and counts of subsequent hospital admissions was investigated using a Poisson regression model.

RESULTS

After controlling for confounding, respondents with hazardous consumption (Alcohol Use Disorders Identification Test Consumption [AUDIT-C] cut off: 5 points) had an increased rate of hospital admissions for violence, with an incidence rate ratio (IRR) of 2.28 (95% CI: 1.16-4.50) compared to respondents without hazardous alcohol use. Each additional AUDIT-C point was associated with a 20% increase in the incidence rate for violence-related admission (IRR=1.20, 95% CI: 1.06-1.37). Furthermore, interaction analyses showed a significant interaction between gender and AUDIT-C score on hospital admissions for violence (IRR=0.69, 95% CI: 0.53-0.90).

CONCLUSIONS

Results provide evidence that hazardous alcohol use is associated with subsequent hospital admissions for violence in the Danish general population and that gender moderates this relationship.