Comparison of efficacy between buprenorphine and tramadol in the detoxification of opioid (heroin)-dependent subjects

AIM/BACKGROUND

Tramadol is a synthetic opiate and a centrally acting weak m-opioid receptor agonist. The potential advantages of tramadol include ease of administration, low abuse potential, and being nonscheduled. This study compared tramadol and buprenorphine for controlling withdrawal symptoms in patients with opioid dependence syndrome.

METHODS

Consenting male subjects between 20 and 45 years of age who fulfilled the ICD-10-DCR criteria for opiate dependence syndrome were randomly assigned in a double-blind, double-dummy placebo-controlled trial for detoxification. Those with multiple drug dependence, abnormal cardiac, renal and hepatic functions, psychosis, or organic mental illness were excluded. Assessments included Subjective Opiate Withdrawal Scale (SOWS), Objective Opiate Withdrawal Scale (OOWS), Visual Analog Scale (VAS), and Side Effect Check List. Subjects were evaluated daily and study duration was 10 days.

RESULTS

Sixty two subjects were enrolled. The mean SOWS and OOWS and VAS were significantly lower in the buprenorphine group on second and third day of detoxification as compared to the tramadol group. Although the retention rate was higher for buprenorphine group throughout the study, when compared with tramadol the difference was not significant on any day. Three subjects in the tramadol group had seizures.

CONCLUSIONS

Tramadol was found to have limited detoxification efficacy in moderate to severe opioid withdrawal and substantial risk of seizures as compared to buprenorphine. Further studies are warranted to examine its efficacy in mild opioid withdrawal symptoms and its potential use in outpatient settings where its administration advantages may be valuable.

Evaluation of the quality of life (Whoqol-Bref) among methadone and suboxone substitution state program patients and healthy volunteers in Georgia

to evaluate QOL patients being treated with methadone and Suboxone in State-sponsored programs in Georgia. The WHOQOL-BREF (26 questions) version was administered to patients in State substitution program and healthy volunteers to assess their overall function and life satisfaction in physical, mental, social health, and environment domains. Domain scores were calculated and converted to 4-20 and 0-100 scales, identical to the WHOQOL-100. 485 patients (309 from 6 Tbilisi and 176 from 5 regional centers) and 50 healthy volunteers (13 male, 37 female) were surveyed. Significant differences were observed between new admitted patients (0-3 month) and healthy controls by mean physical (47.5 vs. 51.94; CI 95%); psychological (55.0 vs. 60.50; CI 95%) and environmental (46.2 vs. 52.2; CI 95%) domains, but not by social relationships or between Tbilisi and regions. The Social domain scores were raised in accordance with time spent in treatment reaching a maximum improvement within 1-3 years (social- 72.8 vs. 67.7; CI 95%), further with few descending tends round the healthy people's scores. These pilot data show decrements in QOL among patients entering maintenance treatment with improvements in the course of maintenance treatment. It is possible that the increased indicators in social domain up to especially high level within the first 3 years is the result of subjective factors, with the subsequent return to healthy community level.

HIV infection risk among injection drug users in a methadone maintenance treatment program, Taipei, Taiwan 2007-2010

BACKGROUND

Taiwan has a growing HIV/AIDS epidemic that has recently shifted to an increase among injection drug users (IDUs). This study aimed to measure the prevalence and incidence and identify the correlates of HIV infection among IDUs in a large methadone maintenance treatment program (MMTP) in Taipei, Taiwan.

METHODS

Data from intake interviews and HIV testing completed by IDUs upon admission to the Taipei City Hospital MMTP in 2007-2010 were included in this analysis. HIV testing was repeated semi-annually among maintained clients who were HIV-negative during MMTP admission.

RESULTS

Of 1444 IDUs admitted, 85.9% were male, median age was 40 years, and mean years of injecting was 14.3 (range: 1-64). The prevalence of HIV, HCV, and HIV/HCV co-infection was 13.4%, 91.1%, and 13.2%, respectively. In multivariable analysis, HIV infection was associated with sharing syringes during the 6 months prior to admission (OR = 14.76, 95% CI 10.31-21.13), homelessness (OR = 6.46, 95% CI 1.49-28.00), and lifetime number of MMTP admissions (OR = 1.76, 95% CI 1.30-2.38) and times incarcerated (OR = 1.10, 95% CI 1.03-1.18). HIV seroincidence was 1.15/100 person-years at risk (95% CI .62-8.77/100 PY) among IDUs who were HIV-negative at first admission.

CONCLUSIONS

Taiwanese IDUs in MMTP have a high HIV prevalence, which was associated with syringe sharing and other factors related to social marginalization. Our findings highlight the importance of harm reduction programs, including syringe exchange, along with HIV-prevention education.

Facilitating medical withdrawal from opiates in rural Ontario

CONTEXT

The abuse of oxycodone in Northwestern Ontario, Canada, has escalated at alarming rates raising concerns that opiate use has reached epidemic proportions, particularly among the First Nations communities. The authors were involved in establishing Ontario's first rural inpatient medical withdrawal unit to serve patients seeking abstinence.

ISSUES

The development of the medical withdrawal support services (MWSS) required creative and adaptive strategies to respond to the geographical, cultural and institutional circumstances.

LESSONS LEARNED

Key factors to support program efficacy and successful outcomes for clients during the inaugural eight months of operation are interprofessional and collaborative approaches with a cultural awareness.Key words: addiction, Canada, First Nation, medical withdrawal.

Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis

OBJECTIVE

To quantify the effect of opiate substitution treatment in relation to HIV transmission among people who inject drugs.

DESIGN

Systematic review and meta-analysis of prospective published and unpublished observational studies.

DATA SOURCES

Search of Medline, Embase, PsychINFO, and the Cochrane Library from the earliest year to 2011 without language restriction.

REVIEW METHODS

We selected studies that directly assessed the impact of opiate substitution treatment in relation to incidence of HIV and studies that assessed incidence of HIV in people who inject drugs and that might have collected data regarding exposure to opiate substitution treatment but not have reported it. Authors of these studies were contacted. Data were extracted by two reviewers and pooled in a meta-analysis with a random effects model.

RESULTS

Twelve published studies that examined the impact of opiate substitution treatment on HIV transmission met criteria for inclusion, and unpublished data were obtained from three additional studies. All included studies examined methadone maintenance treatment. Data from nine of these studies could be pooled, including 819 incident HIV infections over 23,608 person years of follow-up. Opiate substitution treatment was associated with a 54% reduction in risk of HIV infection among people who inject drugs (rate ratio 0.46, 95% confidence interval 0.32 to 0.67; P<0.001). There was evidence of heterogeneity between studies (I(2)=60%, χ(2)=20.12, P=0.010), which could not be explained by geographical region, site of recruitment, or the provision of incentives. There was weak evidence for greater benefit associated with longer duration of exposure to opiate substitution treatment.

CONCLUSION

Opiate substitution treatment provided as maintenance therapy is associated with a reduction in the risk of HIV infection among people who inject drugs. These findings, however, could reflect comparatively high levels of motivation to change behaviour and reduce injecting risk behaviour among people who inject drugs who are receiving opiate substitution treatment.

Childhood sexual abuse characteristics, intimate partner violence exposure, and psychological distress among women in methadone treatment

Traumatic experiences and their biopsychosocial sequelae present complex challenges in substance use treatment. For women with substance use problems, childhood sexual abuse (CSA), intimate partner violence exposure (IPV), posttraumatic stress disorder (PTSD), and overall psychological distress are often co-occurring concerns. To address gaps in knowledge and to strengthen practice regarding these critical issues in substance use treatment, we drew upon cross-sectional and longitudinal data from baseline and 12-month interviews with a random sample of 416 women in methadone treatment to examine relationships between CSA characteristics, particularly the presence of force and involvement of family, IPV, and mental health concerns. Although CSA involving force and family was not associated with IPV as hypothesized, it was associated with increased risk of PTSD and overall psychological distress. The multivariate findings underscore the psychological vulnerabilities associated with CSA involving force and family and suggest that drug use and financial circumstances may be important targets to reduce IPV risk.

Temporal discounting in heroin-dependent patients: no sign effect, weaker magnitude effect, and the relationship with inhibitory control

Impulsive behavior in heroin-dependent individuals and matched smokers was studied within the framework of temporal discounting. Two well-known effects were examined: the sign and magnitude effects (Kirby, 1997). The study also investigated the relationship between cognitive impulsivity and inhibitory control as measured by a Go/No-go task. Fifty-six heroin-dependent patients in the postmethadone treatment stage and an equal number of matched daily smokers participated in the study. The heroin-dependent patients showed higher discount rates in both gain and loss conditions. They also showed no sign effect by demonstrating similar discount rates in gains and losses. Heroin-dependent patients also exhibited a magnitude effect, which was weaker than that observed in smokers. Differential relationships between impulsivity and inhibitory control were found in the two groups. For smokers, decision-making and inhibitory control behaviors pertained to different psychological processes, whereas for heroin-dependent patients, the two behaviors were partially related. Finally, a significant correlation between length of heroin use and temporal discounting with small magnitude was found. The present study advances our understanding of the specific behavioral impulsive patterns in heroin-dependent individuals.

Quality of life in patients on methadone maintenance treatment: a three-month assessment

OBJECTIVE

To examine the 3-month effect of methadone maintenance treatment (MMT) on quality of life (QOL) of substance-dependent outpatients in Iran.

METHODS

The qausi-experimental study performed at the Oral Maintenance Methadone Treatment Clinic of the Baharan Psychiatric Hospital, a university hospital in Zahedan, southeast of Iran, from 2009 to 2010. One hundred patients with substance-dependence disorder were recruited from the outpatient clinic. Quality of life parametres were measured through the World Health Organization Quality of Life scale (WHO QOL-BREF) prior to the treatment, and 1, 2 and 3 months after starting the treatment in order to assess changes in the Quality of Life across the treatment period. Repeated measurement analysis was used for data analysis.

RESULTS

Of the 100 subjects initially recruited, 83 (83%) completed the study period. The total Quality of Life score improved from pre-treatment to the first month into treatment. The improvement was maintained at the 2-month and 3-month points (P < .05). According to the World Health Organization subscales, the treatment was effective in improving physical and social relationship domains over time (P < .05), but there were no significant improvements in psychological and environmental domains.

CONCLUSIONS

Oral methadone maintenance treatment was effective in improving the overall Quality of Life during the first three months of treatment in substance-dependent outpatients.

Superior methadone treatment outcome in Hmong compared with non-Hmong patients

The Hmong are a distinct ethnic group from Laos. Little is known about how opiate-addicted Hmong respond to methadone maintenance treatment. Therefore, opium-addicted Hmong (exclusive route of administration: smoking) attending an urban methadone maintenance program in Minneapolis, MN, were matched by gender and date of admission with predominately heroin-addicted non-Hmong (predominant route of administration: injection) attending the same program, and both groups were evaluated for 1-year treatment retention, stabilization dose of methadone, and urine drug screen results. Hmong had greater 1-year treatment retention (79.8%) than non-Hmong (63.5%; p < .01). In both groups, methadone dose was significantly associated with retention (p = .005). However, Hmong required lower doses of methadone for stabilization (M = 49.0 vs. 77.1 mg; p < .0001). For both groups, positive urine drug screens were associated with stopping treatment. Further research to determine levels of tolerance and psychosocial and pharmacogenetic factors contributing to differences in methadone treatment outcome and dosing in Hmong may provide further insight into opiate addiction and its treatment.

Treatment of addicts in Bosnia and Herzegovina--constraints and opportunities

Chronology of important historical events in Bosnia and Herzegovina during past two centuries indirectly influenced the incidence and prevalence of different psychoactive substances use and thus the organization of services for the treatment of persons who develop addiction symptoms. The organization of health system in the last war, 1992-1995, suffered enormous damage and the reform process which inevitably followed, included the area of mental health care services and the establishment of network of centers for mental health in the community (CMHC). The centers are functioning within the primary health care almost in whole country, with specialized centers for the prevention and treatment of addicts and the therapeutic communities, which today represents the basic organizational units to help people who have drug related issues. In this paper we will present the possibility of treatment of drug addicts in Bosnia and Herzegovina, from consulting services, psycho-education and early detection of disease, detoxification and substitution programs with Methadone and Suboxone, as well as programs of rehabilitation and resocialization. Although a very complicated political and administrative structure of the country, insufficient financial support, pronounced stigmatization of addicts, insufficient staffing and number of treatment centers are objective obstacles for progress in treatment of addicts, we believe that, with existing resources, these constraints can be converted into new opportunities in terms of improvement of treatment options in the future.

Medically assisted treatment for opiate addiction--suboxone method as prevention of social exclusion of youth--Tuzla model

AIM

To present medically assisted treatment for opiate addiction with substitution medicament Suboxone and prevention of social exclusion of young opiate addicts in Bosnia and Herzegovina.

GENERAL OVERVIEW

Until recently there was no solution for long-term and comprehensive treatment of young persons who suffer from opiate addiction. This is not an illness that impairs only psychological and physical health of addicts with possible fatal aftermaths, but serious societal problem due to its consequences such as delinquency, crimes and violence that lead young people to social exclusion. There are no capacities within the existing health facilities for long-term stationary treatment, which is necessary for drug addiction. In addition, far less adequate solution is placement of young addicts into penal and correctional institutions, which are stigmatizing and contribute to their exclusion from normal social life. Hence, the latest medically assisted method of substitution treatment with a combination of buprenorphine and naloxone (Suboxone) is introduced. This medicament, with its characteristics, offers possibility for outpatient treatment, and prompt and effective results of detoxification and weaning of opiates is to be achieved. Opiate addicts that undergo this treatment benefit from "clear mind" and capability for occupational and social activities, which significantly improves the quality of their family and social relations. With Suboxone substitution method, the institutional (inpatient) treatment is to be avoided and social exclusion of young addicts treated with Suboxone prevented.

CONCLUSION

Medically assisted treatment for opiate addiction with Suboxone is conducted in outpatient setting with the involvement of close relatives who are not addicted. It brings back "clear mind" to previous addicts, does not stigmatize but contribute to re-socialization and prevention of social exclusion of young opiate addicts.

Evaluation and management of opioid dependence in pregnancy

BACKGROUND

Opioid use disorders are a growing public health problem in the United States. Most women who are opioid-dependent are of childbearing age, and management of opioid dependence during pregnancy poses unique challenges. Assessment includes evaluation for addiction, withdrawal syndromes, and comorbid psychiatric diagnoses. Consultation-liaison (C-L) psychiatrists may also be involved in acute pain management, perinatal medication management, buprenorphine induction, and stabilization. For the past four decades, the standard of care has included methadone maintenance, but the increasing use of buprenorphine creates new treatment issues and opportunities.

OBJECTIVE

To educate C-L psychiatrists in emergency and obstetrical settings about the appropriate approach toward the evaluation and basic management of women with opioid dependence in pregnancy.

METHOD

The authors reviewed the consensus literature and all new treatment options on opioid dependence during pregnancy.

DISCUSSION

In this review, the authors summarize known and emerging management strategies for opioid dependence in pregnancy pertinent to C-L psychiatrists.

Cost-effectiveness of methadone maintenance therapy as HIV prevention in an Indonesian high-prevalence setting: a mathematical modeling study

BACKGROUND

Indonesia faces an HIV epidemic that is in rapid transition. Injecting drug users (IDUs) are among the most heavily affected risk populations, with estimated prevalence of HIV reaching 50% or more in most parts of the country. Although Indonesia started opening methadone clinics in 2003, coverage remains low.

METHODS

We used the Asian Epidemic Model and Resource Needs Model to evaluate the long-term population-level preventive impact of expanding Methadone Maintenance Therapy (MMT) in West Java (43 million people). We compared intervention costs and the number of incident HIV cases in the intervention scenario with current practice to establish the cost per infection averted by expanding MMT. An extensive sensitivity analysis was performed on costs and epidemiological input, as well as on the cost-effectiveness calculation itself.

RESULTS

Our analysis shows that expanding MMT from 5% coverage now to 40% coverage in 2019 would avert approximately 2400 HIV infections, at a cost of approximately US$7000 per HIV infection averted. Sensitivity analyses demonstrate that the use of alternative assumptions does not change the study conclusions.

CONCLUSION

Our analyses suggest that expanding MMT is cost-effective, and support government policies to make MMT widely available as an integrated component of HIV/AIDS control in West Java.

Methadone and perinatal outcomes: a prospective cohort study

AIMS

  Methadone use in pregnancy has been associated with adverse perinatal outcomes and neonatal abstinence syndrome (NAS). This study aimed to examine perinatal outcomes and NAS in relation to (i) concomitant drug use and (ii) methadone dose.

DESIGN

  Prospective cohort study.

SETTING

  Two tertiary care maternity hospitals.

PARTICIPANTS

  A total of 117 pregnant women on methadone maintenance treatment recruited between July 2009 and July 2010.

MEASUREMENTS

  Information on concomitant drug use was recorded with the Addiction Severity Index. Perinatal outcomes included pre-term birth (<37 weeks' gestation), small-for-gestational-age (<10th centile) and neonatal unit admission. NAS outcomes included: incidence of medically treated NAS, peak Finnegan score, cumulative dose of NAS treatment and duration of hospitalization.

FINDINGS

  Of the 114 liveborn infants 11 (9.6%) were born pre-term, 49 (42.9%) were small-for-gestational-age, 56 (49.1%) had a neonatal unit admission and 29 (25.4%) were treated medically for NAS. Neonates exposed to methadone-only had a shorter hospitalization than those exposed to methadone and concomitant drugs (median 5.0 days versus 6.0 days, P = 0.03). Neonates exposed to methadone doses ≥80 mg required higher cumulative doses of morphine treatment for NAS (median 13.2 mg versus 19.3 mg, P = 0.03). The incidence and duration of NAS did not differ between the two dosage groups.

CONCLUSIONS

  The incidence and duration of the neonatal abstinence syndrome is not associated with maternal methadone dose, but maternal opiate, benzodiazepine or cocaine use is associated with longer neonatal hospitalization.

Towards combination HIV prevention for injection drug users: addressing addictophobia, apathy and inattention

PURPOSE OF REVIEW

Recent breakthroughs in HIV-prevention science led us to evaluate the current state of combination HIV prevention for injection drug users (IDUs). We review the recent literature focusing on possible reasons why coverage of prevention interventions for HIV, hepatitis C virus (HCV) and tuberculosis among IDUs remains dismal. We make recommendations for future HIV research and policy.

RECENT FINDINGS

IDUs disproportionately under-utilize voluntary HIV counseling and testing (VCT), primary care and antiretroviral therapy (ART), especially in countries that have the largest burden of HIV among IDUs. IDUs present later in the course of HIV infection and experience greater morbidity and mortality. Why are IDUs under-represented in HIV-prevention research, access to treatment for both HIV and addiction, and access to HIV combination prevention? Possible explanations include addictophobia, apathy, and inattention, which we describe in the context of recent literature and events.

SUMMARY

This commentary discusses the current state of HIV-prevention interventions for IDUs including VCT, needle and syringe program (NSP), opioid substitution therapy (OST), ART and pre-exposure chemoprophylaxis (PrEP), and discusses ways to work towards true combination HIV prevention for IDU populations. Communities need to overcome tacit assumptions that IDUs can navigate through systems that are maintained as separate silos, and begin to take a rights-based approach to HIV prevention to ensure that IDUs have equitable access to life-saving prevention and treatments.

Office-based opioid dependence treatment

BACKGROUND

Opioid misuse and abuse occurring in association with the treatment of chronic non-cancer pain are not new phenomena, but their increasing prevalence in recent years is unprecedented. Advancements in pharmaceutical technologies have provided opioid-related drugs, which lack the pure mu agonist activity characteristic of the typical opioid congeners. This absent or altered mu receptor activity imparts an opioid receptor antagonistic or partial agonistic pharmacologic action, which serves to modulate the development of opioid-induced tolerance and physical dependence and facilitate detoxification and withdrawal from opioids. Opioid antagonists and partial agonists are being used in abuse deterrent strategy regimens to prevent opioid tolerance and the development of dependence, as well as in the management of opioid detoxification and treatment of withdrawal. The specific opioid antagonists and partial agonists used in these various therapeutic modalities will be the focus of this review.

OBJECTIVES

Evaluate the comparative therapeutic utility of opioid antagonists and partial agonists in preventing the development of opioid tolerance and treating opioid dependence, detoxification, and withdrawal. A primary focus is the use of opioid antagonists and partial agonists within an office-based practice.

METHODS

A narrative review of the current literature involving the therapeutic use of opioid antagonists and partial agonists in the management of opioid tolerance, dependence, detoxification, and withdrawal. A computerized literature search in the PubMed, EMBASE, BioMed, and Cochrane Library review databases from 2008 through 2010 was performed. This search included systematic and narrative reviews, prospective and retrospective studies, as well as cross-references from bibliographies of notable primary and review articles and abstracts from scientific meetings. US Food and Drug Administration records and pharmaceutical manufacturers' product literature were also used in the search.

CONCLUSION

Opioid dependency, whether it results from the misuse or abuse of prescription or street drugs, continues to be a significant public health issue. Passage of DATA 2000 and US Food and Drug Administration approval of buprenorphine and buprenorphine/ naloxone has revolutionized opioid dependence therapy. The traditional addiction medicine therapy regimen of methadone maintenance, with its inherent legal limitations and restrictions, has been challenged by an office-based dependence practice with buprenorphine serving as a prominent therapeutic tool.

Conversion of chronic pain patients from full-opioid agonists to sublingual buprenorphine

BACKGROUND

Sublingual buprenorphine-naloxone (buprenorphine SL) is a preparation that is used to treat opioid dependence. In addition, the Drug Enforcement Administration (DEA) has acknowledged the legality of an off-label use to treat pain with a sublingual buprenorphine preparation. Buprenorphine SL is unique among the opioid class of analgesics; this compound has a high affinity for the mu-receptor, yet only partially activates it. Thus, buprenorphine SL can provide analgesia, yet minimize opioid side effects. Many patients on high doses of traditional opioid medication develop tolerance. Despite escalating medication dosage, a subset of patients had a paradoxical increase in pain, which has been characterized as opioid-induced hyperalgesia (OIH).  Buprenorphine SL, on the other hand, may even be anti-hyperalgesic and may have utility in treating these challenging patients.

OBJECTIVE

To determine the effectiveness of converting patients from traditional full agonist opioid medication to sublingual buprenorphine, as well as to identify patient groups that are most likely to benefit from this therapy. Patients who underwent conversion either had developed tolerance with diminished analgesia or were experiencing side effects on their opioid medications.

STUDY DESIGN

An observational report of outcomes assessment.

SETTING

An interventional pain management practice setting in the United States.

METHODS

Retrospective data from clinical records was compiled on 104 de-identified chronic pain patients whose personal information had been redacted (60 men and 44 women, aged 21-78) and who had previously been treated with opioid-agonist drugs; they were converted to buprenorphine SL in tablet form during the study. Chronic pain was defined as persistent pain for at least 6 months. Data collected from patient profiles included age, sex, diagnosis, medication history, pre-induction opioid intake, reason for detoxification, pre-induction Clinical Opiate Withdrawal Score (COWS), and if applicable, cause of buprenorphine SL cessation. Pain levels and Quality of Life scores were recorded before and after conversion to buprenorphine SL.

OUTCOME MEASURES

Level of analgesia for patients who continued conversion to sublingual buprenorphine for more than 2 months.

RESULTS

After initiation of buprenorphine SL therapy for more than 2 months, the mean pain scores on a scale from 0-10 decreased by 2.3 points (P < 0.001). Patient Quality of Life (QoL scale) was not significantly affected by buprenorphine SL therapy (P = 0.14). The success rate was highest for patients using morphine, oxycodone, and fentanyl before buprenorphine SL induction. These patient groups had a 3.7 point decrease in pain for those taking morphine, a 2.5 point decrease in pain for those taking oxycodone, and a 2.2 point decrease for those taking fentanyl. The smallest pain reduction was seen in the patient group using oxymorphone before conversion with a 1.1 point decrease in pain. Patients taking between 100-199 mg morphine equivalent per day experienced the greatest reduction (2.7 points) in pain scores. Patients taking between 200 and 299 mg morphine equivalent before buprenorphine SL induction exhibited a decrease of over 2 points on average. Patients taking > 400 mg morphine equivalent reported the smallest reduction in pain scores, on average a 1.1 point decrease.

LIMITATIONS

This study is limited by its observational nature.

CONCLUSIONS

Patients continuing buprenorphine SL therapy for more than 60 days reported significant decreases in pain (2.3 points). Patients on doses of opioid medication between 100-199 mg morphine equivalents seemed to fare better with conversion to buprenorphine SL than patients on the highest doses (> 400 mg morphine equivalents). The opioid drug used by the patient before buprenorphine SL induction appears to have some effect on buprenorphine SL conversion success. Patients previously taking morphine, oxycodone, and fentanyl had the greatest decrease in pain after conversion to buprenorphine SL.

Just call it "treatment"

Although many in the addiction treatment field use the term "medication-assisted treatment" to describe a combination of pharmacotherapy and counseling to address substance dependence, research has demonstrated that opioid agonist treatment alone is effective in patients with opioid dependence, regardless of whether they receive counseling. The time has come to call pharmacotherapy for such patients just "treatment". An explicit acknowledgment that medication is an essential first-line component in the successful management of opioid dependence.

Methadone and metabolites in hair of methadone-assisted pregnant women and their infants

INTRODUCTION

Methadone is the recommended pharmacotherapy for opioid-dependent pregnant women. The primary aims of this study were to determine whether a dose-concentration relationship exists between cumulative maternal methadone dose, methadone and metabolite concentrations in maternal hair during pregnancy and whether maternal hair methadone and metabolite concentrations predict neonatal outcomes.

MATERIALS AND METHODS

Hair specimens were collected monthly from opioid-dependent mothers enrolled in methadone treatment and 4 of their infants. Hair specimens were segmented (3 cm), washed (maternal hair only), and analyzed for methadone, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), and 2-ethyl-5-methyl-3,3-diphenylpyrroline by liquid chromatography tandem mass spectrometry.

RESULTS

There was large intersubject variability and no dose-concentration relationship for cumulative methadone dose and methadone, EDDP, 2-ethyl-5-methyl-3,3-diphenylpyrroline, or total concentrations in hair. For individual women, a positive trend was noted for cumulative methadone dose and methadone and EDDP concentrations in hair. There was a positive linear trend for cumulative methadone dose and EDDP/methadone ratio in maternal hair, perhaps reflecting methadone's induction of its own metabolism. Maternal methadone concentrations were higher than those in infant hair, and infant EDDP hair concentrations were higher than those in maternal hair. Maternal methadone dose, and methadone and EDDP hair concentrations were not correlated with peak infant neonatal abstinence syndrome (NAS) scores, days to peak NAS, duration of NAS, time to NAS onset, birth length, head circumference, or amount of neonatal morphine pharmacotherapy. Maternal cumulative third trimester methadone dose was positively correlated with infant birth weight.

CONCLUSIONS

Methadone and EDDP in pregnant women's hair are markers of methadone exposure and do not predict total methadone dose, nor neonatal outcomes from in utero methadone exposure.

Methadone as social control: institutionalized stigma and the prospect of recovery

Methadone maintenance treatment (MMT) is an intervention used to treat opioid (heroin) dependence. Several investigators have found that MMT is effective in reducing heroin use and other behaviors; however, a disproportionate number of MMT clients leave treatment prematurely. Moreover, MMT outcome variables are often limited in terms of their measurement. Utilizing an integrated theoretical framework of social control and stigma, we focused on the experiences of methadone maintenance from the perspective of clients. We pooled interview data from four qualitative studies in two jurisdictions and found linkages between social control and institutional stigma that serve to reinforce "addict" identities, expose undeserving customers to the public gaze, and encourage clients to be passive recipients of treatment. We discuss the implications for recovery and suggest recommendations for change.

Opioid detoxification and naltrexone induction strategies: recommendations for clinical practice

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.

The combination very low-dose naltrexone-clonidine in the management of opioid withdrawal

BACKGROUND

The management of withdrawal absorbs substantial clinical efforts in opioid dependence (OD). The real challenge lies in improving current pharmacotherapies. Although widely used, clonidine causes problematic adverse effects and does not alleviate important symptoms of opioid withdrawal, alone or in combination with the opioid antagonist naltrexone. Very low-dose naltrexone (VLNTX) has been shown to attenuate withdrawal intensity and noradrenaline release following opioid agonist taper, suggesting a combination with clonidine may result in improved safety and efficacy.

OBJECTIVES

We investigated the effects of a VLNTX-clonidine combination in a secondary analysis of data from a double-blind, randomized opioid detoxification trial.

METHODS

Withdrawal symptoms and treatment completion were compared following VLNTX (.125 or .25 mg/day) and clonidine (.1-.2 mg q6h) in 127 individuals with OD undergoing 6-day methadone inpatient taper at a community program.

RESULTS

VLNTX was more effective than placebo or clonidine in reducing symptoms and signs of withdrawal. The use of VLNTX in combination with clonidine was associated with attenuated subjective withdrawal compared with each medication alone, favoring detoxification completion in comparison with clonidine or naltrexone placebo. VLNTX/clonidine was effective in reducing symptoms that are both undertreated and well controlled with clonidine treatment and was not associated with significant adverse events compared with other treatments.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Preliminary results elucidate neurobiological mechanisms of OD and support the utility of controlled studies on a novel VLNTX + low-dose clonidine combination for the management of opioid withdrawal.

[Changes in psychosocial symptoms of opiate users over six months with buprenorphine/naloxone substitution therapy]

AIMS

The main target of our research was to measure the changes in psychological symptoms (anxiety, depression, craving) of patients receiving buprenorphine-naloxone substitution treatment for six months, and the evaluation of the changes using the clients' dependency parameters (ASI).

METHODS

The level of dependency was investigated using the Addicton Severity Index (ASI). The psychiatric symptoms related to Axis I and II disorders were examined using the Structured Clinical Interview for DSM-IV, SCID I and SCID II. The degree of craving was measured using the Heroin Craving Questionnaire, the assessment of the symptoms of depression using BDI and HAM-D, recorded by the medical attendant of the patient. To survey the extent of anxiety, we used STAI-S, and HAM-A. All patients receiving Suboxone therapy in Hungary between November 2007 and April 2008 were included in the study (n=80). During this time, Suboxone therapy was available in 6 locations.

RESULTS

We found significant improvement in almost all observed fields of behavioural and symptomatic dimensions during the first month. The only exception was the dimension of subsistence/livelihood of ASI, the changes were only at the tendency level. During the next five months of therapy, there was no further sign of improvement or decline in the observed fields, the only exception was again the subsistence/livelihood dimension of the ASI.

CONCLUSIONS

Our results indicate that buprenorphine/naloxone treatment is a promising possibility for patients in need of opiate-substitution treatment.

Opioid dependency in pregnancy and length of stay for neonatal abstinence syndrome

OBJECTIVE

To examine opioid replacement therapy in pregnancy and effect on neonatal outcomes, including length of hospital stay for neonatal abstinence syndrome.

DESIGN

Retrospective descriptive study.

SETTING

Labor and delivery unit and neonatal intensive care unit (NICU), Eastern Maine Medical Center, Bangor, Maine.

PARTICIPANTS

One hundred fifty-two opioid-dependent pregnant women on methadone maintenance therapy (MMT) (n = 136) or buprenorphine maintenance therapy (BMT) (n = 16) during pregnancy and their neonates. The neonates were born between January 1, 2005 and December 31, 2007.

METHODS

A review of the electronic medical record (EMR) was conducted of all opioid-dependent women who were maintained on MMT or BMT at the time of admission for labor and delivery and their neonates.

RESULTS

Maternal methadone dose and concomitant in-utero exposure to benzodiazepines prolonged the length of hospital stay for neonates. Length of stay was shorter in breastfed neonates than formula-fed neonates or neonates who received formula and breast milk. Neonates with prenatal exposure to MMT spent more days in the hospital (21 vs. 14 days) for treatment of neonatal abstinence syndrome (NAS) than infants with prenatal exposure to BMT.

CONCLUSION

These findings are consistent with previous research on the simultaneous use of methadone and benzodiazepines during pregnancy and provide further direction for the treatment of opioid dependency during pregnancy. Harm reduction strategies for opioid-dependent pregnant women in substance abuse treatment with MMT may one day include guidance on daily treatment doses and recommendations to avoid the concomitant use of benzodiazepines to lessen NAS. Breastfeeding should be recommended to shorten length of stay. Understanding perinatal and neonatal outcomes of pregnant women on methadone or buprenorphine will help to identify optimal treatment for opioid dependency in pregnancy.

Short-term safety of buprenorphine/naloxone in HIV-seronegative opioid-dependent Chinese and Thai drug injectors enrolled in HIV Prevention Trials Network 058

BACKGROUND

Buprenorphine/naloxone (BUP/NX) is not licenced for use in China or Thailand and there was little clinical experience with this drug combination in these countries at the inception of HIV Prevention Trial Network (HPTN) 058, a randomized trial comparing risk reduction counselling combined with either short-term or long-term medication assisted treatment with BUP/NX to prevent HIV infection and death amongst opioid-dependent injectors.

METHODS

We conducted a safety phase that included the first 50 subjects enrolled at each of the three initial study sites (N=150). Clinical and laboratory assessments were conducted at baseline and weekly for the first 4 weeks. Changes in laboratory parameters were estimated with random effects models.

RESULTS

BUP/NX was well tolerated by study subjects and opioid withdrawal scores decreased substantially during the 3-day induction. Two participants experienced grade 3 clinical adverse events, which were categorized as probably not related to the study drug. Grade 2 or 3 increases in alanine aminotransferase (ALT) occurred in 25 (17%) subjects. The magnitude of ALT increase over 4-week follow-up was strongly associated with baseline ALT elevation.

CONCLUSIONS

In Chinese and Thai opioid-dependent injectors, we found BUP/NX to be effective in reducing opioid withdrawal symptoms and safe during short-term use. ALT increases were observed over 4-week-follow-up, which are consistent with reports from Western populations. Long-term safety and efficacy evaluations are indicated.

Current and potential pharmacological treatment options for maintenance therapy in opioid-dependent individuals

Opioid dependence, manifesting as addiction to heroin and pharmaceutical opioids is increasing. Internationally, there are an estimated 15.6 million illicit opioid users. The global economic burden of opioid dependence is profound both in terms of HIV and hepatitis C virus transmission, direct healthcare costs, and indirectly through criminal activity, absenteeism and lost productivity. Opioid agonist medications, such as methadone and buprenorphine, that stabilize neuronal systems and provide narcotic blockade are the most effective treatments. Prolonged provision of these medications, defined as maintenance treatment, typically produces improved outcomes when compared with short-duration tapers and withdrawal. The benefits of opioid agonist maintenance include decreased illicit drug use, improved retention in treatment, decreased HIV risk behaviours and decreased criminal behaviour. While regulations vary by country, these medications are becoming increasingly available internationally, especially in regions experiencing rapid transmission of HIV due to injection drug use. In this review, we describe the rationale for maintenance treatment of opioid dependence, discuss emerging uses of opioid antagonists such as naltrexone and sustained-release formulations of naltrexone and buprenorphine, and provide a description of the experimental therapies.

Exercise as an adjunct treatment for opiate agonist treatment: review of the current research and implementation strategies

Opiate dependence is a significant public health concern linked to poor quality of life, comorbid psychiatric disorders, and high costs to society. Current opiate agonist treatments are an effective but limited intervention. Adjunctive interventions could improve and augment opiate agonist treatment outcomes, including drug abstinence, quality of life, and physical health. This article reviews exercise as an adjunctive intervention for opiate agonist treatment, especially in regards to improving mood and overall quality of life, while reducing other substance use. Poor adherence and dropout frequently prevent many individuals from garnering the many physical and mental health benefits of exercise. Strategies for implementing an exercise intervention, including safety considerations, are discussed.

Buprenorphine therapy for opioid addiction in rural Washington: the experience of the early adopters

BACKGROUND

The introduction of buprenorphine as office-based treatment for opioid dependence was designed to expand treatment capacity, but virtually there are no data about use of this medication in rural areas.

METHODS

The survey of the first cohort of physicians in rural Washington State who obtained buprenorphine waivers (2002-2010) to determine the volume of treated patients, physician appraisal of the efficacy of this treatment, and perceived barriers to treatment was conducted. Twenty-four (73 percent) of the 33 rural buprenorphine-certified physicians practicing in the state were interviewed in 2010.

RESULTS

Twenty physicians (83 percent) were actively prescribing buprenorphine/naloxone for treatment of addiction. Those currently prescribing averaged 23 active patients and had treated 125 patients since certification. All respondents reported that buprenorphine was efficacious in the treatment of addiction and 95 percent recommended that other rural colleagues adopt buprenorphine treatment. The following four major barriers were cited: 1) lack of adequate financial support from Medicaid, the largest source of third-party coverage for these patients; 2) unavailability of local mental health and behavioral addiction treatment services; 3) difficulty in finding consultants to assist in managing complex patients; and 4) shortages of other rural physicians providing this service.

CONCLUSIONS

Buprenorphine is viewed as a highly effective treatment of opioid addiction by early adopters in rural Washington State, but relatively few rural physicians currently provide this service. Inadequate insurance coverage, a shortage of effective links with consultants and colleagues, and the lack of mental health services are persistent barriers to the use of this modality in rural Washington State.

A multilevel analysis of regional and individual effects on methadone maintenance treatment in Taiwan

OBJECTIVE

This study evaluated the direct and interactive effects of regional-level and individual-level characteristics on methadone maintenance treatment (MMT), after considering the individual characteristics in Taiwan.

METHODS

This study utilized a survey research method. Opioid-dependent patients who participated in the outpatient MMT program in 2009 and met the eligibility criteria were recruited from five hospitals. The impact of MMT on self-perceived health was assessed by using questionnaires. This study assessed the participants' quality of life and treatment outcomes during 3-month follow-up visits, before evaluating the direct effects of regional and individual characteristics. Multilevel linear models were used to estimate whether regional levels influenced individual behavior and treatment outcomes.

RESULTS

Three hundred thirty-four opioid-dependent patients agreed to participate in this study. After the follow-up period, 127 participants completed the study (completion rate = 38%). Participants receiving MMT demonstrated significant improvements in psychological state, HIV risk-taking behavior, social functioning, and health. Regional characteristics, such as the lower than junior high school rate, low-income family rate, and related crime rates, of the study regions were negatively associated with improvements in drug abuse behavior.

CONCLUSIONS

This study shows that MMT can significantly improve the HIV risk-taking behavior and health of the study participants. Disadvantaged regions, however, exhibit poor treatment outcomes. This study suggests actions to minimize the treatment variations between regions.

Timing of buprenorphine adoption by privately funded substance abuse treatment programs: the role of institutional and resource-based interorganizational linkages

Identifying facilitators of more rapid buprenorphine adoption may increase access to this effective treatment for opioid dependence. Using a diffusion of innovations theoretical framework, we examine the extent to which programs' interorganizational institutional and resource-based linkages predict the likelihood of being an earlier adopter, later adopter, or nonadopter of buprenorphine. Data were derived from face-to-face interviews with administrators of 345 privately funded substance abuse treatment programs in 2007-2008. Results of multinomial logistic regression models show that interorganizational and resource linkages were associated with timing of adoption. Programs reporting membership in provider associations were more likely to be earlier adopters of buprenorphine. Programs that relied more on resource linkages, such as detailing activities by pharmaceutical companies and the National Institute on Drug Abuse website, were more likely to be earlier adopters of buprenorphine. These findings suggest that institutional and resource-based interorganizational linkages may expose programs to effective treatments, thereby facilitating more rapid and sustained adoption of innovative treatment techniques.

Urinalysis-based comparative evaluation of pattern of use of dextropropoxyphene and buprenorphine among opioid-dependent subjects

OBJECTIVE

In view of increasing safety concerns, there is a need to assess benefits of use of dextropropoxyphene as opioid substitution treatment, if any. This study aims at urinalysis-based comparative evaluation of pattern of use of dextropropoxyphene and buprenorphine among opioid-dependent subjects.

SETTING

Laboratory of a tertiary care drug-dependence treatment center.

PARTICIPANTS

Patients on buprenorphine and dextropropoxyphene therapy and their urinalysis records.

INTERVENTIONS

Nonexperimental chart review method.

MAIN OUTCOME MEASURE(S)

"Use," "abuse, "and 'prescribed but not used rates" for buprenorphine and dextropropoxyphene were compared, using chi2-test with level of significance at p < 0.05.

RESULTS

Rate of "use" and "abuse" was significantly high for dextropropoxyphene. Rate of 'prescribed but not used" was significantly high for buprenorphine (p < 0.05).

CONCLUSIONS

Despite apparent benefits of dextropropoxyphene use in terms of better rates of "use" and 'prescribed but not used" as compared to buprenorphine, one needs to review the situation in light of recent reports of adverse effects with dextropropoxyphene and limited resources available.

Comparison of methadone and buprenorphine for opiate detoxification (LEEDS trial): a randomised controlled trial

BACKGROUND

Many opiate users require prescribed medication to help them achieve abstinence, commonly taking the form of a detoxification regime. In UK prisons, drug users are nearly universally treated for their opiate use by primary care clinicians, and once released access GP services where 40% of practices now treat drug users. There is a paucity of evidence evaluating methadone and buprenorphine (the two most commonly prescribed agents in the UK) for opiate detoxification.

AIM

To evaluate whether buprenorphine or methadone help to achieve drug abstinence at completion of a reducing regimen for heroin users presenting to UK prison health care for detoxification.

DESIGN

Open-label, pragmatic, randomised controlled trial in three prison primary healthcare departments in the north of England.

METHOD

Prisoners (n = 306) using illicit opiates were recruited and given daily sublingual buprenorphine or oral methadone, in the context of routine care, over a standard reduced regimen of not more than 20 days. The primary outcome measure was abstinence from illicit opiates at 8 days post detoxification, as indicated by urine test (self-report/clinical notes where urine sample was not feasible). Secondary outcomes were also recorded.

RESULTS

Abstinence was ascertained for 73.7% at 8 days post detoxification (urine sample = 52.6%, self report = 15.2%, clinical notes = 5.9%). There was no statistically significant difference in the odds of achieving abstinence between methadone and buprenorphine (odds ratio [OR] = 1.69; 95% confidence interval [CI] = 0.81 to 3.51; P = 0.163). Abstinence was associated solely with whether or not the participant was still in prison at that time (15.22 times the odds; 95% CI = 4.19 to 55.28). The strongest association for lasting abstinence was abstinence at an earlier time point.

CONCLUSION

There is equal clinical effectiveness between methadone and buprenorphine in achieving abstinence from opiates at 8 days post detoxification within prison.

Mandatory naltrexone treatment prevents relapse among opiate-dependent anesthesiologists returning to practice

OBJECTIVE

Anesthesiologists with opioid use disorders are at high risk for relapse. In 2005, the impaired professionals monitoring program of the State of Florida implemented a policy whereby anesthesiologists referred for opiate use disorders were contractually obligated to take naltrexone for 2 years. Naltrexone ingestion was witnessed and verified via random urine drugs screens or administered via intramuscular injection.

METHOD

Charts were reviewed for the 11 anesthesiologists who underwent mandated pharmacotherapy with naltrexone, and 11 anesthesiologists who began monitoring immediately before implementation of this policy.

RESULTS

Eight of 11 anesthesiologists who did not take naltrexone experienced a relapse on opiates. Only 1 of 11 anesthesiologists experienced a relapse on opiates after taking naltrexone, whereas another relapsed on an inhalant (nitrous oxide). It is noteworthy that 5 of the 11 anesthesiologists who took naltrexone had relapsed before naltrexone treatment, and 7 of the 11 anesthesiologists who did not take naltrexone experienced multiple documented relapses. Only 1 of the 11 anesthesiologists who did not take naltrexone successfully returned to the practice of anesthesiology. This individual suffered primarily from alcohol dependence, and suspected opiate abuse was never verified. Others who attempted return to anesthesiology (n = 7) suffered a relapse. In comparison, 9 of the 11 anesthesiologists who took naltrexone have returned to the practice of anesthesiology without a relapse (as verified by continued random urine and hair testing).

CONCLUSION

Mandatory naltrexone treatment may provide anesthesiologists with an additional safeguard to successfully return to work.

Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial

CONTEXT

No randomized trials have examined treatments for prescription opioid dependence, despite its increasing prevalence.

OBJECTIVE

To evaluate the efficacy of brief and extended buprenorphine hydrochloride-naloxone hydrochloride treatment, with different counseling intensities, for patients dependent on prescription opioids.

DESIGN

Multisite, randomized clinical trial using a 2-phase adaptive treatment research design. Brief treatment (phase 1) included 2-week buprenorphine-naloxone stabilization, 2-week taper, and 8-week postmedication follow-up. Patients with successful opioid use outcomes exited the study; unsuccessful patients entered phase 2: extended (12-week) buprenorphine-naloxone treatment, 4-week taper, and 8-week postmedication follow-up.

SETTING

Ten US sites. Patients A total of 653 treatment-seeking outpatients dependent on prescription opioids.

INTERVENTIONS

In both phases, patients were randomized to standard medical management (SMM) or SMM plus opioid dependence counseling; all received buprenorphine-naloxone.

MAIN OUTCOME MEASURES

Predefined "successful outcome" in each phase: composite measures indicating minimal or no opioid use based on urine test-confirmed self-reports.

RESULTS

During phase 1, only 6.6% (43 of 653) of patients had successful outcomes, with no difference between SMM and SMM plus opioid dependence counseling. In contrast, 49.2% (177 of 360) attained successful outcomes in phase 2 during extended buprenorphine-naloxone treatment (week 12), with no difference between counseling conditions. Success rates 8 weeks after completing the buprenorphine-naloxone taper (phase 2, week 24) dropped to 8.6% (31 of 360), again with no counseling difference. In secondary analyses, successful phase 2 outcomes were more common while taking buprenorphine-naloxone than 8 weeks after taper (49.2% [177 of 360] vs 8.6% [31 of 360], P < .001). Chronic pain did not affect opioid use outcomes; a history of ever using heroin was associated with lower phase 2 success rates while taking buprenorphine-naloxone.

CONCLUSIONS

Prescription opioid-dependent patients are most likely to reduce opioid use during buprenorphine-naloxone treatment; if tapered off buprenorphine-naloxone, even after 12 weeks of treatment, the likelihood of an unsuccessful outcome is high, even in patients receiving counseling in addition to SMM.

Opioid-dependent error processing

OBJECTIVE

To evaluate error processing in contrasting opioid treatment samples by finding the relative risk of fatal dosing errors leading to opioid overdose in a controlled cohort of detoxified patients with opioid dependence.

METHODS

Data linkage was performed between the Western Australian deaths register and recorded admissions to the Perth Naltrexone Clinic and community-based methadone program. Death register and corresponding data of coronial findings for all the patients who were treated with rapid opioid detoxification under sedation and oral naltrexone were compared with corresponding data for all the patients who were prescribed methadone over a 2-year period.

RESULTS

Data for naltrexone-treated patients (n = 1,097) and community-based methadone-treated patients (n = 2,520) showed mortality rates to be 2.6 percent per year for naltrexone treatment when compared with O.7 percent for methadone treatment (p < 0.001). This was due to 4.3 times the relative risk of death from opioid toxicity for naltrexone-treated patients (p < 0.001).

CONCLUSIONS

Naltrexone increases vulnerability to overdose as enhanced opioid effects following neuroanatomical blockade can reverse behavioral tolerance and lead to greater fatal dosing errors on reinstatement of opioid dependence.

Effects of a randomized contingency management intervention on opiate abstinence and retention in methadone maintenance treatment in China

AIMS

Methadone maintenance treatment has been made available in China in response to the rapid spread of human immunodeficiency virus (HIV), but high rates of dropout and relapse are problematic. The aim of this study was to apply and test if a contingency management (or motivational incentives) intervention can improve treatment retention and reduce drug use.

DESIGN

Random assignment to usual care with (n = 160) or without (n = 159) incentives during a 12-week trial. Incentives participants earned draws for a chance to win prizes on two separate tracks targeting opiate-negative urine sample or consecutive attendance; the number of draws increased with continuous abstinence or attendance.

SETTING

Community-based methadone maintenance clinics in Shanghai and Kunming.

PARTICIPANTS

The sample was 23.8% female, mean age was 38, mean years of drug use was 9.4 and 57.8% had injected drugs in the past 30 days.

MEASUREMENTS

Treatment retention and negative drug urine.

FINDINGS

Relative to the treatment-as-usual (control) group, better retention was observed among the incentive group in Kunming (75% versus 44%), but no difference was found in Shanghai (90% versus 86%). Submission of negative urine samples was more common among the incentive group than the usual care (74% versus 68% in Shanghai, 27% versus 18% in Kunming), as was the longest duration of sustained abstinence (7.7 weeks versus 6.5 in Shanghai, 2.5 versus 1.6 in Kunming). The average total prize amount was 371 Yuan (or $55) per participant (527 for Shanghai versus 216 in Kunming).

CONCLUSIONS

Contingency management improves treatment retention and drug abstinence in methadone maintenance treatment clinics in China, although there can be considerable site differences in magnitude of effects.

Can a 12-step program work in methadone maintenance treatment?

Three consecutive, professionally led (as opposed to self-help) groups following the 12-step program (TSP) were integrated into a methadone maintenance treatment (MMT) program that included 32 heroin-addicted individuals in recovery. This report describes our experience in meeting the challenges that arose and our conclusions regarding the therapeutic potential of this integration. A professional therapeutic staff guided the groups. In-depth interviews of 10 participants and the reflections of the group leaders provided data for learning about the groups' experience. Initially the participants rejected the concepts of Step 1, powerlessness and unmanageability of life. The assimilation of Step 4 (defining character defect) also aroused some resistance. The participants eventually adopted the pragmatic aspects of TSP, including its terminology. The establishment of a common language of recovery helped to create group coherence and a sense of belonging, and helped to meet the needs of those who felt stigmatized by both the nonaddicted and addicted population undergoing nonmethadone recovery. TSP could be adapted to various aspects of daily life, produced a sense of self-efficacy, and stimulated motivation for change. Therapeutic implications are discussed.

Group-based strategies for stress reduction in methadone maintenance treatment: what do patients want?

OBJECTIVES

To assess methadone maintenance treatment (MMT) patients' willingness to use, and perceived efficacy of, conventional and unconventional group stress reduction treatments.

METHODS

A survey, developed by the authors, was administered to 150 MMT patients.

RESULTS

Levels of treatment willingness and perceived efficacy for both conventional and unconventional treatments were relatively high; however, ratings for conventional interventions were, on average, significantly higher than those for unconventional ones. The highest rated conventional and unconventional treatments in terms of willingness and perceived efficacy were nutrition and spiritual counseling, respectively, whereas the lowest rated conventional and unconventional group treatments were anger management and visualization training, respectively. White race was a significant predictor of lower willingness to try conventional and unconventional group therapies and lower perceived efficacy of unconventional group treatment, whereas female sex and older age were significant predictors of higher levels of willingness to try unconventional group treatment. Higher levels of substance use problems were associated with increased willingness to try conventional group treatment. Higher levels of anxiety emerged as a significant independent predictor of treatment willingness and perceived efficacy for both conventional and unconventional group treatments.

CONCLUSIONS

The relatively high levels of treatment willingness and perceived efficacy of conventional and unconventional group stress reduction treatments point to the feasibility of offering these interventions in MMT and suggest that, in particular, high levels of anxiety are associated with greater treatment willingness and perceived treatment efficacy.

The source of methadone in overdose deaths in Western Virginia in 2004

OBJECTIVES

Methadone-related overdose deaths increased in the United States by 468% from 1999 to 2005. Current studies associate the nonmedical use of methadone with methadone-related deaths. This study describes medical examiner cases in rural Virginia in 2004 with methadone identified by toxicology and compares cases according to source of methadone.

METHODS

In 2004, all intentional and unintentional poisoning deaths from the Office of The Chief Medical Examiner, Western District of Virginia, were reviewed to identify cases in which methadone was a direct or contributing cause of death. The Virginia Prescription Monitoring Program was reviewed for prescription opioids in the name of these identified decedents. Decedent participation in local opioid treatment programs (OTP) was also assessed.

RESULTS

The source of methadone in the 61 methadone-related overdose deaths was mostly nonprescribed (67%), although 28% of decedents were prescribed methadone for analgesia. Only 5% of decedents were actively enrolled in an OTP. The majority of deaths were attributed to polysubstance overdose.

CONCLUSIONS

The majority of methadone overdose deaths in this study were related to illicit methadone use, rather than prescribed or OTP uses. Interventions to decrease methadone-related deaths should focus on reduction of nonprescription use of methadone.

Improving temporal efficiency of outpatient buprenorphine induction

Buprenorphine induction poses a barrier for physician adoption of office-based opioid dependence treatment. We conducted a retrospective chart review of the first 41 patients inducted at a newly established outpatient treatment program to examine the induction process and determine strategies associated with greater induction efficiency. Timed withdrawal scales, medication log, and notes enabled reconstruction of the initial day of buprenorphine treatment. To assess change with experience, consecutive patients were divided into three chronological groups for analyses (Phases 1-3). The time required for induction was substantial in Phase 1 (mean 5.5 hours), but temporal efficiency improved to a mean 1.5 hours spent at the program by Phase 3 (p < .001). Phase 2-3 patients arrived to the program after significantly longer opioid abstinence and were in greater withdrawal, with mean Clinical Opioid Withdrawal Scale scores of 6, 10, and 10 for Phases 1-3, respectively (p < .01). Patients in the later phases had less time delay to medication initiation, 5 minutes in Phase 3 compared to 133 minutes in Phase 1 (p < .001). The mean 7-mg buprenorphine dose administered in the office did not differ between groups, but occurred over a smaller time interval for later phases indicating more rapid titration. Patients in the later phases had more rapid withdrawal relief after buprenorphine initiation and were more likely to have used preinduction ancillary withdrawal medication. The study sheds light on the induction barrier and provides practical procedural information to inform clinical guidelines and hopefully mitigate procedural aspects of the induction barrier.

Cognitive functioning in opioid-dependent patients treated with buprenorphine, methadone, and other psychoactive medications: stability and correlates

BACKGROUND

In many but not in all neuropsychological studies buprenorphine-treated opioid-dependent patients have shown fewer cognitive deficits than patients treated with methadone. In order to examine if hypothesized cognitive advantage of buprenorphine in relation to methadone is seen in clinical patients we did a neuropsychological follow-up study in unselected sample of buprenorphine- vs. methadone-treated patients.

METHODS

In part I of the study fourteen buprenorphine-treated and 12 methadone-treated patients were tested by cognitive tests within two months (T1), 6-9 months (T2), and 12-17 months (T3) from the start of opioid substitution treatment. Fourteen healthy controls were examined at similar intervals. Benzodiazepine and other psychoactive comedications were common among the patients. Test results were analyzed with repeated measures analysis of variance and planned contrasts. In part II of the study the patient sample was extended to include 36 patients at T2 and T3. Correlations between cognitive functioning and medication, substance abuse, or demographic variables were then analyzed.

RESULTS

In part I methadone patients were inferior to healthy controls tests in all tests measuring attention, working memory, or verbal memory. Buprenorphine patients were inferior to healthy controls in the first working memory task, the Paced Auditory Serial Addition Task and verbal memory. In the second working memory task, the Letter-Number Sequencing, their performance improved between T2 and T3. In part II only group membership (buprenorphine vs. methadone) correlated significantly with attention performance and improvement in the Letter-Number Sequencing. High frequency of substance abuse in the past month was associated with poor performance in the Letter-Number Sequencing.

CONCLUSIONS

The results underline the differences between non-randomized and randomized studies comparing cognitive performance in opioid substitution treated patients (fewer deficits in buprenorphine patients vs. no difference between buprenorphine and methadone patients, respectively). Possible reasons for this are discussed.