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Zhang Y, Xu Z, Zhang S, Desrosiers A, Schottenfeld RS, Chawarski MC. Profiles of psychiatric symptoms among amphetamine type stimulant and ketamine using inpatients in Wuhan, China. J Psychiatr Res 2014; 53:99-102. [PMID: 24613031 PMCID: PMC4004368 DOI: 10.1016/j.jpsychires.2014.02.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 01/16/2014] [Accepted: 02/13/2014] [Indexed: 11/28/2022]
Abstract
UNLABELLED Amphetamine type stimulants (ATS) and ketamine have emerged as major drug problems in China, and chronic extensive exposure to these substances frequently co-occurs with psychiatric symptoms. This study compares the psychiatric symptoms of patients reporting ATS use only, ATS and ketamine use, or ketamine use only who were admitted to an inpatient psychiatry ward in Wuhan, China between 2010 and 2011. Data on 375 study participants collected during their ward admission and extracted from their clinical records included their socio-demographics, scores on the Brief Psychiatric Rating Scale (BPRS), and urine toxicology screens. RESULTS The ketamine-only group had significantly lower total BPRS scores and significantly lower scores on Thinking Disorder, Activity, and Hostility-Suspicion BPRS subscales than the ATS-only and ATS + ketamine groups (p < 0.001 for all comparisons). The ketamine-only group also had significantly higher scores on the subscales of Anxiety-Depression and Anergia. The ATS-only group had significantly higher scores on subscales of Thinking Disorder, Activity, and Hostility-Suspicion and significantly lower scores on Anxiety-Depression and Anergia subscales than the ketamine-only and ATS + ketamine groups (p < 0.001 for all comparisons). A K-means cluster method identified three distinct clusters of patients based on the similarities of their BPRS subscale profiles, and the identified clusters differed markedly on the proportions of participants reporting different primary drugs of abuse. The study findings suggest that ketamine and ATS users present with different profiles of psychiatric symptoms at admission to inpatient treatment.
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Schottenfeld RS, Chawarski MC, Cubells JF, George TP, Lappalainen J, Kosten TR. Randomized clinical trial of disulfiram for cocaine dependence or abuse during buprenorphine treatment. Drug Alcohol Depend 2014; 136:36-42. [PMID: 24462581 DOI: 10.1016/j.drugalcdep.2013.12.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 12/10/2013] [Accepted: 12/10/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Disulfiram may be efficacious for treating cocaine dependence or abuse, possibly through inhibiting dopamine β-hydroxylase (DβH). Consequently, this randomized, placebo-controlled clinical trial of disulfiram during buprenorphine maintenance treatment evaluated the study hypothesis that disulfiram is superior to placebo and explored whether disulfiram response is greatest for participants with a single nucleotide polymorphism coding for genetically low DβH (T-allele carriers). METHODS We randomized 177 buprenorphine-treated opioid dependent participants with cocaine dependence or abuse to 12 weeks of double-blind treatment with disulfiram 250mg daily (n=91) or placebo (n=86). Of 155 participants genotyped, 84 were CC-homozygous, and 71 CT or TT genotypes. Primary outcomes included days per week cocaine use, number of cocaine-negative urine tests, and maximum consecutive weeks of cocaine abstinence. We analyzed an intention-to-treat comparison between disulfiram and placebo. We also explored potential pharmacogenetic interactions and examined treatment responses of four participant groups based on medication (disulfiram or placebo) by genotype (CC-homozygous or T-allele carrier) classification. RESULTS Disulfiram participants reported significantly less frequent cocaine use; the differences in cocaine-negative urine tests or consecutive weeks abstinence were not significant. Frequency of cocaine use was lowest in disulfiram-treated T-allele carriers; differences in cocaine-negative urine tests or consecutive weeks abstinence were not significant among the four medication-genotype groups. CONCLUSIONS The findings provide limited support for the efficacy of disulfiram for reducing cocaine use and suggest that its mechanism of action may involve inhibition of DβH. Further studies of its efficacy, mechanism of action, and pharmacogenetics of response are warranted.
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Singh D, Chawarski MC, Schottenfeld R, Vicknasingam B. Substance Abuse and the HIV Situation in Malaysia. J Food Drug Anal 2013; 21:S46-S51. [PMID: 25278737 DOI: 10.1016/j.jfda.2013.09.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Heroin continues to be the main drug used in Malaysia, while amphetamine-type stimulants (ATS) have been recently identified as a growing problem. A cumulative total of 300,241 drug users were detected between 1988 and 2006. It is also estimated that Malaysia has 170,000 injecting drug users. HIV prevalence among drug users in the country ranges from 25% to 45%. Currently, there are approximately 380 general medical practice offices that offer agonist maintenance treatments for approximately 10,000 patients. There are 27,756 active patients in 333 general medical practice offices and government-run methadone maintenance treatment (MMT) centers. The Needle Syringe Exchange Program (NSEP) reached out to 34,244 injection drug users (IDUs) in 2011. In the last 2 years (2011 and 2012) the number of detected drug addicts decreased from 11,194 to 9015. The arrests made by the police related to opiate and cannabis use increased from 41,363 to 63,466 between the years 2008 and 2010, but decreased since 2010. An almost four-fold increase in the number of ATS and ketamine users was detected from 2006 (21,653 users) 2012 (76,812). Between 2004 and 2010, the yearly seizures for heroin ranged between 156 to 270 kg. However, in 2010 and 2011, heroin seizures showed a significant increase of 445kg and 410.02 kg, respectively. There has been a seizure of between 600 to 1000kg of syabu yearly from 2009 to 2012. Similar to heroin, increased seizures for Yaba have also been observed over the last 2 years. A significant increase has also been recorded for the seizures of ecstasy pills from 2011 (47,761 pills) to 2012 (634,573 pills). The cumulative number of reported HIV infections since 1986 is 94,841. In 2011, sexual activity superseded injection drug use as the main transmission factor for the epidemic. HIV in the country mainly involves males, as they constitute 90% of cumulative HIV cases and a majority of those individuals are IDUs. However, HIV infection trends are shifting from males to females. There are 37,306 people living with HIV (PLHIV) who are eligible for treatment, and 14,002 PLHIV were receiving antiretroviral treatment (ART) in 2011. The decreasing trend of heroin users who have been detected and arrested could be due to the introduction of medical treatments and harm reduction approaches for drug users, resulting in fewer drug users being arrested. However, we are unable to say with certainty why there has been an increase in heroin seizures in the country. There has been an increasing trend in both ATS users and seizures. A new trend of co-occurring opiate dependence and ATS underscores the need to develop and implement effective treatments for ATS, co-occurring opiate and ATS, and polysubstance abuse disorders. The low numbers of NSEP clients being tested for HIV underscores our caution in interpreting the decline of HIV infections among drug users and the importance of focusing on providing education, prevention, treatment, and outreach to those who are not in treatment.
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Zeng H, Lee TMC, Waters JH, So KF, Sham PC, Schottenfeld RS, Marienfeld C, Chawarski MC. Impulsivity, cognitive function, and their relationship in heroin-dependent individuals. J Clin Exp Neuropsychol 2013; 35:897-905. [DOI: 10.1080/13803395.2013.828022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Chawarski MC, Vicknasingam B, Mazlan M, Schottenfeld RS. Lifetime ATS use and increased HIV risk among not-in-treatment opiate injectors in Malaysia. Drug Alcohol Depend 2012; 124:177-80. [PMID: 22266088 PMCID: PMC4641448 DOI: 10.1016/j.drugalcdep.2011.12.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 12/28/2011] [Accepted: 12/28/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Malaysia has been experiencing significant drug abuse problems since the 1970s, and drug abuse is the major driver of HIV transmission in Malaysia. We investigated risk factors for HIV associated with use of amphetamine type stimulants (ATS) among not-in-treatment opiate injectors in Malaysia. METHODS Between October of 2006 and May of 2008, we conducted a series of surveys in three major urban areas of Malaysia. A total of 732 opiate IDUs (679 males and 53 females) were enrolled in the three surveys. The survey instruments consisted of a structured interview on demographic characteristics, drug use history (including year of first use, and past month history of use of illicit drugs; lifetime and past month history of IDU or needle or equipment sharing), and HIV status. RESULTS There were 194/704 (27.6%) HIV positive participants in the sample. Two factors were significantly associated with HIV infection in this sample: lifetime history of ATS use (OR [95%CI]: 2.3 [1.5-3.6]) and lifetime history of sharing of injection equipment (OR [95% CI]: 4.2 [1.8-9.8]). Both HIV-positive and HIV-negative participants reported high levels of current needle/equipment sharing practices: 82% vs. 75%, respectively. CONCLUSIONS ATS use spread rapidly in the study sample after 1997 and is associated with an increased risk of HIV infection in this population already at high risk because of opiate IDU. Out-of-treatment IDUs in Malaysia engage in high risk behaviors regardless of their HIV status. Increased education and public health prevention measures are needed to reduce HIV transmission risks in this population.
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Deng Q, Tang Q, Schottenfeld RS, Hao W, Chawarski MC. Drug use in rural China: a preliminary investigation in Hunan Province. Addiction 2012; 107:610-613. [PMID: 21906200 PMCID: PMC4596718 DOI: 10.1111/j.1360-0443.2011.03648.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS To compare characteristics and illicit drug abuse patterns among drug abusers in rural and urban areas of Hunan Province, China. MEASUREMENTS AND DESIGN: Data collected by public security bureau on newly registered drug abusers between 2005 and 2008 in five urban and five rural areas (n = 1639) were extracted anonymously and analyzed. SETTING AND PARTICIPANTS All newly registered drug users in urban (n = 812) and rural (n = 827) areas of Hunan Province were included. FINDINGS Drug users from the rural areas were younger [31 (6.6) versus 34 (8.0) years, P < 0.001], with a higher proportion of males (86% versus 82%, P < 0.05) or married (34% versus 27%, P < 0.01). Rural drug users reported an earlier onset of drug use [27 (5.9) versus 30 (7.9) years old, P < 0.001], were more likely to report heroin as their primary drug of abuse (53% versus 47%, P < 0.001) and had a lower prevalence of criminal activities (19% versus 31%, P < 0.001). Rural drug users were less likely to report needle sharing (1.8% versus 4.3%, P < 0.01), less likely to report being human immunodeficiency virus positive (0.8% versus 2.6%, P < 0.01) and less likely to report prior drug treatment participation (2.8% versus 6.8%, P < 0.001). CONCLUSIONS Drug abuse is a substantial problem in both urban and rural areas in China. The very low proportion of newly registered drug users reporting any prior drug abuse treatment points to the importance of expanding substance abuse treatments, especially in rural areas where treatment penetration is even lower than in urban areas.
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Vicknasingam B, Mazlan M, Schottenfeld RS, Chawarski MC. Injection of buprenorphine and buprenorphine/naloxone tablets in Malaysia. Drug Alcohol Depend 2010; 111:44-9. [PMID: 20478668 DOI: 10.1016/j.drugalcdep.2010.03.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 03/16/2010] [Accepted: 03/16/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Buprenorphine maintenance is efficacious for treating opioid dependence, but problems with diversion and misuse of buprenorphine (BUP) may limit its acceptability and dissemination. The buprenorphine/naloxone combination tablet (BNX) was developed to reduce potential problems with diversion and abuse. This paper provides data regarding the characteristics of BUP injection drug users in Malaysia and preliminary data regarding the impact of withdrawing BUP and introducing BNX. BUP was introduced in 2002 and subsequently withdrawn from the Malaysian market in 2006. BNX was introduced in 2007. METHODS A two wave survey of BUP IDUs was conducted shortly prior to BUP withdrawal from the Malaysian market (n=276) and six months after BNX was introduced (n=204). Six focus groups with BUP and/or BNX IDUs were also conducted shortly before the second wave. RESULTS In addition to current BUP or BNX IDU, 96% of first wave participants and 97% second wave participants reported lifetime heroin IDU preceding the onset of their BUP/BNX IDU. Additionally, 58% of first and 64% of second wave survey participants reported current heroin IDU. Benzodiazepine abuse, often injected with BUP, was reported in both the surveys. Focus group participants reported that BNX was not as desirable as BUP, nonetheless, the results of the second wave survey suggest a continuing widespread BNX IDU, at least in Kuala Lumpur. CONCLUSIONS In Malaysia, BUP and BNX IDU occur among heroin IDUs. The introduction of BNX and withdrawal of BUP may have helped to reduce, but did not eliminate the problems with diversion and abuse.
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Sullivan LE, Moore BA, O'Connor PG, Barry DT, Chawarski MC, Schottenfeld RS, Fiellin DA. The association between cocaine use and treatment outcomes in patients receiving office-based buprenorphine/naloxone for the treatment of opioid dependence. Am J Addict 2010; 19:53-8. [PMID: 20132122 PMCID: PMC3107713 DOI: 10.1111/j.1521-0391.2009.00003.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Cocaine use in patients receiving methadone is associated with worse treatment outcomes. The association between cocaine use and office-based buprenorphine/naloxone treatment outcomes is not known. We evaluated the association between baseline and in-treatment cocaine use, treatment retention, and urine toxicology results in 162 patients enrolled in a 24-week trial of primary care office-based buprenorphine/naloxone maintenance. Patients with baseline cocaine metabolite-negative urine toxicology tests compared with those with cocaine metabolite-positive tests had more mean weeks of treatment retention (18.3 vs. 15.8, p = .04), a greater percentage completed 24 weeks of treatment (50% vs. 33%, p = .04) and had a greater percentage of opioid-negative urines (47% vs. 34%, p = .02). Patients with in-treatment cocaine metabolite-negative urine toxicology tests compared with cocaine metabolite-positive patients had more mean weeks of treatment retention (19.0 vs. 16.5, p = .003), a greater percentage completed 24 weeks of treatment (60% vs. 30%, p < .001), and had a greater percentage of opioid-negative urines (51% vs. 35%, p = .001). We conclude that both baseline and in-treatment cocaine use is associated with worse treatment outcomes in patients receiving office-based buprenorphine/naloxone and may benefit from targeted interventions.
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Barry DT, Fulgieri MD, Lavery ME, Chawarski MC, Najavits LM, Schottenfeld RS, Pantalon MV. Research- and community-based clinicians' attitudes on treatment manuals. Am J Addict 2008; 17:145-8. [PMID: 18393058 DOI: 10.1080/10550490701860880] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
We assessed the attitudes of 18 research- and 22 community-based substance abuse clinicians on treatment manuals. Research and community clinicians exhibited favorable attitudes toward manuals, and the majority (72% and 77%, respectively) reported an interest in learning more about substance use disorder (SUD) treatment manuals. Among community clinicians, greater years of experience was significantly associated with less favorable attitudes toward treatment manuals. Research clinicians endorsed significantly higher ratings for the importance attached to "theoretical rationale/overview" and "main session points to address" than community clinicians. Findings suggest that community SUD clinicians are already familiar with and have positive attitudes toward manuals, but specific subgroups have concerns that should be addressed.
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Schottenfeld RS, Chawarski MC, Mazlan M. Maintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial. Lancet 2008; 371:2192-200. [PMID: 18586174 PMCID: PMC4041792 DOI: 10.1016/s0140-6736(08)60954-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Expansion of access to effective treatments for heroin dependence is a worldwide health priority that will also reduce HIV transmission. We compared the efficacy of naltrexone, buprenorphine, and no additional treatment, in patients receiving detoxification and subsequent drug counselling, for maintenance of heroin abstinence, prevention of relapse, and reduction of HIV risk behaviours. METHODS 126 detoxified heroin-dependent patients, from an outpatient research clinic and detoxification programme in Malaysia, were randomly assigned by a computer-generated randomisation sequence to 24 weeks of manual-guided drug counselling and maintenance with naltrexone (n=43), buprenorphine (n=44), or placebo (n=39). Medications were administered on a double-blind and double-dummy basis. Primary outcomes, assessed by urine testing three times per week, were days to first heroin use, days to heroin relapse (three consecutive opioid-positive urine tests), maximum consecutive days of heroin abstinence, and reductions in HIV risk behaviours over 6 months. The study was terminated after 22 months of enrolment because buprenorphine was shown to have greater efficacy in an interim safety analysis. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00383045. FINDINGS We observed consistent, linear contrasts in days to first heroin use (p=0.0009), days to heroin relapse (p=0.009), and maximum consecutive days abstinent (p=0.0007), with all results best for buprenorphine and worst for placebo. Buprenorphine was associated with greater time to first heroin use than were naltrexone (hazard ratio 1.87 [95% CI 1.21-2.88]) or placebo (2.02 [1.29-3.16]). With buprenorphine, we also recorded significantly greater time to heroin relapse (2.17 [1.38-3.42]), and maximum consecutive days abstinent than with placebo (mean days 59 [95% CI 43-76] vs 24 [13-35]; p=0.003); however, for these outcomes, differences between buprenorphine and naltrexone were not significant. Differences between naltrexone and placebo were not significant for any outcomes. HIV risk behaviours were significantly reduced from baseline across all three treatments (p=0.003), but the reductions did not differ significantly between the three groups. INTERPRETATION Our findings lend support to the widespread dissemination of maintenance treatment with buprenorphine as an effective public-health approach to reduce problems associated with heroin dependence.
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D'Onofrio G, Pantalon MV, Degutis LC, Fiellin DA, Busch SH, Chawarski MC, Owens PH, O'Connor PG. Brief intervention for hazardous and harmful drinkers in the emergency department. Ann Emerg Med 2008; 51:742-750.e2. [PMID: 18436340 DOI: 10.1016/j.annemergmed.2007.11.028] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Revised: 10/23/2007] [Accepted: 11/08/2007] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE To determine the efficacy of emergency practitioner-performed brief intervention for hazardous/harmful drinkers in reducing alcohol consumption and negative consequences in an emergency department (ED) setting. METHODS A randomized clinical trial (Project ED Health) was conducted in an urban ED from May 2002 to November 2003 for hazardous/harmful drinkers. Patients 18 years or older who screened above National Institute for Alcohol Abuse and Alcoholism guidelines for "low-risk" drinking or presented with an injury in the setting of alcohol ingestion were eligible. The mean number of drinks per week and binge-drinking episodes during the past 30 days were collected at 6 and 12 months; negative consequences and use of treatment services, at 12 months. A Brief Negotiation Interview performed by emergency practitioners was compared to scripted Discharge Instructions. RESULTS A total of 494 hazardous/harmful drinkers were studied. The 2 groups were similar with respect to baseline characteristics. In the Brief Negotiation Interview group, the mean number of drinks per week at 12 months was 3.8 less than the 13.6 reported at baseline. The Discharge Instructions group decreased 2.6 from 12.4 at baseline. Likewise, binge-drinking episodes per month decreased by 2.0 from a baseline of 6.0 in the Brief Negotiation Interview group and 1.5 from 5.4 in the Discharge Instructions group. For each outcome, the time effect was significant and the treatment effect was not. CONCLUSION Among ED patients with hazardous/harmful drinking, we did not detect a difference in efficacy between emergency practitioner-performed Brief Negotiation Interview and Discharge Instructions. Further studies to test the efficacy of brief intervention in the ED are needed.
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Chawarski MC, Mazlan M, Schottenfeld RS. Behavioral drug and HIV risk reduction counseling (BDRC) with abstinence-contingent take-home buprenorphine: a pilot randomized clinical trial. Drug Alcohol Depend 2008; 94:281-4. [PMID: 18164145 DOI: 10.1016/j.drugalcdep.2007.11.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 11/11/2007] [Accepted: 11/13/2007] [Indexed: 10/22/2022]
Abstract
This pilot randomized clinical trial evaluated whether the efficacy of office-based buprenorphine maintenance treatment (BMT), provided with limited counseling or oversight of medication adherence is improved by the addition of individual drug counseling and abstinence-contingent take-home doses of buprenorphine. After a 2-week buprenorphine and stabilization period, heroin dependent individuals (n=24) in Muar, Malaysia were randomly assigned to Standard Services BMT (physician administered advice and support, and weekly, non-contingent medication pick-up) or Enhanced Services (nurse-delivered manual-guided behavioral drug and HIV risk reduction counseling (BDRC) and abstinence-contingent take-home buprenorphine (ACB), 7 day supply maximum). Outcomes included retention, proportion of opioid-negative urine tests, self-reported drug use, and self-reported HIV risk behaviors. 12/12 (100%) of Enhanced Services and 11/12 (92%) of Standard Services participants completed the entire protocol. The proportion of opioid-negative urine tests increased significantly over time for both groups (p<0.001), and the reductions were significantly greater in the Enhanced Services group (p<0.05); Enhanced Services group achieved higher overall proportions of opiate negative urine toxicology tests (87% vs. 69%, p=0.04) and longer periods of consecutive abstinence from opiates (10.3 weeks vs. 7.8 weeks, p=0.154). Both groups significantly reduced HIV risk behaviors during treatment (p<0.05), but the difference between Enhanced and Standard Services (26% vs. 17% reductions from the baseline levels, respectively) was not statistically significant (p=0.9). Manual-guided behavioral drug and HIV risk reduction counseling and abstinence-contingent take-home buprenorphine appear promising for adding to the efficacy of office-based BMT provided with limited drug counseling and medication oversight.
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Fiellin DA, Moore BA, Sullivan LE, Becker WC, Pantalon MV, Chawarski MC, Barry DT, O'Connor PG, Schottenfeld RS. Long-Term Treatment with Buprenorphine/Naloxone in Primary Care: Results at 2–5 Years. Am J Addict 2008; 17:116-20. [DOI: 10.1080/10550490701860971] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Sullivan LE, Moore BA, Chawarski MC, Pantalon MV, Barry D, O'Connor PG, Schottenfeld RS, Fiellin DA. Buprenorphine/naloxone treatment in primary care is associated with decreased human immunodeficiency virus risk behaviors. J Subst Abuse Treat 2007; 35:87-92. [PMID: 17933486 DOI: 10.1016/j.jsat.2007.08.004] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Revised: 07/31/2007] [Accepted: 08/08/2007] [Indexed: 10/22/2022]
Abstract
Methadone treatment reduces human immunodeficiency virus (HIV) risk, but the effects of primary-care-based buprenorphine/naloxone on HIV risk are unknown. The purpose of this study was to determine whether primary-care-based buprenorphine/naloxone was associated with decreased HIV risk behavior. We conducted a longitudinal analysis of 166 opioid-dependent persons (129 men and 37 women) receiving buprenorphine/naloxone treatment in a primary care clinic. We compared baseline and 12- and 24-week overall, drug-related, and sex-related HIV risk behaviors using the AIDS/HIV Risk Inventory (ARI). Buprenorphine/naloxone treatment was associated with significant reductions in overall and drug-related ARI scores from baseline to 12 and 24 weeks. Intravenous drug use in the past 3 months was endorsed by 37%, 12%, and 7% of patients at baseline and at 12 and 24 weeks, respectively (p< .001). Sex while you or your partner were "high" was endorsed by 64%, 13%, and 15% of patients at baseline and at 12 and 24 weeks, respectively (p< .001). Inconsistent condom use during sex with a steady partner was high at baseline and did not change over time. We conclude that primary-care-based buprenorphine/naloxone treatment is associated with decreased drug-related HIV risk, but additional efforts may be needed to address sex-related HIV risk when present.
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Chawarski MC, Fiellin DA, O'Connor PG, Bernard M, Schottenfeld RS. Utility of sweat patch testing for drug use monitoring in outpatient treatment for opiate dependence. J Subst Abuse Treat 2007; 33:411-5. [PMID: 17512157 PMCID: PMC3632440 DOI: 10.1016/j.jsat.2007.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2007] [Accepted: 03/03/2007] [Indexed: 11/26/2022]
Abstract
We evaluated the utility of sweat testing for monitoring of drug use in outpatient clinical settings and compared sweat toxicology with urine toxicology and self-reported drug use during a randomized clinical trial of the efficacy of buprenorphine for treatment of opioid dependence in primary care settings. All study participants (N = 63) were opiate-dependent, treatment-seeking volunteers. The results based on toxicology tests obtained from 188 properly worn and unadulterated patches (out of 536 applied) show that the level of agreement between positive sweat test results and positive urine results was 33% for opiates and 92% for cocaine. The findings of this study, that there is a low acceptability of sweat patch testing by patients (only 54.3% were brought back attached to the skin) and that weekly sweat testing is less sensitive than weekly urine testing in detecting opiate use, suggest limited utility of sweat patch testing in outpatient clinical settings.
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Moore BA, Fiellin DA, Barry DT, Sullivan LE, Chawarski MC, O'Connor PG, Schottenfeld RS. Primary care office-based buprenorphine treatment: comparison of heroin and prescription opioid dependent patients. J Gen Intern Med 2007; 22:527-30. [PMID: 17372805 PMCID: PMC1829433 DOI: 10.1007/s11606-007-0129-0] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Prescription opioid dependence is increasing, but treatment outcomes with office-based buprenorphine/naloxone among these patients have not been described. METHODS We compared demographic, clinical characteristics and treatment outcomes among 200 patients evaluated for entry into a trial of primary care office-based buprenorphine/naloxone treatment stratifying on those who reported exclusive heroin use (n = 124), heroin and prescription opioid use (n = 47), or only prescription opioid use (n = 29). RESULTS Compared to heroin-only patients, prescription-opioid-only patients were younger, had fewer years of opioid use, and less drug treatment history. They were also more likely to be white, earned more income, and were less likely to have Hepatitis C antibodies. Prescription-opioid-only patients were more likely to complete treatment (59% vs. 30%), remained in treatment longer (21.0 vs. 14.2 weeks), and had a higher percent of opioid-negative urine samples than heroin only patients (56.3% vs. 39.8%), all p values < .05. Patients who used both heroin and prescription opioids had outcomes that were intermediate between heroin-only and prescription-opioid-only patients. CONCLUSIONS Individuals dependent on prescription opioids have an improved treatment response to buprenorphine/naloxone maintenance in an office-based setting compared to those who exclusively or episodically use heroin.
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Barry DT, Moore BA, Pantalon MV, Chawarski MC, Sullivan LE, O'Connor PG, Schottenfeld RS, Fiellin DA. Patient satisfaction with primary care office-based buprenorphine/naloxone treatment. J Gen Intern Med 2007; 22:242-5. [PMID: 17356993 PMCID: PMC1824745 DOI: 10.1007/s11606-006-0050-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Factors associated with satisfaction among patients receiving primary care-based buprenorphine/naloxone are unknown. OBJECTIVE To identify factors related to patient satisfaction in patients receiving primary care-based buprenorphine/naloxone that varied in counseling intensity (20 vs 45 minutes) and office visit frequency (weekly vs thrice weekly). DESIGN AND PARTICIPANTS One hundred and forty-two opioid-dependent subjects. MEASUREMENTS Demographics, drug treatment history, and substance use status at baseline and during treatment were collected. The primary outcome was patient satisfaction at 12 weeks. RESULTS Patients' mean overall satisfaction score was 4.4 (out of 5). Patients were most satisfied with the medication and ancillary services and indicated strong willingness to refer a substance-abusing friend for the same treatment. Patients were least satisfied with their interactions with other opioid-dependent patients, referrals to Narcotics Anonymous, and the inconvenience of the treatment location. Female gender (beta = .17, P = .04) and non-White ethnicity/race (beta = .17, P = .04) independently predicted patient satisfaction. Patients who received briefer counseling and buprenorphine/naloxone dispensed weekly had greater satisfaction than those whose medication was dispensed thrice weekly (mean difference 4.9, 95% confidence interval 0.08 to 9.80, P = .03). CONCLUSIONS Patients are satisfied with primary care office-based buprenorphine/naloxone. Providers should consider the identified barriers to patient satisfaction.
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Mazlan M, Schottenfeld RS, Chawarski MC. New challenges and opportunities in managing substance abuse in Malaysia. Drug Alcohol Rev 2007; 25:473-8. [PMID: 16939945 DOI: 10.1080/09595230600883354] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Until recently, Malaysia has lagged behind in the treatment of drug addiction and related disorders, despite experiencing severe drug problems. By the end of 2004, 234,000 heroin users or heroin-dependent individuals had been registered in the official government registry, but other estimates exceed 500,000 for heroin abusers in the country. Amphetamine-type stimulant abuse is also increasing and of considerable public and government concern. Among the population of drug users, HIV and other infectious diseases rates are very high. In the Western Pacific regions, Malaysia has the second highest HIV prevalence (after Vietnam) among adult populations (0.62%) and the highest proportion of HIV cases resulting from injection drug use (76.3%). Drug use and related disorders exert a heavy burden on the country's health care and legal systems. Historically, drug abusers were rehabilitated involuntarily in correctional, rather than health-care, facilities. This primarily criminal treatment approach had limited effectiveness which led to widespread public dissatisfaction and the recent introduction of medical treatments for addiction. Naltrexone was introduced in 1999; buprenorphine was introduced in 2001 and methadone in 2003. Agonist maintenance programmes were embraced rapidly by the medical community in Malaysia. Currently, over 30,000 opiate-dependent patients are treated with agonist maintenance treatments by more than 500 medical practitioners in Malaysia. Despite these recent advances, treatments for amphetamine-type stimulant abuse or dependence are underdeveloped, and diversion of agonist medications is an emerging concern.
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Sullivan LE, Barry D, Moore BA, Chawarski MC, Tetrault JM, Pantalon MV, O'Connor PG, Schottenfeld RS, Fiellin DA. A Trial of Integrated Buprenorphine/Naloxone and HIV Clinical Care. Clin Infect Dis 2006; 43 Suppl 4:S184-90. [PMID: 17109305 DOI: 10.1086/508182] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Untreated opioid dependence adversely affects the care of human immunodeficiency virus (HIV)-positive patients. Buprenorphine, a partial opioid agonist, is available for maintenance treatment of opioid dependence in HIV specialty settings. We investigated the feasibility and efficacy of integrating buprenorphine, along with 2 levels of counseling, into HIV clinical care. METHODS HIV-positive, opioid-dependent patients were enrolled in a 12-week pilot study and randomized to receive daily buprenorphine/naloxone treatment along with either brief physician management or physician management combined with nurse-administered drug counseling and adherence management. Primary outcomes included treatment retention; illicit drug use, assessed by urine toxicology test and self-report; CD4 lymphocyte counts; and log(10) HIV type 1 (HIV-1) RNA levels. RESULTS Of the 16 patients who received at least 1 dose of buprenorphine, 13 (81%) completed 12 weeks of treatment. The proportion of opioid-positive weekly urine test results decreased from 100% at baseline to 32% (month 1), 20% (month 2), and 16% (month 3). Only 4 patients reported any opioid use (in the prior 7 days) during the 12-week study. CD4 lymphocyte counts remained stable over the course of the study. The mean log(10) HIV-1 RNA level (+/- standard deviation) declined significantly, from 3.66+/-1.06 log(10) HIV-1 RNA copies/mL at baseline to 3.0+/-0.57 log(10) HIV-1 RNA copies/mL at month 3 (P<.05). No significant differences based on counseling intervention were detected. All 13 patients who completed the study continued to receive treatment in an extension phase of at least 0-15 months' duration. CONCLUSIONS We conclude that it is feasible to integrate buprenorphine into HIV clinical care for the treatment of opioid dependence. Patients experienced good treatment retention and reductions in their opioid use. HIV biological markers remained stable or improved during buprenorphine/naloxone treatment.
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Fiellin DA, Pantalon MV, Chawarski MC, Moore BA, Sullivan LE, O'Connor PG, Schottenfeld RS. Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence. N Engl J Med 2006; 355:365-74. [PMID: 16870915 DOI: 10.1056/nejmoa055255] [Citation(s) in RCA: 242] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The optimal level of counseling and frequency of attendance for medication distribution has not been established for the primary care, office-based buprenorphine-naloxone treatment of opioid dependence. METHODS We conducted a 24-week randomized, controlled clinical trial with 166 patients assigned to one of three treatments: standard medical management and either once-weekly or thrice-weekly medication dispensing or enhanced medical management and thrice-weekly medication dispensing. Standard medical management was brief, manual-guided, medically focused counseling; enhanced management was similar, but each session was extended. The primary outcomes were the self-reported frequency of illicit opioid use, the percentage of opioid-negative urine specimens, and the maximum number of consecutive weeks of abstinence from illicit opioids. RESULTS The three treatments had similar efficacies with respect to the mean percentage of opioid-negative urine specimens (standard medical management and once-weekly medication dispensing, 44 percent; standard medical management and thrice-weekly medication dispensing, 40 percent; and enhanced medical management and thrice-weekly medication dispensing, 40 percent; P=0.82) and the maximum number of consecutive weeks during which patients were abstinent from illicit opioids. All three treatments were associated with significant reductions from baseline in the frequency of illicit opioid use, but there were no significant differences among the treatments. The proportion of patients remaining in the study at 24 weeks did not differ significantly among the patients receiving standard medical management and once-weekly medication dispensing (48 percent) or thrice-weekly medication dispensing (43 percent) or enhanced medical management and thrice-weekly medication dispensing (39 percent) (P=0.64). Adherence to buprenorphine-naloxone treatment varied; increased adherence was associated with improved treatment outcomes. CONCLUSIONS Among patients receiving buprenorphine-naloxone in primary care for opioid dependence, the efficacy of brief weekly counseling and once-weekly medication dispensing did not differ significantly from that of extended weekly counseling and thrice-weekly dispensing. Strategies to improve buprenorphine-naloxone adherence are needed. (ClinicalTrials.gov number, NCT00023283 [ClinicalTrials.gov].).
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Chawarski MC, Mazlan M, Schottenfeld RS. Heroin dependence and HIV infection in Malaysia. Drug Alcohol Depend 2006; 82 Suppl 1:S39-42. [PMID: 16769444 DOI: 10.1016/s0376-8716(06)80007-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2005] [Revised: 08/22/2005] [Accepted: 10/12/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Malaysia is experiencing severe problems with heroin dependence and HIV infection. This, study evaluated drug use and other HIV risk behaviors and their association with HIV and other infectious diseases in heroin-dependent subjects enrolled in a clinical trial of drug abuse treatment in Muar, Malaysia. METHODS Baseline assessment of treatment-seeking subjects (n=177) included the Addiction Severity Index; AIDS Risk Inventory; serological tests for HIV, hepatitis B, and hepatitis C; and chest X-ray. RESULTS All of the subjects were male; 67.8% were Malays, 28.8% Chinese, and 2.3%. Indian. Subjects had a mean (SD) age of 37.2 (9.1) years and 14.4 (8.5) years of using heroin; 76.3% reported lifetime injection drug use (IDU), and 41.5% reported current IDU; 30 of 156 (19.2%) tested HIV positive, 143 of 159 (89.9%) tested hepatitis C positive, and 25 of 159 (15.7%) had radiological evidence of pulmonary tuberbulosis. Malay subjects had a significantly higher prevalence of current IDU, needle sharing (p<0.01), and HIV infection (p<0.05) compared with Chinese subjects. Lifetime IDU, needle sharing, lack of consistent condom use, and Malay ethnicity were significantly associated with HIV infection. CONCLUSIONS The high prevalence of HIV infection among heroin-dependent individuals, in Malaysia supports the important of interventions to reduce the major risk factors for HIV, including IDU, needle sharing, and unprotected sex.
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Baklanov DV, Marcu CB, Juhasz DF, Caracciolo EA, Chawarski MC, Donohue TJ. Coronary stenting is safe and effective in a high-risk octogenarian patient cohort. CONNECTICUT MEDICINE 2006; 70:15-9. [PMID: 16479871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Octogenarians represent an increasing percentage of patients with coronary heart disease and are an inherently high-risk population. We sought to define the immediate and long-term results of coronary stenting in the "real-world" environment of a community teaching hospital. METHODS One hundred ninety-seven consecutive patients older then 80 years who underwent 214 coronary stent procedures were studied. Each patient had postprocedural serial cardiac enzymes and ECG's collected, and was followed for a minimum of 12 months after the procedure. Procedural success was defined as less than 20% residual stenosis, TIMI 3 flow, and absence of major complications (death, nonfatal myocardial infarction, emergent coronary artery bypass graft surgery and stroke). Sixty-five percent of patients presented with an acute coronary syndrome and 93% were functionally New York Heart Association (NYHA) Class III or IV. RESULTS Procedural success was 95%. Death during the index hospitalization occurred in 3% of patients. An additional 4.1% of patients died during follow-up. The target vessel revascularization rate (TVR) during follow up was 8.6%. Multivariate analysis of selected angiographic and clinical variables did not reveal any predictors of major cardiac events. CONCLUSIONS Despite a high-risk clinical and angiographic profile, coronary stenting can be safely performed in octogenarians with a high procedural success rate, low complication rate, and excellent 12-month outcome.
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Chawarski MC, Moody DE, Pakes J, O'Connor PG, Schottenfeld RS. Buprenorphine tablet versus liquid: A clinical trial comparing plasma levels, efficacy, and symptoms. J Subst Abuse Treat 2005; 29:307-12. [PMID: 16311183 DOI: 10.1016/j.jsat.2005.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2005] [Revised: 05/06/2005] [Accepted: 08/23/2005] [Indexed: 11/19/2022]
Abstract
We evaluated peak plasma concentrations, trough concentrations, and the 24-hour area under the concentration curve (AUC(0-24 h)) during maintenance with sublingual (SL) liquid or tablet formulations in 57 opiate-dependent volunteers. Study participants were assigned randomly to one of three SL daily buprenorphine dose pairs and maintained for 2 weeks with the liquid formulation followed by 2 weeks with the corresponding tablet dose. Plasma samples were obtained after at least 10 days of maintenance with the liquid formulation and after at least 10 days of that with the tablet formulation. The bioequivalence of the tablet compared with the liquid doses ranged from 57% to 75% based on peak concentrations, from 102% to 108% based on trough concentrations, and from 66% to 86% based on 24-hour AUC, but there was a large intersubject and intrasubject variability in plasma concentrations, with greater variability following tablets than liquid. Measures of withdrawal symptoms or illicit opioid use were not associated with buprenorphine dose, formulation, or plasma buprenorphine levels.
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Schottenfeld RS, Chawarski MC, Pakes JR, Pantalon MV, Carroll KM, Kosten TR. Methadone versus buprenorphine with contingency management or performance feedback for cocaine and opioid dependence. Am J Psychiatry 2005; 162:340-9. [PMID: 15677600 DOI: 10.1176/appi.ajp.162.2.340] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Physicians may prescribe buprenorphine for opioid agonist maintenance treatment outside of narcotic treatment programs, but treatment guidelines for patients with co-occurring cocaine and opioid dependence are not available. This study compares effects of buprenorphine and methadone and evaluates the efficacy of combining contingency management with maintenance treatment for patients with co-occurring cocaine and opioid dependence. METHOD Subjects with cocaine and opioid dependence (N=162) were provided manual-guided counseling and randomly assigned in a double-blind design to receive daily sublingual buprenorphine (12-16 mg) or methadone (65-85 mg p.o.) and to contingency management or performance feedback. Contingency management subjects received monetary vouchers for opioid- and cocaine-negative urine tests, which were conducted three times a week; voucher value escalated during the first 12 weeks for consecutive drug-free tests and was reduced to a nominal value in weeks 13-24. Performance feedback subjects received slips of paper indicating the urine test results. The primary outcome measures were the maximum number of consecutive weeks abstinent from illicit opioids and cocaine and the proportion of drug-free tests. Analytic models included two-by-two analysis of variance and mixed-model repeated-measures analysis of variance. RESULTS Methadone-treated subjects remained in treatment significantly longer and achieved significantly longer periods of sustained abstinence and a greater proportion drug-free tests, compared with subjects who received buprenorphine. Subjects receiving contingency management achieved significantly longer periods of abstinence and a greater proportion drug-free tests during the period of escalating voucher value, compared with those who received performance feedback, but there were no significant differences between groups in these variables during the entire 24-week study. CONCLUSIONS Methadone may be superior to buprenorphine for maintenance treatment of patients with co-occurring cocaine and opioid dependence. Combining methadone or buprenorphine with contingency management may improve treatment outcome.
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Baird JC, Chawarski MC. Context-Constrained Judgment of the Perceived Risk of HIV/AIDS1. JOURNAL OF APPLIED SOCIAL PSYCHOLOGY 2005. [DOI: 10.1111/j.1559-1816.2005.tb02092.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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