Changes in somatic disease incidents during opioid maintenance treatment: results from a Norwegian cohort study

Objectives To examine the effect of opioid maintenance treatment (OMT) on somatic morbidity in a cohort of OMT patients. Design Retrospective cohort study. Setting OMT programme in two Norwegian counties. Participants 200 OMT patients, participation rate 71.2%. Main outcome measures Incidence rates (IR) before, during and after OMT for acute/subacute hospital-treated somatic disease incidents (drug-related, non-drug-related, injuries) and rates for inpatient days and outpatient treatment contacts. Results IR for drug-related hospital treatment episodes were 76% lower during compared to before OMT (before versus during incidence rate ratio (IRR) 4.2 (95% CI 2.9 to 6.2), p<0.001) and 11 times higher after compared to during OMT (after versus during IRR 11.1 (6.6 to 18.5), p<0.001). For non-drug-related treatment episodes, IR were 35% higher during than before OMT (before versus during IRR 0.7 (0.6 to 1.0), p=0.02) and 32% higher after compared to during OMT (IRR 1.4 (0.9 to 2.2), p=0.15), while injuries showed little change according to OMT status. Although patients with on-going drug-taking during OMT showed less reduction in drug-related hospital-treated incidents during treatment than patients not using illicit drugs, the quartile with most drug-taking showed a significant reduction (before versus during IRR 3.6 (2.4 to 5.3)). Patients who had experienced cessation of OMT showed a significant reduction in drug-related treatment episodes during OMT (before versus during IRR 1.7 (1.0 to 2.9)), although less than patients without OMT interruptions (before versus during IRR 6.1 (3.6 to 10.6)), and a significant increase after OMT cessation compared with during OMT (IRR 5.4 (3.0 to 9.7)). Conclusion Acute/subacute drug-related somatic morbidity is reduced during compared to before OMT. This was also found for patients with on-going drug-taking during OMT. However, acute drug-related health problems show an increase after OMT cessation, and this is a matter of concern. Further studies on somatic morbidity after OMT cessation should be carried out.

Psychoactive substance use among patients admitted to an acute psychiatric ward: laboratory findings and associations with clinical characteristics

BACKGROUND

Estimates of psychoactive substance use among acutely admitted psychiatric patients vary among studies, and few have used comprehensive laboratory methods.

AIMS

This study used chromatography-based analyses of blood and urine to identify the rates of substance use among acute psychiatric admissions, and to study the associations with socio-demographic variables, clinical characteristics and patients' reports of symptoms, substance use and need for treatment.

METHODS

A cross-sectional study was conducted in 2006/2007 in Oslo, Norway. Blood and urine samples were collected from 298 acute psychiatric admissions and extensively analysed for alcohol, medicinal and illicit drugs. Psychotic symptoms were assessed with the positive subscale of the Positive and Negative Syndrome Scale. Patient self-report questionnaires included the Alcohol and Drug Use Disorder Identification Tests. Patients were also asked if they needed professional help for substance use.

RESULTS

Psychoactive substances were detected in 63% of the 298 admissions, medicinal drugs in 46%, alcohol in 12% and illicit drugs in 28%. Patients using alcohol had a high suicidal risk score at admission and the shortest length of stay (median 1 day). Use of illicit drugs was associated with psychotic symptoms and readmission. Self-report questionnaires indicated harmful use of alcohol for half of the patients and of other substances for one-third. A need for professional help for substance use was reported by one-third of patients.

CONCLUSION

Given the high rates of substance use and the important clinical associations, drug screening seems warranted in acute psychiatric settings. Interventions designed for substance-using patients should be developed and integrated.

Opioid maintenance patients with QTc prolongation: congenital long QT syndrome mutation may be a contributing risk factor

OBJECTIVES

This study investigates opioid maintenance treatment (OMT) patients found to have corrected QT (QTc) interval above 500 ms, with particular focus on past medical history, genetic testing and cardiac investigations.

METHODS

Detailed medical and cardiac history was obtained, with particular focus upon risk factors. Cardiac investigations, including genetic testing for the five most common long QT syndrome (LQTS) mutations, exercise electrocardiography (ECG) and 24-h ECG recordings, were performed.

RESULTS

Of 200 OMT patients assessed with ECG, seven methadone maintained patients identified with QTc interval above 500 ms participated in this study. Two were identified as heterozygous LQTS mutation carriers. Both had experienced cardiac symptoms prior to and during OMT. No other risk factors for QTc prolongation were detected among the seven patients. Six of the seven patients underwent further cardiac investigations. QTc intervals fluctuated widely over 24h and during exercise for all patients. Only one of the LQTS mutation carriers switched to buprenorphine and started on a beta-blocker. Despite strong medical advice and information, none of the other patients wanted to switch to buprenorphine or take other cardiac protective measures.

CONCLUSION

Findings indicate the importance of recording a thorough past medical history, focusing specifically on previous cardiac symptoms, and on other known risk factors for QTc prolongation, prior to initiating patients on methadone.

Challenges to antagonist blockade during sustained-release naltrexone treatment

AIMS

Naltrexone is a competitive opioid antagonist that effectively blocks the action of heroin and other opioid agonists. Sustained-release naltrexone formulations are now available that provide long-acting opioid blockade. This study investigates the use of heroin and other opioids among opioid-dependent patients receiving treatment with long-acting naltrexone implants, their subjective experience of drug 'high' after opioid use, and factors associated with opioid use.

METHODS

Participants (n = 60) were opioid-dependent patients receiving treatment with naltrexone implants. Outcome data on substance use, drug 'high', depression and criminal activity were collected over a 6-month period. Blood samples were taken to monitor naltrexone plasma levels, and hair samples to verify self-reported opioid use.

FINDINGS

More than half [n = 34 or 56%; 95% confidence interval (CI) 44-68%)] the patients challenged the blockade with illicit opioids during the 6-month treatment period; 44% (n = 26; 95% CI 32-56%) were abstinent from opioids. Mean opioid use was reduced from 18 [standard deviation (SD)13] days during the month preceding treatment to 6 days (SD 11) after 6 months. Of the respondents questioned on opioid 'high' (n = 31), nine patients (30%; 95% CI 16-47%) reported partial drug 'high' following illicit opioid use, and three (12%; 95% CI 3-26%) reported full 'high'. Opioid use was associated with use of non-opioid drugs and criminal behaviour.

CONCLUSIONS

Challenging naltrexone blockade with heroin on at least one occasion is common among sustained-release naltrexone patients, but only a minority of patients use opioids regularly. Challenges represent a warning sign for poor outcomes and often occur in the context of polydrug use and social adjustment problems.

Retention in naltrexone implant treatment for opioid dependence

BACKGROUND

Naltrexone's usefulness in the treatment of opioid dependence stems from its ability to block the action of heroin and other opioids. However, many patients are ambivalent towards naltrexone and often drop out of treatment with orally administered naltrexone. Sustained release naltrexone seems promising in reducing opioid use, but the extent to which patients remain in treatment beyond the first dosage of naltrexone is not clear.

METHODS

Patients (n=61) receving treatment with sustained release naltrexone implants were offered a second naltrexone implant after 6 months. Patients who remained in treatment were compared to those who did not, on drug use, mental health, and social problems before and during naltrexone implant treatment. Information was obtained on other treatments sought by patients who discontinued naltrexone. Blood samples were used to verify naltrexone release, and hair samples to confirm opioid intake.

RESULTS

Of the patients who received the first naltrexone implant, 51% (n=31) remained in naltrexone implant treatment. Among those who discontinued treatment, 21% expressed a wish to reimplant but failed to attend for reimplantation and 28% declined reimplantation: 6 non-retained patients initiated maintenance or residential treatment. Remaining in naltrexone treatment was related to pre-study length of employment, illicit drug use, and concern for family problems. Higher levels of substance misuse and criminal activity during naltrexone treatment were negatively related to subsequent retention.

CONCLUSION

Rates of retention among opioid-dependent patients receiving naltrexone implant treatment are encouraging and support this as a feasible long-term treatment option.

Staff attitudes and the associations with treatment organisation, clinical practices and outcomes in opioid maintenance treatment

BACKGROUND

In opioid maintenance treatment (OMT) there are documented treatment differences both between countries and between OMT programmes. Some of these differences have been associated with staff attitudes. The aim of this study was to 1) assess if there were differences in staff attitudes within a national OMT programme, and 2) investigate the associations of staff attitudes with treatment organisation, clinical practices and outcomes.

METHODS

This study was a cross-sectional multicentre study. Norwegian OMT staff (n = 140) were invited to participate in this study in 2007 using an instrument measuring attitudes towards OMT. The OMT programme comprised 14 regional centres. Data describing treatment organisation, clinical practices and patient outcomes in these centres were extracted from the annual OMT programme assessment 2007. Centres were divided into three groups based upon mean attitudinal scores and labelled; "rehabilitation-oriented", "harm reduction-oriented" and "intermediate" centres.

RESULTS

All invited staff (n = 140) participated. Staff attitudes differed between the centres. "Rehabilitation-oriented" centres had smaller caseloads, more frequent urine drug screening and increased case management (interdisciplinary meetings). In addition these centres had less drug use and more social rehabilitation among their patients in terms of long-term living arrangements, unemployment, and social security benefits as main income. "Intermediate" centres had the lowest treatment termination rate.

CONCLUSIONS

This study identified marked variations in staff attitudes between the regional centres within a national OMT programme. These variations were associated with measurable differences in caseload, intensity of case management and patient outcomes.

Naltrexone implants compared to methadone: outcomes six months after prison release

BACKGROUND

After prison release, offenders with heroin use problems are at high risk of relapse and overdose death. There is a particular need for treatments that can be initiated in prison and continued after release into the community. Methadone maintenance treatment has been shown to reduce heroin use, criminality and mortality. Naltrexone implant treatment has not previously been evaluated in prison settings.

METHODS

This study compares the effects of naltrexone implants and methadone treatment on heroin and other illicit drug use, and criminality among heroin-dependent inmates after release from prison.

RESULTS

Forty-six volunteers were randomly allocated to naltrexone implants or methadone before release. Intention-to-treat analyses showed reductions in both groups in frequency of use of heroin and benzodiazepines, as well as criminality, 6 months after prison release.

CONCLUSIONS

Naltrexone implants may be a valuable treatment option in prison settings.

Cognitive impairment in dual diagnosis inpatients with schizophrenia and alcohol use disorder

Cognitive impairment has been found independently among individuals with schizophrenia and individuals with alcohol use disorders. Less is known about the nature and severity of cognitive impairment in patients with a dual diagnosis, though the co-occurrence of these disorders may further exacerbate cognitive impairment. The study investigates the possible additive effect of alcohol use disorder and schizophrenia on cognitive impairment among patients diagnosed with schizophrenia. Participants were inpatients with schizophrenia (n=30), inpatients with a dual diagnosis of schizophrenia and alcohol use disorder (n=30), and matched controls (n=30): all completed a comprehensive neuropsychological battery. Both patient groups were significantly impaired, relative to controls, across the battery. Dual diagnosis patients were significantly more impaired than schizophrenia patients on delayed verbal memory, and executive functioning, primarily set-shifting, working memory, and planning, and had higher psychiatric morbidity scores. The findings provide support for an additive effect of the two disorders on cognitive impairment. These cognitive deficits may affect capacity to engage in treatment, increase risk of relapse, and adversely affect treatment outcomes. An understanding of the cognitive profile of people with dual diagnosis may help to tailor treatment delivery to meet their specific needs, enhance cognitive strengths, accommodate deficits and improve treatment outcomes.

Mortality among opiate users: opioid maintenance therapy, age and causes of death

AIMS

This study investigates how age of opioid users is related to causes of death prior to, during and after opioid maintenance treatment (OMT), and estimates risks of death from various causes in relation to age.

DESIGN, SETTING AND PARTICIPANTS

Data on all opiate dependents in Norway (1997-2003) who applied for and were accepted for OMT (n = 3789) were cross-linked with the Norwegian death register. The total observation time was 10 934 person-years.

FINDINGS

A total of 213 deaths was recorded. Of these, 73% were subject to autopsy, and causes of death were known for 208 cases: the overall death rate was 1.9%. Deaths were due to drug overdose (54%), somatic (32%) and traumatic causes (14%). Overdose deaths among all age groups were reduced during OMT but age had a differential effect upon risk when out of treatment. Younger opioid users were at greater risk of overdose before entering treatment; older users were at greater risk after leaving treatment. Older OMT patients were at higher risk of both somatic and traumatic deaths, and deaths during OMT were most likely to be due to somatic causes.

CONCLUSIONS

The high rates of overdose prior to and after treatment emphasize the need to provide rapid access to OMT, to retain patients in treatment and to re-enrol patients. The high prevalence among older patients of deaths due to somatic causes has implications for screening, treatment and referral, and may also lead to increased treatment costs.