The Maudsley Addiction Profile (MAP): a brief instrument for assessing treatment outcome

A call for consensus in defining efficacy in clinical trials for opioid addiction: combined results from a systematic review and qualitative study in patients receiving pharmacological assisted therapy for opioid use disorder

Background

Given the complex nature of opioid addiction treatment and the rising number of available opioid substitution and antagonist therapies (OSAT), there is no ‘gold standard’ measure of treatment effectiveness, and each successive trial measures a different set of outcomes which reflect success in arbitrary or opportune terms. We sought to describe the variation in current outcomes employed across clinical trials for opioid addiction, as well as determine whether a discrepancy exists between the treatment targets that patients consider important and how treatment effectiveness is measured in the literature.

Methods

We searched nine commonly used databases (e.g., EMBASE, MEDLINE) from inception to August 1, 2015. Outcomes used across trials were extracted and categorized according to previously established domains. To evaluate patient-reported goals of treatment, semi-structured interviews were conducted with 18 adults undergoing methadone treatment.

Results

We identified 60 trials eligible for inclusion. Once outcomes were categorized into eight broad domains (e.g., abstinence/substance abuse), we identified 21 specific outcomes with furthermore 53 subdomains and 118 measurements. Continued opioid use and treatment retention were the most commonly reported measures (46%, n = 28). The majority of patients agreed that abstinence from opioids was a primary goal in their treatment, although they also stressed goals under-reported in clinical trials.

Conclusions

There is inconsistency in the measures used to evaluate the effectiveness of OSATs. Individual and population level decision making is being guided by a standard of effect considered useful to researchers yet in direct conflict with what patients deem important.

Trial registration

PROSPERO, CRD42013006507.

Suicidal ideation and behaviour in patients with persecutory delusions: Prevalence, symptom associations, and psychological correlates

BACKGROUND

To determine the prevalence of suicidal ideation and behaviour - and their correlates - in patients with persecutory delusions.

METHODS

110 patients with persecutory delusions in the context of non-affective psychosis were assessed for suicidal thoughts and behaviours over the past month. Symptom and psychological assessments were also completed.

RESULTS

The severity of suicidal ideation was: no suicidal ideation (n = 26, 23.6%); wish to be dead (n = 21, 19.1%); nonspecific active suicidal thoughts (n = 14, 12.7%); suicidal thoughts with methods but no intent (n = 29, 26.4%); suicidal thoughts with intent but no specific plan (n = 13, 11.8%); and suicidal intent with plan (n = 7, 6.4%). In the past month, five patients (4.5%) had made an actual, interrupted, or aborted suicide attempt. The severity of suicidal ideation was associated with higher levels of depression, paranoia, hallucinations, anger, insomnia, negative beliefs about the self and others, pessimism, worry, and delusion safety-seeking behaviours and lower levels of psychological well-being and reward responsiveness. Severity of ideation was not associated with cannabis or alcohol use, working memory, pain, or meaningful activity levels.

CONCLUSIONS

Patients with persecutory delusions are typically in a severe state of psychological stress, and at risk of suicide, as indicated by very high levels of suicidal ideation. This exploratory study also identifies correlates of suicidal ideation that could be investigated in causal research designs.

Profiles of visuospatial memory dysfunction in opioid-exposed and dependent populations

BACKGROUND

Chronic opioid exposure is common world-wide, but behavioural performance remains under-investigated. This study aimed to investigate visuospatial memory performance in opioid-exposed and dependent clinical populations and its associations with measures of intelligence and cognitive impulsivity.

METHODS

We recruited 109 participants: (i) patients with a history of opioid dependence due to chronic heroin use (n = 24), (ii) heroin users stabilised on methadone maintenance treatment (n = 29), (iii) participants with a history of chronic pain and prescribed tramadol and codeine (n = 28) and (iv) healthy controls (n = 28). The neuropsychological tasks from the Cambridge Neuropsychological Test Automated Battery included the Delayed Matching to Sample (DMS), Pattern Recognition Memory, Spatial Recognition Memory, Paired Associate Learning, Spatial Span Task, Spatial Working Memory and Cambridge Gambling Task. Pre-morbid general intelligence was assessed using the National Adult Reading Test.

RESULTS

As hypothesised, this study identified the differential effects of chronic heroin and methadone exposures on neuropsychological measures of visuospatial memory (p < 0.01) that were independent of injecting behaviour and dependence status. The study also identified an improvement in DMS performance (specifically at longer delays) when the methadone group was compared with the heroin group and also when the heroin group was stabilised onto methadone. Results identified differential effects of chronic heroin and methadone exposures on various neuropsychological measures of visuospatial memory independently from addiction severity measures, such as injecting behaviour and dependence status.

Living With Dual Diagnosis and Homelessness: Marginalized Within a Marginalized Group

Objective: Concurrent mental and substance use disorders or dual diagnosis are highly prevalent among individuals experiencing homelessness. Studies have indicated that dual diagnosis leads to poorer health outcomes and higher health service utilization among those affected. This study aims to estimate the prevalence of dual diagnoses among homeless populations in British Columbia (BC), Canada, and understand their characteristics and specific factors associated with dual diagnoses. Methods: The BC Health of the Homeless Survey is a cross-sectional study involving the homeless population of three cities in BC. The survey assessed addiction and concurrent disorders with standardized interviews-the Mini-International Neuropsychiatric Interview Plus, the Maudsley Addiction Profile, and the Brief Symptom Inventory-in a sample of 500 individuals who are homeless living in shelters or on the street. We characterized individuals after categorizing them into four groups: those without any current mental disorder, those with substance use disorders only, those with mental disorders only, and those with concurrent substance use and mental disorders. Focusing on the concurrent disorder group, we completed a multivariate analysis comparing individuals with dual diagnosis to those without concurrent disorders. Results: Consistent with previous studies, we found that individuals with dual diagnoses report more severe physical and psychological symptoms. Among the homeless, they were more likely to be Aboriginal and younger and more likely to not make it into a shelter. They also reported substantially more difficulties in getting the health care service that they need. Conclusions: Within this marginalized group, individuals with dual diagnosis were more likely to be from groups considered to be more vulnerable with more complex needs. They were having more problems accessing even basic support, such as shelters and health care. Without a systematic approach in providing appropriate care to individuals with dual diagnosis, the most vulnerable clients are not only the ones likely to suffer the most but also the ones having the most problems meeting their basic needs.

Management of endocarditis among persons who inject drugs: A narrative review of surgical and psychiatric approaches and controversies

BACKGROUND

People who inject drugs (PWID) represent a high-risk subgroup of endocarditis patients. This is highlighted by poorer post-operative outcomes in injection drug use-related infective endocarditis (IDU-IE), which is largely attributable to the increased vulnerability of prosthetic valves to re-infection. Consequently, many centres do not perform valve replacement on these patients. A parallel, but often underrecognized, component of care is the role of multidisciplinary management for individuals with IDU-IE, including perioperative addictions and psychiatric care. Consequently, surgical management options in IDU-IE remain a controversial topic.

OBJECTIVES

To determine the characteristics of optimal surgical and psychiatric care for individuals with IDU-IE.

METHODS

We conducted a narrative synthesis of the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative text, organizing the findings into several key themes: clinical characteristics and factors associated with mortality in IDU-IE, alternative surgical management options, perioperative risk stratification techniques, principles of psychiatric and addictions management in IDU-IE, ethical considerations and controversies, and future research directions.

RESULTS/CONCLUSIONS

Managing IDU-IE involves the treatment of two comorbidities: the intra-cardiac infection and the underlying substance use disorder. Cardiac surgery represents a high-intensity intervention with appreciable risk, and the benefit it is not always clear. As patients often present acutely, it is not feasible to use drug abstinence as a prerequisite to surgery. Involvement of inpatient psychiatry and addictions teams, however, appears to be an evidence-based approach that can bridge IDU-IE patients with opioid agonist therapy in hospital and adequate outpatient treatment options for their underlying addiction upon their discharge from hospital. It is likely that a majority of these patients are not receiving optimal psychiatric management despite increasing recognition of efficacy. Further interdisciplinary studies are needed to elucidate optimal surgical and multidisciplinary protocols.

BACKGROUND

Infective endocarditis (IE) is an infection of the innermost lining of the heart often affecting the heart valves. Over the last few decades, the epidemiology of IE has shifted in the developed world and while it continues to be a significant cause of morbidity and mortality, there has been a significant increased incidence among persons who inject drugs (PWID). To date, well-conducted epidemiologic studies of IE among PWID have been sparse, which has limited our ability to fully characterize this disease phenomenon. To address this knowledge deficit, we conducted a narrative synthesis of the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative text, and organized our findings into six key themes: clinical characteristics and factors associated with mortality in IDU-IE, alternative surgical management options, perioperative risk stratification techniques, principles of psychiatric and addictions management in IDU-IE, ethical considerations and controversies, and future research directions.

Sociodemographic characteristics of patients with children in a methadone maintenance program: a cross-sectional study

Background

Ever-increasing numbers of opioid use disorder (OUD) in Canada has created the recent opioid crisis. One common treatment for OUD is methadone maintenance treatment (MMT). Various factors, including being a parent which entails specific stressors, may increase susceptibility to negative treatment outcomes. This study aims to investigate differences between OUD patients with and without children in socio-demographic and clinical outcomes.

Methods

Data for this study are part of a larger program. All participants are 18+ years old with OUD, provided consent, and receiving MMT. We performed a multivariable logistic regression to examine the differences between participants’ parental status, sociodemographic variables, and clinical parameters including MMT outcomes. We performed subgroup analyses on individuals with children younger than 18.

Results

A total of 1099 participants were included, with 64% having children. Participants with children were older (OR 1.06, 95% CI 1.04, 1.08), more likely to be female (OR 2.39, 95% CI 1.75, 3.27), living with a partner (OR 1.75, 95% CI 1.27, 2.41), first exposed to opioids through a prescription (OR 1.517, 95% CI 1.13, 2.04) and had lower levels of education (OR 1.86, 95% CI 1.20, 2.87). There was no significant difference in illicit opioid use patterns between groups. Same results held true in the subgroup analyses based on the age of the children except for participant age.

Conclusion

Our results demonstrate social and demographic differences between parents and non-parents receiving MMT. These differences highlight the need to understand necessary additional support for parents such as child support and other necessary therapies.

A systematic review and discussion of symptom specific cognitive behavioural approaches to delusions and hallucinations

Studies on cognitive behavioural therapy for psychosis (CBTp) have developed from evaluating generic approaches to focusing on specific symptoms. The evidence for targeted studies on delusions and hallucinations was reviewed. We included randomized controlled trials (RCTs) examining the effect of individualized CBT-based interventions focusing either on delusions or on hallucinations. Twelve suitable RCTs were identified. Four RCTs focused on delusions, of which three took a focused approach targeting mechanisms assumed causal to persecutory delusions. Eight RCTs focused on hallucinations, a common component of these studies being a focus on the perceived power imbalance between the voice(s) and the voice-hearer, to reduce distress and dysfunction. Only three RCTS were powered adequately; the remainder were pilot trials. All trials reported effect sizes against treatment-as-usual above d=0.4 on at least one primary outcome at post-therapy, with several effects in the large range. Effects on the primary outcome were maintained for five of the seven studies that had significant outcomes and reported a follow-up comparison, but most of the follow-up periods were brief. Although targeted studies are still in their infancy, the results are promising with a tendency towards higher effects compared to the small-to-moderate range found for generic CBTp. In clinical practice, CBTp will need to continue including a range of approaches that can be adapted to patients in a flexible manner according to the primary goals and prevalent combination of symptoms. However, symptom-focused and causal-interventionist approaches are informative research strategies to evaluate the efficacy of separate components or mechanisms of generic CBTp.

Substance misuse in patients who have comorbid chronic pain in a clinical population receiving methadone maintenance therapy for the treatment of opioid dependence

AIMS

To compare specific substance misuse in treatment-seeking, opioid-dependent patients with and without comorbid chronic pain, and to assess the respective value of urinalysis and patient reports in assessing substance misuse.

METHODS

Participants comprised a clinical population in a regional NHS Substance Misuse Service in the East of Scotland (N = 521). The Brief Pain Inventory - Short Form was used to assess pain, and the Maudsley Addiction Profile and urinalysis were used to assess substance misuse at study inception. Urinalysis was used to assess substance misuse during the 5-year follow-up period. Data were hosted, linked, anonymized and analyzed within a national Safe Haven.

RESULTS

Compared with opioid-dependent patients with no pain, a significantly higher proportion of treatment-seeking, opioid-dependent patients with chronic pain were engaged in non-medical benzodiazepine use (69% versus 58%; p = 0.016) and illicit cannabinoid use (84% versus 65%; p = 0.025) at study inception. Furthermore, a significantly higher proportion of this group was shown to continue non-medical benzodiazepine use (70% versus 42%; p = 0.037) and illicit cannabinoid use (100% versus 31%; p = 0.002) during the 5-year follow-up period. There were significant correlations between drug screen results and patient-reported use of opioids (Tetrachoric ϱ = 0.4944; p < 0.001), benzodiazepines (Tetrachoric ϱ = 0.2641; p = 0.001) and cannabinoids (Tetrachoric ϱ = 0.8384; p < 0.001).

CONCLUSIONS

Whilst gaining control of illicit opioid use during treatment, opioid-dependent patients with comorbid chronic pain demonstrated persistent problematic use of benzodiazepines and cannabinoids. This pattern of misuse was shown to persist during the 5-year follow-up period.

Extended-release naltrexone (XR-NTX) for opioid use disorder in clinical practice: Vivitrol's Cost and Treatment Outcomes Registry

BACKGROUND AND AIMS

Extended-release naltrexone (XR-NTX), a μ-opioid receptor antagonist for prevention of relapse to opioid dependence, has demonstrated efficacy compared with placebo and comparative effectiveness with buprenorphine-naloxone. We report outcomes for XR-NTX in Vivitrol's Cost and Treatment Outcomes Registry.

DESIGN

Observational, open-label, single-arm, multi-center registry assessing baseline characteristics and clinical and health-related quality-of-life outcomes associated with XR-NTX treatment in clinical practice.

SETTING

32 US treatment centers from 2011 to 2013.

PARTICIPANTS

Patients with opioid dependence who were prescribed XR-NTX treatment and then enrolled into the registry.

MEASUREMENTS

Monthly visits were evaluated for the full population and for patient ubgroups retrospectively, defined by injection number, focusing on the period between baseline and month 6 (1-, 2/3- or 6-XR-NTX).

FINDINGS

Of 403 enrolled patients, 395 were analyzed. Most patients (n = 349) received out-patient care. On average, patients received five injections (median = 3; range = 1-25). The median number of injections administered within 6 months was higher in patients who at baseline were employed (three versus two unemployed, P = 0.02) or had private insurance (five versus two self-payment, P = 0.005; versus two state-funded, P < 0.001). The 1-, 2/3- and 6-XR-NTX groups had 132, 152 and 111 patients, respectively. At baseline, the 6-XR-NTX patients were more likely to meet normal/minimal mental illness criteria and attend school and less likely to report recent drug use. Within 6 months, the 6-XR-NTX group demonstrated improvements in employment, mental health and psychosocial functioning, and decreases in opioid craving, drug use and drug-related behavior.

CONCLUSIONS

Among opioid-dependent people receiving XR-NTX treatment, better mental health, higher education and lower recent drug use at baseline are associated with greater treatment duration; in turn, longer treatment duration is associated with lower relapse rates and improved outcomes generally.

The association between cannabis use and suicidal behavior in patients with psychiatric disorders: an analysis of sex differences

BACKGROUND

Cannabis is the most commonly used illicit drug. In the general population, its use has been linked to a heightened propensity for suicidal behavior (SB). We hypothesize that this association varies in patients with psychiatric disorders. SB is known to vary by sex and therefore an investigation of cannabis' association with SB must consider sex differences. The purpose of this study is to investigate the association between cannabis use and suicide attempts in men and women with psychiatric disorders.

METHODS

We merged data collected for two studies based in Ontario, Canada (n = 985). We employed a multivariable logistic regression to assess the association between cannabis use and suicide attempts in men and women with psychiatric disorders.

RESULTS

We analyzed data from 465 men and 444 women. Amongst these, 112 men and 158 women had attempted suicide. The average age of our participants was 40 years (standard deviation (SD) 12.4). We found no significant association between suicide attempts and cannabis use in men (odds ratio (OR) = 1.34, 95% confidence interval (CI) 0.81, 2.22, p = 0.260) or women (OR = 0.97, 95% CI 0.61, 1.54, p = 0.884). In a sensitivity analysis using a sample of patients with substance use disorder only, the heaviness of cannabis use was associated with small but significant association with SB in men (OR = 1.03, 95% CI 1.01, 1.05, p = 0.007).

CONCLUSION

Our findings indicate that there is no association between cannabis use and suicidal behavior in men or women with psychiatric disorders unlike what was reported for the general population, though the heaviness of cannabis use may have an effect in men. The impact of cannabis use in psychiatric disorders needs ongoing examination in light of its common use, impending legalization with expected increased access and the uncertainty about cannabis' effects on prognosis of psychiatric disorders. In addition, research should continue to investigate modifiable risk factors of SB in this population of which cannabis is not a significant factor based on this study.

Changes in psychological well-being among heroin-dependent adolescents during psychologically supported opiate substitution treatment

AIM

Heroin-dependent adolescents demonstrate high rates of comorbid psychological problems. Among heroin-dependent adults, opiate substitution treatment (OST) programmes appear to reduce mental health problems. We sought to examine the impact of OST on psychological well-being in adolescents, as this is unknown.

METHODS

We conducted a prospective study examining psychological well-being in heroin dependent adolescents, aged 18 years or younger, engaged in outpatient psychologically supported OST. Patients were treated with either methadone or buprenorphine. This was complimented with individual key working, counselling (motivational interviewing and cognitive behavioral therapy) and group work focusing on life skills. The Beck Youth Inventory was used to measure psychological well-being at treatment entry and repeated after 4 months of treatment.

RESULTS

Among 55 consecutive treatment episodes, we examined the 32 episodes where the patient persisted with the OST programme. Polysubstance use was the norm at treatment entry. At follow-up, the median doses of methadone and buprenorphine were 50 mgs and 8 mgs, respectively. Only three patients were treated with antidepressant medication. There was significant improvement in the mean depression (65.0 to 57.9, P = 0.001), anxiety (61.7 to 57.0, P = 0.006) and anger (57.8 to 54.6, P = 0.009) subscale scores. The self-concept and disruptive behaviour subscale scores did not improve significantly.

CONCLUSION

In this relatively short-term follow-up, psychosocially assisted OST appears to be associated with improved psychological well-being in heroin-dependent adolescents, especially in the area of depressive and anxiety symptoms.

Opioid substitution treatment and heroin dependent adolescents: reductions in heroin use and treatment retention over twelve months

BACKGROUND

Opioid dependence is a major health concern across the world and does also occur in adolescents. While opioid substitution treatment (OST) has been thoroughly evaluated in adult populations, very few studies have examined its use in adolescents. There are concerns that OST is underutilised in adolescents with heroin dependence. We sought to measure changes in drug use among adolescents receiving OST and also to examine treatment attrition during the first 12 months of this treatment.

METHODS

We included all heroin dependent patients aged under 18.5 years commencing OST at one outpatient multidisciplinary adolescent addiction treatment service in Dublin, Ireland. Psycho-social needs were also addressed during treatment. Drug use was monitored by twice weekly urine drugs screens (UDS). Change in the proportion of UDS negative for heroin was examined using the Wilcoxon signed rank test. Attrition was explored via a Cox Regression multivariate analysis.

RESULTS

OST was commenced by 120 patients (51% female and mean age 17.3 years). Among the 39 patients who persisted with OST until month 12, heroin abstinence was 21% (95% confidence interval [CI] = 9-36%) at month three and it was 46% (95% CI = 30-63%) at month 12. Heroin use declined significantly from baseline to month three (p < 0.001) and from month three to month 12 (p = 0.01). Use of other drugs did not change significantly. People using cocaine during month 12 were more likely to be also using heroin (p = 0.02). Unplanned exit occurred in 25% patients by 120 days. The independent predictors of attrition were having children, single parent family of origin, not being in an intimate relationship with another heroin user and evidence of cocaine use just before treatment entry.

CONCLUSIONS

We found that heroin dependent adolescent patients achieved significant reductions in heroin use within three months of starting OST and this improved further after a year of treatment, about half being heroin abstinent at that stage. Patient drop out from treatment remains a challenge, as it is in adults. Cocaine use before and during treatment may be a negative prognostic factor.

Augmenting Outpatient Alcohol Treatment as Usual With Online Alcohol Avoidance Training: Protocol for a Double-Blind Randomized Controlled Trial

Background

Recent theoretical models emphasize the role of impulsive processes in alcohol addiction, which can be retrained with computerized Cognitive Bias Modification (CBM) training. In this study, the focus is on action tendencies that are activated relatively automatically.

Objective

The aim of the study is to examine the effectiveness of online CBM Alcohol Avoidance Training using an adapted Approach-Avoidance Task as a supplement to treatment as usual (TAU) in an outpatient treatment setting.

Methods

The effectiveness of 8 online sessions of CBM Alcohol Avoidance Training added to TAU is tested in a double-blind, randomized controlled trial with pre- and postassessments, plus follow-up assessments after 3 and 6 months. Participants are adult patients (age 18 years or over) currently following Web-based or face-to-face TAU to reduce or stop drinking. These patients are randomly assigned to a CBM Alcohol Avoidance or a placebo training. The primary outcome measure is a reduction in alcohol consumption. We hypothesize that TAU + CBM will result in up to a 13-percentage point incremental effect in the number of patients reaching the safe drinking guidelines compared to TAU + placebo CBM. Secondary outcome measures include an improvement in health status and a decrease in depression, anxiety, stress, and possible mediation by the change in approach bias. Finally, patients’ adherence, acceptability, and credibility will be examined.

Results

The trial was funded in 2014 and is currently in the active participant recruitment phase (since May 2015). Enrolment will be completed in 2019. First results are expected to be submitted for publication in 2020.

Conclusions

The main purpose of this study is to increase our knowledge about the added value of online Alcohol Avoidance Training as a supplement to TAU in an outpatient treatment setting. If the added effectiveness of the training is proven, the next step could be to incorporate the intervention into current treatment.

Trial Registration

Netherlands Trial Register NTR5087; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5087 (Archived at WebCite http://www.webcitation.org/6wuS4i1tH)

Use of electronic health records in identifying drug and alcohol misuse among psychiatric in-patients

Aims and method

To assess the usefulness of the electronic patient record, we used the search engine Clinical Record Interactive Search (CRIS) to scan all acute admissions during 2008 for possible substance use disorders. In addition, screening interviews were undertaken with 75 in-patients, and documentation in their files was compared with results of screening interviews.

Results

Of 839 acute admissions during 2008, 47% of males and 29% of females had reference to a substance misuse problem in their file. Documentation was unsystematic and inconsistent and mostly occurred in progress notes rather than in structured questionnaires. Screening interviews and manual review of files of 75 current in-patients confirmed that substance use disorders were common, but poorly documented.

Clinical implications

The study highlights the power of search engines in scanning electronic clinical records, but also identified the limitations of unsystematic documentation in research and practice. Mental health staff were reluctant to diagnose or rate severity of substance misuse problems.

Screening for illicit drug use in psychiatric hospitals: whose job is it?

This review focuses on screening and assessment in general psychiatric settings, where drug use is unlikely to be known to service providers. It builds on the recurrent finding that psychiatric patients are at high risk of substance misuse. The application of self-report questionnaires and rating scales and more in-depth assessment instruments is outlined, as are biological screening techniques. The use of brief self-completion questionnaires probably offers the most practical approach to routine screening by non-specialist staff in general hospital settings. The importance of implementing such tools lies in reaching an accurate diagnosis, choosing treatments more appropriately and monitoring the management of patients' psychiatric disorders.

Criminally invalid: the treatment outcome profile form for substance misuse

Aims and Method

To audit completion of the Treatment Outcome Profile (TOP) form in individuals attending substance misuse services in England. Forms are completed at the start of treatment and every 3 months thereafter. All forms at 3-drug treatment services were inspected over 6 months.

Results

Forms were inspected for 200 service users; 86% were fully completed. Two-thirds (67%) of service users had no declared funding for illicit drug use in the previous month (mean spending £988; s.e. = 149) despite denying any paid employment and criminal activity.

Clinical Implications

The section on crime in the TOP form is unreliable and completely invalid.

Validation and development of a self-report outcome measure (MAP-sc) in opiate addiction

Aims and Method

To develop and assess the viability of a self-completion version of the Maudsley Addiction Profile for assessing and monitoring the functioning of opioid-dependent patients. A total of 206 treatment-seeking opioid-dependent patients completed the Maudsley Addiction Profile interview and a self-completion version at a single clinic appointment at a substance misuse facility. Scores from both formats were compared using correlation coefficients.

Results

Non-parametric correlation coefficients between interview and self-completion version for alcohol, drug, psychiatric, family and legal problems correlated in excess of 0.7 for the majority of the 20 items that were compared.

Clinical Implications

A short, self-administered questionnaire version of the Maudsley Addiction Profile is a feasible alternative to the interview for assessing and monitoring treatment of opioid-dependent patients. The questionnaires were usually completed by clients within 15 min. These would be particularly useful in services with very limited staffing time, such as primary care.

Setting up a methadone maintenance clinic in a hostel in London's West End

Aims and Method

A satellite methadone prescribing service was set up in a hostel in London's West End. The aim was to investigate if it were feasible to engage and retain these hard-to-reach, chaotic, polydrug users in treatment. A basic needs assessment was undertaken with staff and clients at the hostel. Treatment outcomes were assessed at 16 weeks using the Maudsley Addiction Profile.

Results

At 16 weeks 87% of the original cohort (26 out of 30) were still in treatment. There were also significant reductions in mean heroin use (from 29.7 to 14.5 out of the past 30 days, P<0.001) and in the frequency of injecting (from 25.9 to 15.9 days, P<0.001).

Clinical Implications

This outreach clinic offers a model for developing services to homeless people with substance misuse problems.

Treatment preferences of opiate-dependent patients

Aims and Method

To assess the preferences of people attending a substance misuse facility towards the treatment options available for opiate dependency. Interviews were conducted using a card sorting technique.

Results

The majority (60%) of the 101 participants believed that detoxification was superior to maintenance in preventing illicit heroin use. The preferred treatment options were oral methadone, buprenorphine, drug-free rehabilitation, in-patient detoxification and prescription of injectable drugs.

Clinical Implications

Both pharmacological and psychosocial options, including in-patient detoxification and rehabilitation, are among the treatments preferred by clients of substance misuse services. There is also a significant demand for both injectable drugs and dihydrocodeine.

Validation of the Social Satisfaction Questionnaire for outcome evaluation in substance use disorders

Aims and Method

To develop a scale to measure social satisfaction in people with substance use disorders and to test its psychometric properties. The rationale is that social satisfaction is more universal and relevant to treatment planning than assessing social problems. The new Social Satisfaction Questionnaire (SSQ) was derived from an existing social problems questionnaire and validation was undertaken on two large clinic populations.

Results

An eight-item SSQ was tested and found to have good psychometric properties in terms of test–retest reliability, internal consistency, distribution of responses and concurrent validity.

Clinical Implications

The SSQ is suitable for use as the social domain element of an outcome measures package.

AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial

BACKGROUND

A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy. We aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition.

METHODS

We did this single-blind, randomised controlled trial at a single clinical location (South London and Maudsley NHS Trust). Participants were aged 18 to 65 years, had a clinical diagnosis of a schizophrenia spectrum (ICD10 F20-29) or affective disorder (F30-39 with psychotic symptoms), and had enduring auditory verbal hallucinations during the previous 12 months, despite continued treatment. Participants were randomly assigned (1:1) to receive AVATAR therapy or supportive counselling with randomised permuted blocks (block size randomly varying between two and six). Assessments were done at baseline, 12 weeks, and 24 weeks, by research assessors who were masked to therapy allocation. The primary outcome was reduction in auditory verbal hallucinations at 12 weeks, measured by total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations (PSYRATS-AH). Analysis was by intention-to-treat with linear mixed models. The trial was prospectively registered with the ISRCTN registry, number 65314790.

FINDINGS

Between Nov 1, 2013, and Jan 28, 2016, 394 people were referred to the study, of whom 369 were assessed for eligibility. Of these people, 150 were eligible and were randomly assigned to receive either AVATAR therapy (n=75) or supportive counselling (n=75). 124 (83%) met the primary outcome. The reduction in PSYRATS-AH total score at 12 weeks was significantly greater for AVATAR therapy than for supportive counselling (mean difference -3·82 [SE 1·47], 95% CI -6·70 to -0·94; p<0·0093). There was no evidence of any adverse events attributable to either therapy.

INTERPRETATION

To our knowledge, this is the first powered, randomised controlled trial of AVATAR therapy. This brief, targeted therapy was more effective after 12 weeks of treatment than was supportive counselling in reducing the severity of persistent auditory verbal hallucinations, with a large effect size. Future multi-centre studies are needed to establish the effectiveness of AVATAR therapy and, if proven effective, we think it should become an option in the psychological treatment of auditory verbal hallucinations.

FUNDING

Wellcome Trust.

Is the Danish Version of MATE Feasible? A Pilot Study on Feasibility and Adequacy

OBJECTIVE

Assessment is pivotal to the work of health care professionals and social workers, as it provides fundamental, systematic information that is essential when planning interventions. Many patients have addiction problems as well as psychiatric illness and they very often interact. An assessment tool addressing both areas would be beneficial for this large group of patients. This pilot study explores feasibility and adequacy of the Danish translation of the Measurements in Addiction for Triage and Evaluation (MATE) assessment in the following sectors: drug and alcohol treatment, psychiatry, and social service.

METHODS

Thirty staff members from psychiatric hospital, social services, and treatment institutions for alcohol and substance abuse were recruited. Staff that had direct contact with clients were planned to perform at least two MATE interviews.

RESULTS

Nineteen interviews were completed. Information gathered from MATE was reported to be adequate for making a triage decision, but psychiatric staff reported that MATE gathered too much irrelevant information, especially concerning daily life functioning. Overall feasibility was satisfactory, but staff and patients were at some points critical of wording, casting doubt on the understanding of some questions.

CONCLUSIONS

This pilot study found that MATE gathers relevant and sufficient information in an appropriate amount of time.

Coping with Unusual ExperienceS for 12-18 year olds (CUES+): a transdiagnostic randomised controlled trial of the effectiveness of cognitive therapy in reducing distress associated with unusual experiences in adolescent mental health services: study protocol for a randomised controlled trial

BACKGROUND

Childhood 'unusual experiences' (such as hearing voices that others cannot, or suspicions of being followed) are common, but can become more distressing during adolescence, especially for young people in contact with Child and Adolescent Mental Health Services (CAMHS). Unusual experiences that are distressing or have adverse life impact (UEDs) are associated with a range of current and future emotional, behavioural and mental health difficulties. Recommendations for psychological intervention are based on evidence from adult studies, with some support from small, pilot, child-specific evaluations. Research is needed to ensure that the recommendations suit children as well as adults. The CUES+ study (Coping with Unusual ExperienceS for 12-18 year olds) aims to find out whether cognitive behaviour therapy for UEDs (CBT-UED) is a helpful and cost-effective addition to usual community care for 12-18 year olds presenting to United Kingdom National Health Service Child and Adolescent Mental Health Services in four London boroughs.

METHODS

The CUES+ study is a randomised controlled trial comparing CBT-UED plus routine care to routine care alone. CBT-UED comprises up to 16 sessions, including up to 12 individual and up to four family support meetings, each lasting around 45-60 min, delivered weekly. The primary outcome is emotional distress. Secondary outcomes are change in UEDs, risk events (self-harm, attendance at emergency services, other adverse events) and health economic outcomes. Participants will be randomised in a 1:1 ratio after baseline assessment. Randomisation will be stratified by borough and by severity of mental health presentation: 'severe' (an identified psychotic or bipolar disorder) or any 'other' condition. Outcomes will be assessed by a trained assessor blind to treatment condition at 0, 16 and 24 weeks. Recruitment began in February, 2015 and is ongoing until the end of March, 2017.

DISCUSSION

The CUES+ study will contribute to the currently limited child-specific evidence base for psychological interventions for UEDs occurring in the context of psychosis or any other mental health presentation.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials, ID: ISRCTN21802136 . Prospectively registered on 12 January 2015. Protocol V3 31 August 2015 with screening amended.

Does outcome measurement of treatment for substance use disorder reflect the personal concerns of patients? A scoping review of measures recommended in Europe

There are a growing number of authors stating that outcome measurement in treatment for substance use disorders should go beyond substance use and include other bio-psycho-social variables of interest. However, little is known about which topics tend to be covered by outcome measures and whether they reflect the typical concerns of this patient group. This study followed a scoping review methodology in which 42 outcome measures recommended by an EU agency for substance use disorders were reviewed. We identified the domains of problems covered by these 42 measures and then compared them with 54 domains derived from patients, in a previous study. We also explored how similar the existing measures were in terms of domains covered, and which patient derived domains tended to be represented in those measures. We identified 31domains of problems across the 42 measures, with 'substance use' and 'psychological health' among the commonest. Most measures were similar in content to each other and multidimensional. Almost all domains of problems identified in the outcome measures corresponded to concerns reported by patients. On the other hand, we found that several topics of relevance for patients were not covered by any of the measure included in our study. This suggests that existing outcome measurement does not always target aspects that affect patients' lives, as reported directly by patients. Our study shows that outcome measurement needs to adopt a more flexible and comprehensive approach, by taking on board the problems experienced by patients in this population.

Men's and women's response to treatment and perceptions of outcomes in a randomized controlled trial of injectable opioid assisted treatment for severe opioid use disorder

Background

To test whether there are gender differences in treatment outcomes among patients receiving injectable opioids for the treatment of long-term opioid-dependence. The study additionally explores whether men and women have different perceptions of treatment effectiveness.

Methods

This study is a secondary analysis from SALOME, a double-blind, phase III, randomized controlled trial testing the non-inferiorirty of injectable hydromorphone to injectable diacetylmorphine among 202 long-term street opioid injectors in Vancouver (Canada). Given this was a secondary analysis, no a priori power calaculation was conducted. Differences in baseline characteristics and six-month treatment outcomes (illicit heroin use, opioid use, crack cocaine use, non-legal activities, physical and psychological health scores, urine positive for street heroin markers, and retention) were analysed by gender using fitted models. Responses to an open ended question on reasons for treatment effectiveness were explored with a thematic analysis.

Results

Men and women differed significantly on a number of characteristics at baseline. For example, women were significantly younger, presented to treatment with significantly higher rates of prior month sex work (31.5% vs. 0%), and used significantly more crack cocaine (14.71 vs. 8.38 days). After six-months of treatment there were no significant differences in treatment outcomes by gender, after adjusting for baseline values. For both men and women, improved health and quality of life were the most common reasons provided for treatment effectiveness, however women were more specific in the types of health improvements.

Conclusions

Despite presenting to treatment with vulnerabilities not faced to the same extent by men, at six-months women did not differ significantly from men in tested trial efficacy outcomes. While the primary outcome in the trial was the reduction of illicit opioid use, in the open-ended responses both men and women focused their comments on improvement in health and quality of life as reasons for treatment effectiveness. The supervised model of care with injectable medications provides a particularly suitable framework for providing care to opioid-dependent men and women not attracted or retained by other treatments. The absence of statistical differences reported in this secondary analysis may be due to lack of adequate statistical power to detect meaningful effects.

Trial registration

This trial is registered with ClinicalTrials.gov (NCT01447212) Registered: October 4, 2011 at the following link: https://clinicaltrials.gov/ct2/show/NCT01447212.

Reliability and validity of the Treatment Outcome Profile among patients attending methadone maintenance treatment programs in Kunming, China

BACKGROUND & OBJECTIVE

Substance misuse has been a major health and social issue worldwide and has become an important public health issue in China over the past two decades. Methadone maintenance treatment (MMT) has been proved worldwide by large bodies of research to be one of the most effective practices for illicit drug users. The Treatment Outcome Profile (TOP) was developed in 2007 by the UK National Treatment Agency (NTA). It has been proved to be a reliable instrument for outcome measure. This study aim to develop the Chinese version of the Treatment Outcome Profile (TOP), and to assess whether TOP is a reliable outcome measure that can be recommended for use in Chinese MMT program.

METHODS

The Chinese version of TOP was translated and revised based on the English version of TOP. Psychometric properties of TOP were evaluated through face-to-face interviews in 197 patients who had been attending methadone maintenance treatment clinics in Kunming city, Yunnan Institute for Drug Abuse, for less than three months. Patients were interviewed by 3 trained interviewers. Reliability and validity of the instrument were analyzed by measures including test-retest and inter-rater reliability, concurrent validity and change sensitivity. Concurrent validity was assessed by comparing the scores from TOP with scores obtained from validated clinometric instruments. Self-reported opiate use was compared with results of urine analysis. Change sensitivity was judged by t-tests and chi-square tests.

RESULTS & CONCLUSIONS

About 67% of the 197 interviewers were male and 33% were female. Test-retest reliability of TOP scores (after 10 days interval) were good (K=0.65 to 0.95), inter-rater correlations (ICC) ranged from 0.7 to 0.9, and the criterion validity ranged from 0.72 to 0.88. TOP covers a large scope of problems encountered by drug users needed for treatment. The Chinese version of TOP is a reliable and valid assessment tool.

Emotional Processing in Individuals with Substance Use Disorder and Posttraumatic Stress Disorder

Previous research has shown that individuals with substance use disorder (SUD) and posttraumatic stress disorder (PTSD) have emotional processing difficulties. However, no studies have specifically investigated the role of emotional processing in those with co-morbid SUD-PTSD. This study investigated whether there are more emotional processing abnormalities among patients with SUD-PTSD, than those with either a single diagnosis of PTSD or SUD. Emotional processing was assessed in three groups [1) SUD (without PTSD); 2) PTSD (without SUD); and 3) co-morbid SUD-PTSD] using the Emotional Processing Scale (EPS-25) and the International Affective Picture System (IAPS). Each of the three groups reported evidence of emotional processing dysfunction relative to the normal population. Within the SUD-PTSD group there was significant evidence that the additional impact of trauma increased emotional processing dysfunction but less evidence to suggest that substance use increased emotional processing dysfunction further. These findings call into question current United Kingdom guidelines for the treatment of co-morbid SUD-PTSD, which recommend that the drug or alcohol problem should be treated first.

Treatment dropout in web-based cognitive behavioral therapy for patients with eating disorders

Treatment dropout is an important concern in eating disorder treatments as it has negative implications for patients' outcome, clinicians' motivation, and research studies. Our main objective was to conduct an exploratory study on treatment dropout in a two-part web-based cognitive behavioral therapy with asynchronous therapeutic support. The analysis included 205 female patients with eating disorders. Reasons for dropout, treatment experiences, and predictors of dropout were analyzed. Overall treatment dropout was 37.6%, with 18.5% early dropout (before or during treatment part 1) and 19.0% late dropout (after part 1 or during part 2). Almost half of the participants identified personal circumstances as reason for dropout. The other participants mostly reported reasons related to the online delivery or treatment protocol. Predictors of early dropout included reporting less vigor and smoking at baseline and a longer average duration per completed treatment module of part 1. Late dropout was predicted by reporting less vigor at baseline and uncertainty about recommendation of the treatment to others after completion of treatment part 1. Generally, the web-based treatment and online therapeutic support were evaluated positively, although dropouts rated the treatment as significantly less helpful and effective than completers did.

The Impact of Sex Upon Needs and Quality of Life Within a Population on Methadone Treatment

BACKGROUND

Best practice models are calling for a holistic, needs-led, and sex-informed treatment approach to substance misuse treatment. To date, research into the impact of sex on needs and quality of life within methadone-treatment populations using validated research tools is limited.

OBJECTIVES

The aim of the study was to evaluate the impact of sex upon self-rated unmet need and quality of life among people on methadone treatment.

METHODS

Cross-sectional survey of adults attending a specialist methadone treatment clinic, in Dublin, Ireland. Participants completed the Camberwell Assessment of Need Short Appraisal Schedule, Patient Version and the WHO Quality of Life-Brief Version. Ongoing drug use was determined using the Maudsley Addiction Profile and weekly supervised urine toxicology screens. A linear regression analysis was conducted.

RESULTS

One hundred eight of 190 eligible service-users (57%) participated. No significant differences existed between the participants and the nonparticipants on demographic variables or measures of drug use. Among them, 33% were women. Women demonstrated lower levels of ongoing opiate use. Linear regression analysis indicated that women had a greater number of unmet needs (P = 0.02) and lower quality of life in the domains of physical health (P = 0.003), psychological well being (P < 0.001), environmental well being (P = 0.03), and social relationships (P = 0.007). When the Bonferroni adjustment was applied to account for multiple testing, the relationship between psychological well being and female sex remained statistically significant.

CONCLUSIONS

Our study suggests that female sex may be associated with greater self-rated needs and poorer quality of life within a methadone-treated population, in particular, in the domain of psychological well being. Further research in this area is warranted to discover if these findings can be replicated and confirmed in larger samples.

Parenthood, Child Care, and Heroin Use: Outcomes After Three Years

BACKGROUND

Internationally there is a lack of measurement on the impact of childcare on people who use drugs.

OBJECTIVES

The aim of this article was to longitudinally measure drug use, familial and social status and criminal involvement between parents and nonparents who use heroin and have children in their care.

METHODS

From 2003 to 2006, 404 participants were recruited to the Research Outcome Study in Ireland Evaluating Drug Treatment Effectiveness (ROSIE) as part of a longitudinal cohort study design. Participants completed the Maudsley Addiction Profile and 88% (n = 356) completed interviews at the 3-year period. One way between groups ANOVA with post hoc tests and backward, stepwise multiple regression were employed for analysis.

RESULTS

At follow-up, parents who had children in their care used heroin (p = .004), illicit methadone (p ≤ .001) and cocaine (p = .024) on fewer days than those who had no children, or those who had children but did not have children in their care. These differences were not observed at intake. Living with someone at intake who used drugs was found to be significantly associated with increased heroin (p ≤ .001), benzodiazepine (p = .039), and tobacco (p = .030) use at 3 years. Furthermore, a change in childcare status to caring for a child was associated with increased cannabis use (p = .025). Conclusion/Importance: While caring for children was associated with reduced heroin use at 3 years, living with a person who used at intake removed this effect, thus indicating that while individual based addiction theories reflected observed outcomes, social network connectedness was more influential.

Multifaceted impairments in impulsivity and brain structural abnormalities in opioid dependence and abstinence

BACKGROUND

Chronic opioid exposure, as a treatment for a variety of disorders or as drug of misuse, is common worldwide, but behavioural and brain abnormalities remain under-investigated. Only a small percentage of patients who receive methadone maintenance treatment (MMT) for previous heroin misuse eventually achieve abstinence and studies on such patients are rare.

METHOD

The Cambridge Neuropsychological Test Automated Battery and T1 weighted magnetic resonance imaging (MRI) were used to study a cohort of 122 male individuals: a clinically stable opioid-dependent patient group receiving MMT (n = 48), an abstinent previously MMT maintained group (ABS) (n = 24) and healthy controls (n = 50).

RESULTS

Stable MMT participants deliberated longer and placed higher bets earlier in the Cambridge Gambling Task (CGT) and showed impaired strategic planning compared with healthy controls. In contrast, ABS participants showed impairment in choosing the least likely outcome, delay aversion and risk adjustment on the CGT, and exhibited non-planning impulsivity compared with controls. MMT patients had widespread grey matter reductions in the orbitomedial prefrontal cortex, caudate, putamen and globus pallidus. In contrast, ABS participants showed midbrain-thalamic grey matter reductions. A higher methadone dose at the time of scanning was associated with a smaller globus pallidus in the MMT group.

CONCLUSIONS

Our findings support an interpretation of heightened impulsivity in patients receiving MMT. Widespread structural brain abnormalities in the MMT group and reduced brain structural abnormality with abstinence suggest benefit of cessation of methadone intake. We suggest that a longitudinal study is required to determine whether abstinence improves abnormalities, or patients who achieve abstinence have reduced abnormalities before methadone cessation.

Measuring outcomes for TC clients: Higher Ground Drug Rehabilitation Trust

Purpose

The purpose of this paper is to analyse the clinical outcome data collected as part of an 18-week, abstinence-based residential therapeutic community (TC) programme, Higher Ground Drug Rehabilitation Trust (Higher Ground) in New Zealand. Lessons and implications for routine collection of clinical outcome data are identified.

Design/methodology/approach

Higher Ground collects longitudinal data on all consenting clients using a battery of validated psychometric tools, with repeated measures at up to nine points in time from first presentation through to 12-month post-discharge follow up. Data analysis covered clients who entered Higher Ground between 1 July 2012 and 2 June 2015 (n=524).

Findings

Clients presented with histories of addiction which often had significant negative associations with their physical and psychological health, their relationships, work, accommodation and criminal behaviour. By the time they exited the programme, clinically and statistically significant improvements were seen across multiple indicators including: substance use and abstinence; symptoms of post-traumatic stress disorder, depression, anxiety and stress; and a range of social indicators.

Research limitations/implications

Attrition in follow-up research is a significant challenge, with people completing the TC programme being more likely to participate than those who do not. This limits generalizability in post-discharge data. There was no control group, making causal attribution a challenge. Identifying suitable benchmarks from the literature is challenging because of the variety of outcome measures and research methodologies used.

Practical implications

Tracking client outcomes longitudinally using psychometric tools is potentially valuable for TCs and their funding bodies, as it provides insights into patterns of client recovery that can inform ongoing service improvements and resource allocation decisions. However, significant challenges remain.

Originality/value

The study demonstrates the value, and practical challenges, of collecting high-quality outcome data in a TC setting.

From Salt Injection to Naloxone: Accuracy and Myths in Peer Resuscitation Methods for Opiate Overdose

One hundred and eight opiate addicts attending an in-patient opiate treatment unit were interviewed, using a mixed quantitative–qualitative approach, to investigate their experiences of witnessing overdoses, the associated interpretations and perceived cause of the overdose. Poly drug use and frequency of witnessed overdose was high among the sample. Use of 14 different combinations of drugs were reported, 8 of which involved the use of alcohol, and 7 benzodiazepines. Perceived cause of overdose involved attributions relating to the use of alcohol, in particular strong lager, small quantities of heroin and low levels of current opiate tolerance. Peer initiated resuscitation techniques revealed a range of responses from the probably valuable (recovery position, summon ambulance, administer naloxone) to the ineffective or frankly harmful (injecting with salt solution, immersing in a cold bath). The findings highlight the need for an overdose prevention program during in-patient detoxification and rehabilitation.

DEVELOPMENT AND VALIDATION OF 'SURE': A PATIENT REPORTED OUTCOME MEASURE (PROM) FOR RECOVERY FROM DRUG AND ALCOHOL DEPENDENCE

BACKGROUND

Patient Reported Outcome Measures (PROMs) assess health status and health-related quality of life from the patient/service user perspective. Our study aimed to: i. develop a PROM for recovery from drug and alcohol dependence that has good face and content validity, acceptability and usability for people in recovery; ii. evaluate the psychometric properties and factorial structure of the new PROM ('SURE').

METHODS

Item development included Delphi groups, focus groups, and service user feedback on draft versions of the new measure. A 30-item beta version was completed by 575 service users (461 in person [IP] and 114 online [OL]). Analyses comprised rating scale evaluation, assessment of psychometric properties, factorial structure, and differential item functioning.

RESULTS

The beta measure had good face and content validity. Nine items were removed due to low stability, low factor loading, low construct validity or high complexity. The remaining 21 items were re-scaled (Rasch model analyses). Exploratory and confirmatory factor analyses revealed 5 factors: substance use, material resources, outlook on life, self-care, and relationships. The MIMIC model indicated 95% metric invariance across the IP and OL samples, and 100% metric invariance for gender. Internal consistency and test-retest reliability were granted. The 5 factors correlated positively with the corresponding WHOQOL-BREF and ARC subscales and score differences between participant sub-groups confirmed discriminative validity.

CONCLUSION

'SURE' is a psychometrically valid, quick and easy-to-complete outcome measure, developed with unprecedented input from people in recovery. It can be used alongside, or instead of, existing outcome tools.

Food Insecurity among Homeless Adults with Mental Illness

Background

The prevalence of food insecurity and food insufficiency is high among homeless people. We investigated the prevalence and correlates of food insecurity among a cohort of homeless adults with mental illness in Vancouver, British Columbia, Canada.

Methods

Data collected from baseline questionnaires in the Vancouver At Home study were analysed to calculate the prevalence of food insecurity within the sample (n = 421). A modified version of the U.S. Department of Agriculture’s Adult Food Security Survey Module was used to ascertain food insecurity. Univariable and multivariable logistic regression were used to examine potential correlates of food insecurity.

Results

The prevalence of food insecurity was 64%. In the multivariable model, food insecurity was significantly associated with age (adjusted odds ratio [aOR] = 0.97; 95% CI: 0.95–0.99), less than high school completion (aOR = 0.57; 95% CI: 0.35–0.93), needing health care but not receiving it (aOR = 1.65; 95% CI: 1.00–2.72), subjective mental health (aOR = 0.97; 95% CI: 0.96–0.99), having spent over $500 for drugs and alcohol in the past month (aOR = 2.25; 95% CI: 1.16–4.36), HIV/AIDS (aOR = 4.20; 95% CI: 1.36–12.96), heart disease (aOR = 0.39; 95% CI: 0.16–0.97) and having gone to a drop-in centre, community meal centre or program/food bank (aOR = 1.65; 95% CI: 1.01–2.68).

Conclusions

The prevalence of food insecurity was extremely high in a cohort with longstanding homelessness and serious mental illness. Younger age, needing health care but not receiving it, poorer subjective mental health, having spent over $500 for drugs and alcohol in the past month, HIV/AIDS and having gone to a drop-in centre, community meal centre or program/food bank each increased odds of food insecurity, while less than high school completion and heart disease each decreased odds of food insecurity. Interventions to reduce food insecurity in this population are urgently needed.

Efficacy of cocaine contingency management in heroin-assisted treatment: Results of a randomized controlled trial

AIMS

To determine the efficacy of contingency management (CM), targeting cocaine use, as an add-on intervention for heroin dependent patients in supervised heroin-assisted treatment (HAT) with frequent cocaine use.

DESIGN

Multi-center, open-label, parallel group, randomized controlled trial.

SETTING

Twelve specialized addiction treatment centers for HAT in The Netherlands; April 2006-January 2011.

PARTICIPANTS

214 chronic, treatment-refractory heroin dependent patients in HAT, with frequent cocaine use.

INTERVENTIONS

Routine, daily supervised diacetylmorphine treatment, co-prescribed with oral methadone (HAT), with and without 6 months contingency management for cocaine use as an add-on intervention; HAT+CM and HAT-only, respectively.

MEASUREMENTS

Primary outcome was the longest, uninterrupted duration of cocaine abstinence, based upon laboratory urinalysis. Secondary outcome measures included other cocaine-related measures, treatment retention in HAT, and multi-domain health-related treatment response.

FINDINGS

In an intention-to-treat analysis, HAT+CM was more effective than HAT-only in promoting longer, uninterrupted duration of cocaine abstinence (3.7 weeks versus 1.6 weeks; negative binomial regression: Exp(B)=2.34, 95%-CI: 1.70-3.23; p<0.001). This result remained significant in sensitivity analyses and was supported by all secondary, cocaine-related outcome measures. Treatment retention in HAT was high (91.6%) with no difference between the groups. The improvement in multi-domain health-related treatment response during the trial was numerically higher in HAT+CM (from 37.4% to 53.1%; +15.7%) than in HAT-only (from 44.5% to 46.5%; +2.0%), but this difference was statistically not significant.

CONCLUSIONS

Contingency management is an effective add-on intervention to promote longer, uninterrupted periods of cocaine abstinence in chronic, treatment-refractory heroin dependent patients in heroin-assisted treatment with frequent cocaine use. The trial has been registered in The Netherlands National Trial Register under clinical trial registration number NTR4728.

Sustained-release dexamfetamine in the treatment of chronic cocaine-dependent patients on heroin-assisted treatment: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Heroin-assisted treatment is effective for methadone treatment-refractory heroin-dependent patients, but continued comorbid cocaine dependence remains problematic. Sustained-release dexamfetamine is a promising agonist pharmacotherapy for cocaine dependence and we aimed to assess its acceptance, efficacy, and safety.

METHODS

In this multicentre, randomised, double-blind, placebo-controlled trial, patients who were treatment-refractory, as indicated by at least two earlier failed treatments aimed at reducing or abstaining from cocaine use, and who regularly (≥8 days/month) used crack-cocaine were enrolled from four heroin-assisted treatment centres in the Netherlands. Eligible patients were randomly assigned (1:1) to receive either 12 weeks of daily, supervised prescription of 60 mg/day oral sustained-release dexamfetamine or placebo in addition to co-prescribed methadone and diacetylmorphine. Randomisation was done by the collaborating pharmacist, using a computer-generated random number sequence with stratification by treatment centre in blocks of four per stratum. Randomisation was masked to patients, staff, and researchers throughout the study. The primary outcome was the number of self-reported days of cocaine use during study treatment, assessed every 4 weeks. Primary and safety analyses were done in the intention-to-treat population. The study was registered with the European Union Drug Regulating Authorities Clinical Trials (EUdraCT 2013-004024-11) and with The Netherlands Trial Register (NTR2576).

FINDINGS

Between Aug 8, 2014, and Feb 27, 2015, 111 patients were assessed for eligibility, of whom 73 were enrolled and randomised; 38 patients were assigned to the sustained-release dexamfetamine group and 35 to the placebo group. Sustained-release dexamfetamine treatment resulted in significantly fewer days of cocaine use than placebo treatment (mean 44·9 days [SD 29·4] vs 60·6 days [24·3], respectively [95% CI of difference 3·1-28·4]; p=0·031; Cohen's standardised effect size d=0·58). One or more adverse events were reported by 28 (74%) patients in the dexamfetamine group and by 16 (46%) patients in the placebo group. Most adverse events were transient and well-tolerated.

INTERPRETATION

Sustained-release dexamfetamine is a well accepted, effective, and safe agonist pharmacotherapy for comorbid treatment-refractory cocaine dependence in heroin-dependent patients in heroin-assisted treatment. Future research should aim to replicate these findings in chronic cocaine-dependent and other stimulant-dependent patients in more routine treatment settings, including strategies to optimise treatment adherence like medication management interventions and contingency management.

FUNDING

Netherlands Organisation for Health Research and Development.

A 9-month follow-up of a 3-month web-based alcohol treatment program using intensive asynchronous therapeutic support

BACKGROUND

Web-based alcohol interventions have demonstrated efficacy in randomized controlled trials. However, most studies have involved self-help interventions without therapeutic support.

OBJECTIVES

To examine the results of a 3-month web-based alcohol treatment program using intensive, asynchronous (non-simultaneous) therapeutic support ( www.alcoholdebaas.nl ) at 9-month follow-up assessment.

METHODS

This study reports the follow-up results of 144 problem drinking participants who received a web-based alcohol treatment program. We investigated whether the intervention effects at treatment completion (3 months) continued to exist at 6 and 9 months of follow-up. The primary outcome measure was weekly alcohol consumption. Repeated measures analysis with a mixed model approach was used to address loss to follow-up.

RESULTS

Weekly alcohol consumption significantly improved between baseline and 9 months (F(1,74) = 85.6, p < 0.001). Post-hoc tests revealed that the reduction occurred during the first 3 months (from 39.9-11.4 standard units a week). Although alcohol consumption had risen to 19.5 units per week at 9 months, it still decreased by more than 20 units compared to baseline drinking. Significant improvements with medium to large effect sizes were found on the secondary outcomes (depression, general health, and quality of life) at 9 months.

CONCLUSION

The web-based alcohol treatment with intensive asynchronous therapeutic support has been shown to be effective in reducing alcohol consumption and improving health status at post treatment assessments. The present study showed that most of these improvements were sustained after 9 months. Despite the lack of a control group and the high dropout rate, our findings suggest that web-based treatment can achieve relevant health gains in the long term.