51
|
Ruhm CJ. Drivers of the fatal drug epidemic. JOURNAL OF HEALTH ECONOMICS 2019; 64:25-42. [PMID: 30784811 DOI: 10.1016/j.jhealeco.2019.01.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 12/23/2018] [Accepted: 01/09/2019] [Indexed: 05/06/2023]
Abstract
This study examines the contributions of the medium-run evolution of local economies and of changes in the "drug environment' in explaining county-level changes in drug and related mortality rates from 1999 to 2015. A primary finding is that drug mortality rates did increase more in counties experiencing relative economic decline than in those with more robust growth, but that the relationship is weak and mostly accounted for by confounding factors. In the preferred estimates, less than one-tenth of the rise in drug and opioid-involved fatality rates is explained and the contribution is even smaller, quite possibly zero, when allowing for plausible selection on unobservables. Conversely, the risk of drug deaths varies systematically over time across population subgroups in ways that are consistent with an important role for the public health environment related to the availability and cost of drugs. In particular, the relative risk and share of drug mortality increased rapidly for males and younger adults, compared to their counterparts, when the primary driver of the fatal drug epidemic transitioned from prescription to illicit opioids. These results suggest that efforts to improve local economies, while desirable for other reasons, are not likely to yield significant reductions in overdose mortality, but with greater potential for interventions directly addressing the drug environment.
Collapse
Affiliation(s)
- Christopher J Ruhm
- Frank Batten School of Leadership & Public Policy, University of Virginia, 235 McCormick Road, P.O. Box 400893, Charlottesville, VA, 22904-4893, United States.
| |
Collapse
|
52
|
Reddon H, Marshall BDL, Milloy MJ. Elimination of HIV transmission through novel and established prevention strategies among people who inject drugs. Lancet HIV 2018; 6:e128-e136. [PMID: 30558843 DOI: 10.1016/s2352-3018(18)30292-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/01/2018] [Accepted: 10/12/2018] [Indexed: 11/16/2022]
Abstract
Despite the effectiveness of existing HIV prevention strategies for people who inject drugs (PWID), uncontrolled outbreaks of HIV among this group are common and occur around the world. In this Review, we summarise recent evidence for novel and established HIV prevention approaches to eliminate HIV transmission among PWID. Effective HIV prevention strategies include mobile needle and syringe programmes, pre-exposure prophylaxis, supervised injection facilities, and, to a lesser extent, some behavioural interventions. Studies have also shown the cost-effectiveness of long-standing HIV prevention strategies including needle and syringe programmes, opioid agonist therapy, and antiretroviral therapy for prevention. Although each individual intervention can reduce the risk of HIV acquisition among PWID, there is a consensus that a combination of approaches is required to achieve substantial and durable reductions in HIV transmission. Unfortunately, in many settings, the implementation of these interventions is often limited by public and political opposition that manifests as structural barriers to HIV prevention, such as the criminalisation of drug use. Given that there is ample evidence showing the effectiveness of several HIV prevention methods, social and political advocacy will be needed to overcome these barriers and integrate innovative HIV prevention approaches with addiction science to create effective drug policies.
Collapse
Affiliation(s)
- Hudson Reddon
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Canadian Institutes of Health Research, Canadian HIV Trials Network, Vancouver, BC, Canada
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - M-J Milloy
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, St Paul's Hospital, Vancouver, BC, Canada.
| |
Collapse
|
53
|
Bruce RD. Opioid addiction, opioid addiction treatment, and HIV infection. TOPICS IN ANTIVIRAL MEDICINE 2018; 26:89-92. [PMID: 30384332 PMCID: PMC6291298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Available data indicate that opioid substitution treatment can successfully reduce rates of HIV transmission and that patients receiving such treatment can adhere to therapies for HIV, hepatitis C, and tuberculosis infection. Integration of opioid substitution treatment into the HIV clinic setting can make such treatment easier and improve retention in treatment. This article summarizes a presentation by R. Douglas Bruce, MD, MA, MS, at the IAS-USA continuing education program held in Chicago, Illinois, in May 2018.
Collapse
|
54
|
Gonek M, McLane VD, Stevens DL, Lippold K, Akbarali HI, Knapp PE, Dewey WL, Hauser KF, Paris JJ. CCR5 mediates HIV-1 Tat-induced neuroinflammation and influences morphine tolerance, dependence, and reward. Brain Behav Immun 2018; 69:124-138. [PMID: 29146238 PMCID: PMC5857418 DOI: 10.1016/j.bbi.2017.11.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/02/2017] [Accepted: 11/07/2017] [Indexed: 12/16/2022] Open
Abstract
The HIV-1 regulatory protein, trans-activator of transcription (Tat), interacts with opioids to potentiate neuroinflammation and neurodegeneration within the CNS. These effects may involve the C-C chemokine receptor type 5 (CCR5); however, the behavioral contribution of CCR5 on Tat/opioid interactions is not known. Using a transgenic murine model that expresses HIV-1 Tat protein in a GFAP-regulated, doxycycline-inducible manner, we assessed morphine tolerance, dependence, and reward. To assess the influence of CCR5 on these effects, mice were pretreated with oral vehicle or the CCR5 antagonist, maraviroc, prior to morphine administration. We found that HIV-1 Tat expression significantly attenuated the antinociceptive potency of acute morphine (2-64 mg/kg, i.p.) in non-tolerant mice. Consistent with this, Tat attenuated withdrawal symptoms among morphine-tolerant mice. Pretreatment with maraviroc blocked the effects of Tat, reinstating morphine potency in non-tolerant mice and restoring withdrawal symptomology in morphine-tolerant mice. Twenty-four hours following morphine administration, HIV-1 Tat significantly potentiated (∼3.5-fold) morphine-conditioned place preference and maraviroc further potentiated these effects (∼5.7-fold). Maraviroc exerted no measurable behavioral effects on its own. Protein array analyses revealed only minor changes to cytokine profiles when morphine was administered acutely or repeatedly; however, 24 h post morphine administration, the expression of several cytokines was greatly increased, including endogenous CCR5 chemokine ligands (CCL3, CCL4, and CCL5), as well as CCL2. Tat further elevated levels of several cytokines and maraviroc pretreatment attenuated these effects. These data demonstrate that CCR5 mediates key aspects of HIV-1 Tat-induced alterations in the antinociceptive potency and rewarding properties of opioids.
Collapse
Affiliation(s)
- Maciej Gonek
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, Richmond, P.O. Box 980613, VA 23298-0613, USA
| | - Virginia D. McLane
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, Richmond, P.O. Box 980613, VA 23298-0613, USA
| | - David L. Stevens
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, Richmond, P.O. Box 980613, VA 23298-0613, USA
| | - Kumiko Lippold
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, Richmond, P.O. Box 980613, VA 23298-0613, USA
| | - Hamid I. Akbarali
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, Richmond, P.O. Box 980613, VA 23298-0613, USA
| | - Pamela E. Knapp
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, Richmond, P.O. Box 980613, VA 23298-0613, USA,Department of Anatomy and Neurobiology, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, P.O. Box 980709, Richmond, VA 23298-0709, USA,Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, P.O. Box 980059, Richmond, VA 23298-0059, USA
| | - William L. Dewey
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, Richmond, P.O. Box 980613, VA 23298-0613, USA,Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, P.O. Box 980059, Richmond, VA 23298-0059, USA
| | - Kurt F. Hauser
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, Richmond, P.O. Box 980613, VA 23298-0613, USA,Department of Anatomy and Neurobiology, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, P.O. Box 980709, Richmond, VA 23298-0709, USA,Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, P.O. Box 980059, Richmond, VA 23298-0059, USA
| | - Jason J. Paris
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Medical College of Virginia (MCV) Campus, Richmond, P.O. Box 980613, VA 23298-0613, USA,Department of BioMolecular Sciences, University of Mississippi, School of Pharmacy, P.O. Box 1848, University, MS 38677-1848, USA,Research Institute of Pharmaceutical Sciences, University of Mississippi, School of Pharmacy, P.O. Box 1848, University, MS 38677-1848, USA,Address for Correspondence: Jason J. Paris, Ph.D. Assistant Professor of Pharmacology, The University of Mississippi, School of Pharmacy, P.O. Box 1848, 315 Faser Hall, University, MS 38677-1848, U.S.A. Phone: +1-662-915-3096,
| |
Collapse
|
55
|
Eligibility for heroin-assisted treatment (HAT) among people who inject opioids and are living with HIV in a Canadian setting. Addict Sci Clin Pract 2018; 13:3. [PMID: 29409539 PMCID: PMC5812056 DOI: 10.1186/s13722-017-0104-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/12/2017] [Indexed: 01/23/2023] Open
Abstract
Objectives A growing body of evidence supports the effectiveness of injectable diacetylmorphine (i.e., heroin) for individuals with treatment-refractory opioid use disorder. Despite this evidence, and the increasing toll of opioid-associated morbidity and mortality, it remains controversial in some settings. To investigate the possible contribution of heroin-assisted treatment (HAT) to HIV treatment-related outcomes, we sought to estimate the proportion and characteristics of HIV-positive people who inject opioids that might be eligible for HAT in Vancouver, Canada. Methods We used data from a prospective cohort of people living with HIV who use illicit drugs in Vancouver, Canada. Using generalized estimating equations (GEE), we assessed the longitudinal relationships between eligibility for HAT, using criteria from previous clinical trials and guidelines, with behavioural, social, and clinical characteristics. Results Between 2005 and 2014, 478 participants were included in these analyses, contributing 1927 person-years of observation. Of those, 94 (19.7%) met eligibility for HAT at least once during the study period. In a multivariable GEE model, after adjusting for clinical characteristics, being eligible for HAT was positively associated with homelessness, female gender, high-intensity illicit drug use, drug dealing and higher CD4 count. Conclusions In our study of HIV-positive people with a history of injection drug use, approximately 20% of participants were eligible for HAT at ≥ 1 follow-up period. Eligibility was linked to risk factors for sub-optimal HIV/AIDS treatment outcomes, such as homelessness and involvement in the local illicit drug trade, suggesting that scaling-up access to HAT might contribute to achieving optimal HIV treatment in this setting.
Collapse
|
56
|
Knudsen HK, Cook J, Lofwall MR, Walsh SL, Studts JL, Havens JR. A mixed methods study of HIV-related services in buprenorphine treatment. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2017; 12:37. [PMID: 28814313 PMCID: PMC5559779 DOI: 10.1186/s13011-017-0122-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 08/06/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Opioid use disorder (OUD) is a major risk factor in the acquisition and transmission of HIV. Clinical practice guidelines call for the integration of HIV services in OUD treatment. This mixed methods study describes the integration of HIV services in buprenorphine treatment and examines whether HIV services vary by prescribers' medical specialty and across practice settings. METHODS Data were obtained via qualitative interviews with buprenorphine experts (n = 21) and mailed surveys from US buprenorphine prescribers (n = 1174). Survey measures asked about screening for HIV risk behaviors at intake, offering HIV education, recommending all new patients receive HIV testing, and availability of on-site HIV testing. Prescribers' medical specialty, practice settings, caseload demographics, and physician demographics were measured. Multivariate models of HIV services were estimated, while accounting for the nesting of physicians within states. RESULTS Qualitative interviews revealed that physicians often use injection behaviors as the primary indicator for whether a patient should be tested for HIV. Interviews revealed that HIV-related services were often viewed as beyond the scope of practice among general psychiatrists. Surveys indicated that prescribers screened for an average of 3.2 of 5 HIV risk behaviors (SD = 1.6) at intake. About 62.0% of prescribers delivered HIV education to patients and 53.2% recommended HIV testing to all new patients, but only 32.3% offered on-site HIV testing. Addiction specialists and psychiatrists screened for significantly more HIV risk behaviors than physicians in other specialties. Addiction specialists and psychiatrists were significantly less likely than other physicians to offer on-site testing. Physicians in individual medical practice were significantly less likely to recommend HIV testing and to offer onsite testing than physicians in other settings. CONCLUSIONS Buprenorphine treatment providers have not uniformly integrated HIV-related screening, education, and testing services for patients. Differences by medical specialty and practice setting suggest an opportunity for targeting efforts to increase implementation.
Collapse
Affiliation(s)
- Hannah K Knudsen
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Ave, Room 204, Lexington, KY, 40508, USA.
| | - Jennifer Cook
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Ave, Room 214, Lexington, KY, 40508, USA
| | - Michelle R Lofwall
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Ave, Room 203, Lexington, KY, 40508, USA
| | - Sharon L Walsh
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Ave, Room 202, Lexington, KY, 40508, USA
| | - Jamie L Studts
- Department of Behavioral Science, University of Kentucky, 1100 Veterans Drive, Medical Behavioral Science Building, Room 127, Lexington, KY, 40536-0086, USA
| | - Jennifer R Havens
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Ave, Room 201, Lexington, KY, 40508, USA
| |
Collapse
|
57
|
Krebs E, Min JE, Evans E, Li L, Liu L, Huang D, Urada D, Kerr T, Hser YI, Nosyk B. Estimating State Transitions for Opioid Use Disorders. Med Decis Making 2017; 37:483-497. [PMID: 28027027 PMCID: PMC5536954 DOI: 10.1177/0272989x16683928] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM The aim was to estimate transitions between periods in and out of treatment, incarceration, and legal supervision, for prescription opioid (PO) and heroin users. METHODS We captured all individuals admitted for the first time for publicly funded treatment for opioid use disorder (OUD) in California (2006 to 2010) with linked mortality and criminal justice data. We used Cox proportional hazards and competing risks models to assess the effect of primary PO use (v. heroin) on the hazard of transitioning among 5 states: (1) opioid detoxification treatment; (2) opioid agonist treatment (OAT); (3) legal supervision (probation or parole); (4) incarceration (jail or prison); and (5) out-of-treatment. Transitions were conditional on survival, and death was modeled as an absorbing state. RESULTS Both primary PO (n = 11,733) and heroin (n = 19,926) users spent most of their median 2.3 y of observation out of treatment. Primary PO users were significantly younger (median age 30 v. 34 y), and a higher percentage were female (43.1% v. 31.5%; P < 0.001), white (74.6% v. 63.1%; P < 0.001), and had completed high school (31.8% v. 18.9%; P < 0.001). When compared to primary heroin users, PO users had a higher hazard of transitioning from detoxification to OAT (Hazard Ratio (HR), 1.65; 95% CI, 1.54 to 1.77), and had a lower hazard of transitioning from out-of-treatment to either detoxification (0.75 [0.70, 0.81]) or OAT (0.90 [0.85, 0.96]). CONCLUSION Our findings can be applied directly in state transition modeling to improve the validity of health economic evaluations. Although PO users tended to remain in treatment for longer durations than heroin users, they also tended to remain out of treatment for longer after transitioning to an out-of-treatment state. Despite the proven effectiveness of time-unlimited treatment, individuals with OUD spend most of their time out of treatment.
Collapse
Affiliation(s)
| | - Jeong E. Min
- British Columbia Centre for Excellence in HIV/AIDS
| | | | - Libo Li
- UCLA Integrated Substance Abuse Programs
| | - Lei Liu
- Northwestern University Feinberg School of Medicine
| | | | | | - Thomas Kerr
- UCLA Integrated Substance Abuse Programs
- Division of AIDS, Faculty of Medicine, University of British Columbia
| | | | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS
- Faculty of Health Sciences, Simon Fraser University
| |
Collapse
|
58
|
Weissman J, Kanamori M, Dévieux JG, Trepka MJ, De La Rosa M. HIV Risk Reduction Interventions Among Substance-Abusing Reproductive-Age Women: A Systematic Review. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2017; 29:121-140. [PMID: 28467160 PMCID: PMC5536169 DOI: 10.1521/aeap.2017.29.2.121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
HIV/AIDS is one of the leading causes of death among reproductive-age women throughout the world, and substance abuse plays a major role in HIV infection. We conducted a systematic review, in accordance with the 2015 Preferred Items for Reporting Systematic Reviews and Meta-analysis tool, to assess HIV risk-reduction intervention studies among reproductive-age women who abuse substances. We initially identified 6,506 articles during our search and, after screening titles and abstracts, examining articles in greater detail, and finally excluding those rated methodologically weak, a total of 10 studies were included in this review. Studies that incorporated behavioral skills training into the intervention and were based on theoretical model(s) were the most effective in general at decreasing sex and drug risk behaviors. Additional HIV risk-reduction intervention research with improved methodological designs is warranted to determine the most efficacious HIV risk-reduction intervention for reproductive-age women who abuse substances.
Collapse
Affiliation(s)
- Jessica Weissman
- Center for Research on U.S. Latino HIV/AIDS and Drug Abuse, Florida International University, Miami, Florida
- Robert Stempel College of Public Health & Social Work, Florida International University
| | - Mariano Kanamori
- Center for Research on U.S. Latino HIV/AIDS and Drug Abuse, Florida International University, Miami, Florida
| | - Jessy G Dévieux
- Robert Stempel College of Public Health & Social Work, Florida International University
| | - Mary Jo Trepka
- Center for Research on U.S. Latino HIV/AIDS and Drug Abuse, Florida International University, Miami, Florida
- Robert Stempel College of Public Health & Social Work, Florida International University
| | - Mario De La Rosa
- Center for Research on U.S. Latino HIV/AIDS and Drug Abuse, Florida International University, Miami, Florida
- Robert Stempel College of Public Health & Social Work, Florida International University
| |
Collapse
|
59
|
Wang C, Shi CX, Zhang B, Chen H, Wang H, Zhang N, Rou K, Cao X, Luo W, Wu Z. HIV seroconversion and risk factors among drug users receiving methadone maintenance treatment in China: A qualitative study. Drug Alcohol Depend 2016; 167:169-74. [PMID: 27567967 PMCID: PMC6625317 DOI: 10.1016/j.drugalcdep.2016.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 08/05/2016] [Accepted: 08/11/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We sought to explore the experiences of drug users in China who were recently diagnosed with HIV infection while engaged in methadone maintenance treatment (MMT) and to better understand their perceptions of MMT, HIV risk, and HIV prevention. METHODS We recruited clients of MMT clinics in Chongqing and Kunming who had a baseline HIV-negative test result upon entry to MMT and had been diagnosed with HIV within the past 12 months. We conducted semi-structured qualitative interviews and thematic data analysis to identify situations and factors that increased HIV risk. RESULTS Among the 27 participants who were interviewed, 15 believed their infection was due to injection drug use, 7 attributed their infection to sexual contact, and 5 were unsure as to how they became infected. High risk behaviors were common; 18 participants continued to use drugs during treatment, and 10 engaged in unprotected sex. Common themes were the difficulty of drug abstinence despite receiving MMT, social pressure to continue using drugs, and low knowledge of effective HIV prevention measures. CONCLUSION While MMT is effective in reducing drug usage and needle sharing, many clients remain at risk of HIV infection due to continued injection drug use and unprotected sex. Clients may benefit from additional counseling on HIV prevention methods as well as structural interventions to increase the availability of clean injection equipment.
Collapse
Affiliation(s)
- Changhe Wang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Beijing 102206, China
| | - Cynthia X Shi
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Beijing 102206, China,Department of Epidemiology of Microbial Diseases and Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College Street, New Haven, CT 06511, USA
| | - Bo Zhang
- Yunnan Institute for Drug Abuse, 471 Xifu Road, Kunming 650228, China
| | - Hong Chen
- Chongqing Center for Disease Control and Prevention, 8 Changjiang 2nd Road, Chongqing 400016, China
| | - Hua Wang
- Yunnan Institute for Drug Abuse, 471 Xifu Road, Kunming 650228, China
| | - Nanci Zhang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Beijing 102206, China
| | - Keming Rou
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Beijing 102206, China
| | - Xiaobin Cao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Beijing 102206, China
| | - Wei Luo
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Beijing 102206, China
| | - Zunyou Wu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Beijing 102206, China.
| |
Collapse
|
60
|
Kourounis G, Richards BDW, Kyprianou E, Symeonidou E, Malliori MM, Samartzis L. Opioid substitution therapy: Lowering the treatment thresholds. Drug Alcohol Depend 2016; 161:1-8. [PMID: 26832931 DOI: 10.1016/j.drugalcdep.2015.12.021] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 12/02/2015] [Accepted: 12/21/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND Opioid substitution therapy (OST) has been established as the gold standard in treating opioid use disorders. Nevertheless, there is still a debate regarding the qualitative characteristics that define the optimal OST intervention, namely the treatment threshold. The aim of this review is twofold: first, to provide a summary and definition of "treatment thresholds", and second, to outline these thresholds and describe how they related to low and high threshold treatment characteristics and outcomes. METHOD We searched the main databases of Medline, PubMed, PsycInfo, EMBASE, CINAHL and the Cochrane Library. Original published research papers, reviews, and meta-analyses, containing the eligible keywords: "opioid substitution", "OST", "low threshold", "high threshold" were searched alone and in combination, up to June, 2015. RESULTS Treatment thresholds were defined as barriers a patient may face prior to and during treatment. The variables of these barriers were classified into treatment accessibility barriers and treatment design barriers. There are increasing numbers of studies implementing low threshold designs with an increasing body of evidence suggesting better treatment outcomes compared to high threshold designs. CONCLUSION Clinical characteristics of low threshold treatments that were identified to increase the effectiveness of OST intervention include increasing accessibility so as to avoid waiting lists, using personalized treatment options regarding medication choice and dose titration, flexible treatment duration, a treatment design that focuses on maintenance and harm reduction with emphasis on the retention of low adherence patients.
Collapse
Affiliation(s)
- Georgios Kourounis
- St George's University of London, Medical School at the University of Nicosia, Agiou Nikolaou Street 93, Engomi, 2408 Nicosia, Cyprus; Department of Addiction Psychiatry, Athalassa Psychiatric Hospital, Cyprus Mental Health Services, Leoforos Lemesou 199/2, 1452 Nicosia, Cyprus
| | - Brian David Wensley Richards
- St George's University of London, Medical School at the University of Nicosia, Agiou Nikolaou Street 93, Engomi, 2408 Nicosia, Cyprus; Department of Addiction Psychiatry, Athalassa Psychiatric Hospital, Cyprus Mental Health Services, Leoforos Lemesou 199/2, 1452 Nicosia, Cyprus
| | - Evdokia Kyprianou
- Cyprus Anti-Drugs Council, Leoforos Lemesou 130, City Home 81, 2015 Strovolos, Cyprus
| | - Eva Symeonidou
- Cyprus Anti-Drugs Council, Leoforos Lemesou 130, City Home 81, 2015 Strovolos, Cyprus
| | - Minerva-Melpomeni Malliori
- Department of Psychiatry, School of Medicine, National and Kapodistrian University of Athens, 72, 74, Vassil. Sophias Avenue, 11528 Athens, Greece
| | - Lampros Samartzis
- St George's University of London, Medical School at the University of Nicosia, Agiou Nikolaou Street 93, Engomi, 2408 Nicosia, Cyprus; Department of Addiction Psychiatry, Athalassa Psychiatric Hospital, Cyprus Mental Health Services, Leoforos Lemesou 199/2, 1452 Nicosia, Cyprus.
| |
Collapse
|
61
|
Maradiaga JA, Nahvi S, Cunningham CO, Sanchez J, Fox AD. "I Kicked the Hard Way. I Got Incarcerated." Withdrawal from Methadone During Incarceration and Subsequent Aversion to Medication Assisted Treatments. J Subst Abuse Treat 2016; 62:49-54. [PMID: 26747509 PMCID: PMC4888768 DOI: 10.1016/j.jsat.2015.11.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/06/2015] [Accepted: 11/15/2015] [Indexed: 11/19/2022]
Abstract
Incarceration is a common experience for individuals with opioid use disorder, including those receiving medication assisted treatments (MAT), such as buprenorphine or methadone. In the United States, MAT is rarely available during incarceration. We were interested in whether challenges with methadone maintenance treatment during incarceration affected subsequent attitudes toward MAT following release. We conducted semi-structured interviews with 21 formerly incarcerated individuals with opioid use disorder in community substance abuse treatment settings. Interviews were audio recorded, transcribed, and analyzed using a grounded theory approach. Themes that emerged upon iterative readings of transcripts were discussed by the research team. The three main themes relating to methadone were: 1) rapid dose reduction during incarceration; 2) discontinuity of methadone during incarceration; and 3) post incarceration aversion to methadone. Participants who received methadone maintenance treatment prior to incarceration reported severe and prolonged withdrawal symptoms from rapid dose reductions or disruption of their methadone treatment during incarceration. The severe withdrawal during incarceration contributed to a subsequent aversion to methadone and adversely affected future decisions regarding reengagement in MAT. Though MAT is the most efficacious treatment for opioid use disorder, current penal policy, which typically requires cessation of MAT during incarceration, may dissuade individuals with opioid use disorder from considering and engaging in MAT after release from incarceration.
Collapse
Affiliation(s)
| | - Shadi Nahvi
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461; Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467.
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461; Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467.
| | - Jennifer Sanchez
- Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467.
| | - Aaron D Fox
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461; Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467.
| |
Collapse
|
62
|
Campbell MD, Kolodner G, Spencer RA, DuPont RL. Drug test results as a predictor of retention among patients using buprenorphine in a comprehensive outpatient treatment program. J Addict Dis 2016; 35:315-324. [DOI: 10.1080/10550887.2016.1139427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
63
|
Abstract
This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants). This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants).
Collapse
Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
| |
Collapse
|
64
|
Fox AD, Masyukova M, Cunningham CO. Optimizing psychosocial support during office-based buprenorphine treatment in primary care: Patients' experiences and preferences. Subst Abus 2015; 37:70-5. [PMID: 26566712 PMCID: PMC4801741 DOI: 10.1080/08897077.2015.1088496] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Buprenorphine maintenance treatment is effective and has been successfully integrated into human immunodeficiency virus (HIV) and primary care settings. However, one key barrier to providers prescribing buprenorphine is their perception that they are unable to provide adequate counseling or psychosocial support to patients with opioid addiction. This qualitative study investigated supportive elements of office-based buprenorphine treatment that patients perceived to be most valuable. METHODS The authors conducted five focus groups with 33 buprenorphine treatment-experienced participants. Focus groups were audio-recorded and transcribed. Iterative readings of transcripts and grounded theory analysis revealed common themes. RESULTS Overall, participants perceived that buprenorphine treatment helped them to achieve their treatment goals and valued the flexibility, accessibility, and privacy of treatment. Participants identified interpersonal and structural elements of buprenorphine treatment that provided psychosocial support. Participants desired good physician-patient relationships, but also valued care delivery models that were patient-centered, created a safe place for self-disclosure, and utilized coordinated team-based care. CONCLUSIONS Participants derived psychosocial support from their prescribing physician, but were also open to collaborative or team-based models of care, as long as they were voluntary and confidential. Buprenorphine-prescribing physicians without access to referral options for psychosocial counseling could focus on maintaining nonjudgmental attitudes and shared decision-making during patient encounters. Adding structure and psychosocial support to buprenorphine treatment through coordinated team-based care also seems to have great promise.
Collapse
Affiliation(s)
- Aaron D Fox
- a Albert Einstein College of Medicine , Bronx , New York , USA
- b Department of Medicine, Montefiore Medical Center , Bronx , New York , USA
| | | | - Chinazo O Cunningham
- a Albert Einstein College of Medicine , Bronx , New York , USA
- b Department of Medicine, Montefiore Medical Center , Bronx , New York , USA
| |
Collapse
|
65
|
Timko C, Schultz NR, Cucciare MA, Vittorio L, Garrison-Diehn C. Retention in medication-assisted treatment for opiate dependence: A systematic review. J Addict Dis 2015; 35:22-35. [PMID: 26467975 DOI: 10.1080/10550887.2016.1100960] [Citation(s) in RCA: 309] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Retention in medication-assisted treatment among opiate-dependent patients is associated with better outcomes. This systematic review (55 articles, 2010-2014) found wide variability in retention rates (i.e., 19%-94% at 3-month, 46%-92% at 4-month, 3%-88% at 6-month, and 37%-91% at 12-month follow-ups in randomized controlled trials), and identified medication and behavioral therapy factors associated with retention. As expected, patients who received naltrexone or buprenorphine had better retention rates than patients who received a placebo or no medication. Consistent with prior research, methadone was associated with better retention than buprenorphine/naloxone. And, heroin-assisted treatment was associated with better retention than methadone among treatment-refractory patients. Only a single study examined retention in medication-assisted treatment for longer than 1 year, and studies of behavioral therapies may have lacked statistical power; thus, studies with longer-term follow-ups and larger samples are needed. Contingency management showed promise to increase retention, but other behavioral therapies to increase retention, such as supervision of medication consumption, or additional counseling, education, or support, failed to find differences between intervention and control conditions. Promising behavioral therapies to increase retention have yet to be identified.
Collapse
Affiliation(s)
- Christine Timko
- a Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System , Palo Alto , California , USA.,b Department of Psychiatry and Behavioral Sciences , Stanford University School of Medicine , Stanford , California , USA
| | - Nicole R Schultz
- c Department of Psychology , Auburn University , Auburn , Alabama , USA
| | - Michael A Cucciare
- d Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System , North Little Rock , Arkansas , USA.,e VA South Central (VISN 16) Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System , North Little Rock , Arkansas , USA.,f Department of Psychiatry , University of Arkansas for Medical Sciences , Little Rock , Arkansas , USA
| | - Lisa Vittorio
- g Research Service, Veterans Affairs Boston Heathcare System , Brockton , Massachusetts , USA
| | - Christina Garrison-Diehn
- a Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System , Palo Alto , California , USA.,b Department of Psychiatry and Behavioral Sciences , Stanford University School of Medicine , Stanford , California , USA.,h Geriatric Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System , Palo Alto , California , USA
| |
Collapse
|
66
|
Implementation and Operational Research: Linkage to Care Among Methadone Clients Living With HIV in Dar es Salaam, Tanzania. J Acquir Immune Defic Syndr 2015; 69:e43-8. [PMID: 26009835 PMCID: PMC4435505 DOI: 10.1097/qai.0000000000000582] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background: The first methadone maintenance treatment clinic in Tanzania was launched in February 2011 to address an emerging HIV epidemic among people who inject drugs. We conducted a retrospective cohort study to understand factors associated with linkage to HIV care and explore how a methadone maintenance treatment clinic can serve as a platform for integrated HIV care and treatment. Methods: This study used routine programmatic and clinical data on clients enrolled in methadone at Muhimbili National Hospital from February 2011 to January 2013. Multivariable proportional hazards regression model was used to examine time to initial CD4 count. Results: Final analyses included 148 HIV-positive clients, contributing 31.7 person-years. At 30, 60, and 90 days, the probability of CD4 screening was 40% [95% confidence interval (CI): 32% to 48%], 55% (95% CI: 47% to 63%), and 63% (95% CI: 55% to 71%), respectively. Clients receiving high methadone doses (≥85 mg/d) [adjusted hazard ratio (aHR): 1.68, 95% CI: 1.03 to 2.74] had higher likelihood of CD4 screening than those receiving low doses (<85 mg/d). Clients with primary education or lower (aHR: 1.62, 95% CI: 1.05 to 2.51) and self-reported poor health (aHR: 1.96, 95% CI: 1.09 to 3.51) were also more likely to obtain CD4 counts. Clients with criminal arrest history (aHR: 0.56, 95% CI: 0.37 to 0.85]) were less likely to be linked to care. Among 17 antiretroviral therapy eligible clients (CD4 ≤ 200), 12 (71%) initiated treatment, of which 7 (41%) initiated within 90 days. Conclusions: Levels of CD4 screening and antiretroviral therapy initiation were similar to Sub-Saharan programs caring primarily for people who do not inject drugs. Adequate methadone dosing is important in retaining clients to maximize HIV treatment benefits and allow for successful linkage to services.
Collapse
|
67
|
Reaching the unreached: treatment as prevention as a workable strategy to mitigate HIV and its consequences in high-risk groups. Curr HIV/AIDS Rep 2015; 11:505-12. [PMID: 25342571 DOI: 10.1007/s11904-014-0238-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
While there have been significant advances in curbing the HIV disease epidemic worldwide, there continues to be significant number of incident cases with 2.3 million new infections in the year 2012 alone. Treatment as prevention (TasP), which involves the use of antiretroviral drugs to decrease the likelihood of HIV illness, death and transmission from infected individuals to their noninfected sexual and /or drug paraphernalia-sharing injecting partners, must be incorporated into any HIV prevention strategy that is going to be successful on a large scale. Especially in resource-limited settings, the focus of the prevention approach should be on high-risk groups who contribute disproportionately to community HIV transmission, including people who inject drugs (PWID), men who have sex with men (MSM) and sex workers. Innovative strategies including integrated care services adapted to different patient care settings have to and can be employed to reach these at-risk populations.
Collapse
|
68
|
Abstract
Medication-assisted treatment of opioid use disorder with physiological dependence at least doubles rates of opioid-abstinence outcomes in randomized, controlled trials comparing psychosocial treatment of opioid use disorder with medication versus with placebo or no medication. This article reviews the current evidence for medication-assisted treatment of opioid use disorder and also presents clinical practice imperatives for preventing opioid overdose and the transmission of infectious disease. The evidence strongly supports the use of agonist therapies to reduce opioid use and to retain patients in treatment, with methadone maintenance remaining the gold standard of care. Combined buprenorphine/naloxone, however, also demonstrates significant efficacy and favorable safety and tolerability in multiple populations, including youth and prescription opioid-dependent individuals, as does buprenorphine monotherapy in pregnant women. The evidence for antagonist therapies is weak. Oral naltrexone demonstrates poor adherence and increased mortality rates, although the early evidence looks more favorable for extended-release naltrexone, which has the advantages that it is not subject to misuse or diversion and that it does not present a risk of overdose on its own. Two perspectives-individualized treatment and population management-are presented for selecting among the three available Food and Drug Administration-approved maintenance therapies for opioid use disorder. The currently unmet challenges in treating opioid use disorder are discussed, as are the directions for future research.
Collapse
|
69
|
Lee J, Kresina TF, Campopiano M, Lubran R, Clark HW. Use of pharmacotherapies in the treatment of alcohol use disorders and opioid dependence in primary care. BIOMED RESEARCH INTERNATIONAL 2015; 2015:137020. [PMID: 25629034 PMCID: PMC4299453 DOI: 10.1155/2015/137020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/22/2014] [Accepted: 09/10/2014] [Indexed: 01/10/2023]
Abstract
Substance-related and addictive disorders are chronic relapsing conditions that substantially impact public health. Effective treatments for these disorders require addressing substance use/dependence comprehensively as well as other associated comorbidities. Comprehensive addressing of substance use in a medical setting involves screening for substance use, addressing substance use directly with the patient, and formulating an appropriate intervention. For alcohol dependence and opioid dependence, pharmacotherapies are available that are safe and effective when utilized in a comprehensive treatment paradigm, such as medication assisted treatment. In primary care, substance use disorders involving alcohol, illicit opioids, and prescription opioid abuse are common among patients who seek primary care services. Primary care providers report low levels of preparedness and confidence in identifying substance-related and addictive disorders and providing appropriate care and treatment. However, new models of service delivery in primary care for individuals with substance-related and addictive disorders are being developed to promote screening, care and treatment, and relapse prevention. The education and training of primary care providers utilizing approved medications for the treatment of alcohol use disorders and opioid dependence in a primary care setting would have important public health impact and reduce the burden of alcohol abuse and opioid dependence.
Collapse
Affiliation(s)
- Jinhee Lee
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, USA
| | - Thomas F. Kresina
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, USA
| | - Melinda Campopiano
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, USA
| | - Robert Lubran
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, USA
| | - H. Westley Clark
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
| |
Collapse
|
70
|
Risk reduction with buprenorphine-naloxone and methadone: patient's choice. J Acquir Immune Defic Syndr 2014; 67:e142. [PMID: 25197828 DOI: 10.1097/qai.0000000000000332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|