Medication-assisted treatment of opioid use disorder: review of the evidence and future directions

Factors associated with physical and sexual violence by police among people who inject drugs in Ukraine: implications for retention on opioid agonist therapy

Introduction

Ukraine's volatile HIV epidemic, one of the largest in Eastern Europe and Central Asia, remains concentrated in people who inject drugs (PWID). HIV prevalence is high (21.3% to 41.8%) among the estimated 310,000 PWID. Opioid agonist therapy (OAT) is the most cost-effective HIV prevention strategy there, yet OAT services are hampered by negative attitudes and frequent harassment of OAT clients and site personnel by law enforcement. This paper examines the various types of police violence that Ukrainian PWID experience and factors associated with the different types of violence, as well as the possible implications of police harassment on OAT retention.

Methods

In 2014 to 2015, we conducted a cross-sectional survey in five Ukrainian cities with 1613 PWID currently, previously and never on OAT, using a combination of respondent-driven sampling, as well as random sampling. We analysed correlates of police violence by multiple factors, including by gender, and their effects on duration of OAT retention. Self-reported physical and sexual violence by police were the two primary outcomes, while retention on OAT was used as a secondary outcome.

Results

Overall, 1033 (64.0%) PWID reported being physically assaulted by police, which was positively correlated with currently or previously being on OAT (69.1% vs. 60.2%; p<0.01). HIV prevalence rates were higher in those receiving OAT than those not on OAT (47.6% vs. 36.1%; p<0.01). Police violence experiences differed by sex, with men experiencing significantly more physical violence, while women experienced more sexual violence (65.9% vs. 42.6%; p<0.01). For PWID who had successfully accessed OAT, longer OAT retention was significantly correlated both with sexual assault by police and fewer non-fatal overdoses.

Conclusions

Police violence is a frequent experience among PWID in Ukraine, particularly for those accessing OAT, an evidence-based primary and secondary HIV prevention strategy. Police violence experiences, however, were different for men and women, and interventions with police that address these sexual differences and focus on non-violent interactions with PWID to improve access and retention on OAT are crucial for improving HIV prevention and treatment goals for Ukraine.

Optimising health and safety of people who inject drugs during transition from acute to outpatient care: narrative review with clinical checklist

The opioid epidemic in the USA continues to worsen. Medical providers are faced with the challenge of addressing complications from opioid use disorders and associated injection drug use. Unsafe injection practices among people who inject drugs (PWID) can lead to several complications requiring acute care encounters in the emergency department and inpatient hospital. Our objective is to provide a narrative review to help medical providers recognise and address key health issues in PWID, who are being released from the emergency department and inpatient hospital. In the midst of rises in overdose deaths and infections such as hepatitis C, we highlight several health issues for PWID, including overdose and infection prevention. We provide a clinical checklist of actions to help guide providers in the care of these complex patients. The clinical checklist includes strategies also applicable to low-resource settings, which may lack addiction treatment options. Our review and clinical checklist highlight key aspects of optimising the health and safety of PWID.

Nonmedical Prescription Opioid Use and DSM-5 Nonmedical Prescription Opioid Use Disorder in the United States

OBJECTIVE

The authors present 12-month and lifetime prevalence, correlates, psychiatric comorbidity, and treatment of nonmedical prescription opioid use (NMPOU) and DSM-5 NMPOU disorder (NMPOUD).

METHODS

Data were derived from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) (N = 36,309).

RESULTS

Prevalences of 12-month and lifetime NMPOU were 4.1% and 11.3%, exceeding rates in the 2001-2002 NESARC (1.8%, 4.7%). Twelve-month and lifetime rates of DSM-5 NMPOUD were 0.9% and 2.1%. NESARC-III DSM-IV NMPOUD rates (0.8%, 2.9%) were greater than those observed in the 2001-2002 NESARC (0.4% and 1.4%). Rates of NMPOU were greater among men, but no sex differential was observed for NMPOUD. Prevalences of NMPOU and NMPOUD were generally greater among 18- to 64-year-old individuals, whites, and Native Americans, and individuals with lower socioeconomic status. Associations were observed between 12-month and lifetime NMPOU and NMPOUD and other drug use disorders, posttraumatic stress disorder, and borderline, schizotypal, and antisocial personality disorders; persistent depression and major depressive disorder (for NMPOU); and bipolar I disorder (for NMPOUD). Only 5.5% and 17.7% of individuals with 12-month NMPOU and NMPOUD were ever treated.

CONCLUSIONS

NMPOU and NMPOUD have considerably increased over the past decade, are associated with a broad array of risk factors and comorbidities, and largely go untreated in the United States. More information on the determinants, characteristics, and outcomes of NMPOU and NMPOUD is needed to support evidence-based interventions and prevention.

Linkage to Primary Care for Persons First Receiving Injectable Naltrexone During Inpatient Opioid Detoxification

INTRODUCTION

Opioid use disorders commonly require ongoing medication-assisted treatment to reduce relapse following discharge from inpatient detoxification programs. Naltrexone, an opioid antagonist, is an increasingly popular treatment option in its once-monthly injectable form (XR-NTX). The aim of this study was to examine the follow-up rates of persons who received an initial injection during inpatient detoxification and scheduled for receipt of a first outpatient injection in the primary care setting.

METHODS

We reviewed the electronic health records of 62 consecutive opioid dependent adults who received an initial injection of XR-NTX during extended inpatient detoxification at Stanley Street Treatment and Resources (SSTAR) in Fall River, Massachusetts, from March 2013 to August 2015, and were referred to the adjacent SSTAR primary care health center for their second injection 1 month later. Demographic information, drug use and opioid treatment history, and aftercare planning were assessed.

RESULTS

Participants averaged 32.4 (±7.8) years of age, 90.3% were non-Latino Caucasian, 35.5% were homeless, 21.3% reported a drug overdose in the last year, and 53.2% had been in detoxification within the last year. Of the 62 participants referred to primary care, 34 (54.8%) followed up to receive their second XR-NTX injection. Twenty of these persons received at least a third XR-NTX injection. No demographic, treatment history, substance use behaviors, or aftercare plan variables were associated with receipt of a second injection (p<.20).

CONCLUSION

Predicting, and therefore improving, XR-NTX continuation during the transition from inpatient detoxification to primary care may be difficult in this population.

Long-term outcomes after randomization to buprenorphine/naloxone versus methadone in a multi-site trial

AIMS

To compare long-term outcomes among participants randomized to buprenorphine or methadone.

DESIGN, SETTING AND PARTICIPANTS

Follow-up was conducted in 2011-14 of 1080 opioid-dependent participants entering seven opioid treatment programs in the United States between 2006 and 2009 and randomized (within each program) to receive open-label buprenorphine/naloxone or methadone for up to 24 weeks; 795 participants completed in-person interviews (~74% follow-up interview rate) covering on average 4.5 years.

MEASUREMENTS

Outcomes were indicated by mortality and opioid use. Covariates included demographics, site, cocaine use and treatment experiences.

FINDINGS

Mortality was not different between the two randomized conditions, with 23 (3.6%) of 630 participants randomized to buprenorphine having died versus 26 (5.8%) of 450 participants randomized to methadone. Opioid use at follow-up was higher among participants randomized to buprenorphine relative to methadone [42.8 versus 31.7% positive opioid urine specimens, P < 0.01, effect size (h) = 0.23 (0.09, 0.38); 5.8 days versus 4.4 days of past 30-day heroin use, P < 0.05, effect size (d) = 0.14 (0.00, 0.28)]. Opioid use during the follow-up period by randomization condition was also significant (F(7,39,600) = 3.16; P < 0.001) due mainly to less treatment participation among participants randomized to buprenorphine than methadone. Less opioid use was associated with both buprenorphine and methadone treatment (relative to no treatment); no difference was found between the two treatments. Individuals who are white or used cocaine at baseline responded better to methadone than to buprenorphine.

CONCLUSIONS

There are few differences in long-term outcomes between buprenorphine and methadone treatment for opioid dependence, and treatment with each medication is associated with a strong reduction in opioid use.

Outcomes for Physicians With Opioid Dependence Treated Without Agonist Pharmacotherapy in Physician Health Programs

AIMS

To compare treatment outcome among substance dependent physicians enrolled in a physician health program (PHP) who have a history of alcohol use only, any opioid use, or non-opioid drug use, in order to determine whether the distinctive PHP system of care management is as effective for individuals with opioid use disorders as for those with alcohol or other drug use disorders.

METHODS

A 5-year, retrospective chart review, intent-to-treat analysis was conducted for all physicians admitted to 16 physician health programs (N=702; 85.5% male; age range=24-75). Analyses compared treatment outcomes for participants based upon their substance(s) of abuse [i.e., 1) "Alcohol Only" (n=204), 2) "Any Opioid" with or without alcohol use (n=339), and 3) "Non-Opioid" drug use with or without alcohol use (n=159)].

RESULTS

In this sample, 75-80% of physicians across the three groups never tested positive for alcohol or drugs during their extended care management period with random drug testing. This included physicians with opioid dependence who did not receive opioid substitution therapy (OST). Of the 22.1% of physicians who had a positive test, two thirds (i.e., 14.5% of the total sample) had just one positive test, and only one third (i.e., 7.6% of the total sample) had more than one positive test. These results were similar in all three groups.

CONCLUSIONS

These results indicate that individuals with opioid use disorders who are managed by PHPs can achieve long-term abstinence from opioids, alcohol, and other drugs without OST through participation in abstinence-based psychosocial treatment with extended, intensive care management following discharge.

Caring for pregnant opioid abusers in Vermont: A potential model for non-urban areas

Opioid addiction is no longer a primarily urban problem. As dependence on heroin and prescription pain relievers has become a significant issue in rural areas, the need for effective treatment of opioid-dependent pregnant women and their neonates has grown accordingly. In addition to the adverse perinatal outcomes associated with opioid addiction in pregnant women, the high costs of caring for these mothers and their babies motivate efforts to develop appropriate treatment models. We found that integration and coordination of services that promote maternal recovery and ability to parent are key requirements for treatment of opioid dependence during pregnancy. Unfortunately, lack of experience and resources makes such coordination a real challenge in rural areas. In this review, we discuss how we managed the challenges of developing a comprehensive program for treatment of opioid dependence during pregnancy. In addition, we outline our approach for facilitating the development of community-based programs to help these patients and families in rural regions of Vermont. Close relationships between our tertiary care center, local hospitals, community health care infrastructure, and legislators bolstered our efforts. In particular, appreciation for the severity and importance of the opioid-dependence problem in Vermont among health care providers and state legislators was paramount for our success in developing a state-wide treatment program. This approach can inform similar efforts in other rural regions of the United States, and has great potential to improve both access and quality of care for women struggling with opioid dependence.